Back to Table of Contents | June 2011

Pulse

Air Care

Minnesota’s medical air transport services bring critical care anywhere it’s needed.

By Howard Bell

On the ground, their medical centers compete. In the air, the medical directors of Minnesota’s three air transport services collaborate. Some of them have known each other for decades. Life Link III’s R.J. Frascone, M.D., and Mayo One’s Daniel Hankins, M.D., interned together at St. Paul-Ramsey Medical Center in 1974. Each was the best man at the other’s wedding. North Memorial Air Care’s Marc Conterato, M.D., and Hankins have collaborated with Frascone on research. “We’re all friends, and we all talk to each other,” Hankins says. All are board-certified emergency medicine physicians who’ve seen air transport in Minnesota grow from novelty to necessity. The medical directors meet several times a year to review cases, share concerns, and tweak patient care protocols. In between, they talk by phone. “Our medical protocols are pretty similar,” Frascone adds. “And we all have similar concerns and challenges.”

The challenges of bringing the critical care capability of a hospital to the field is what they say they like most about their jobs. “Air emergency transport is a totally different animal from hospital emergency medicine,” says Conterato. “In the ER, you’ve got good lighting, lots of tools and drugs, additional staff, and plenty of room. Strip all that away in a helicopter where lighting and temperature can be suboptimal, you’re in a noisy environment, and you’re providing tertiary level care at 3,000 feet in a space half the size of a ground ambulance compartment. You can’t use a stethoscope when you’re wearing a helmet. You can’t hear anything anyway with the rotor noise.”

Flying the Desk
Although they spend most of their time flying their desks (in Minnesota, a physician is not required to be on board a medical helicopter), the medical directors are medically and legally responsible for the care a patient receives during transport. But they do go on occasional missions to remind themselves of the challenges their crews face. Conterato says nearly all 40 of his emergency physician partners “look at me like I’m insane to want to go up.”

Most of the work Conterato and his fellow air transport medical directors do, however, involves developing and updating the protocols that guide crew members through every conceivable transport scenario. They are not usually in direct radio contact with crews. “It’s important that crews take care of patients on standing orders in case radios or cell phones don’t work,” Frascone says, adding that “online” medical direction while a crew is airborne happens only when they are truly stumped.

The medical directors also review records from all critical care runs to make sure the protocols were followed and that adequate documentation was kept, and they help hire the crew and make sure they’re properly trained. In addition, they share responsibility with the pilots for ensuring their fleets meet safety standards prescribed by the Federal Aviation Administration (FAA) and the Commission of Accreditation for Medical Transport Systems, whose board of directors Hankins previously chaired.

Research is another part of the job. Under Frascone’s medical direction, Life Link III has studied the effect of onboard noise levels on newborns inside neonatal isolettes. They’ve also researched the effectiveness of a device that monitors brain waves to study the adequacy of pain medication in unconscious patients. Currently, Life Link is researching the use of ultrasound for diagnosing collapsed lungs. “Life Link III has published more studies than anyone else in the world on the use of ultrasounds in helicopters,” Frascone says.

North Memorial has researched patient temperature control during transports and with Mayo, inducing hypothermia in resuscitated cardiac arrest patients. Mayo has studied the use of packed red blood cells and plasma on helicopters; the “autolaunch” of helicopters, using passerby information rather than waiting for the arrival of first responders to begin the process of dispatching helicopters to the trauma scene; and the transport of harvested organs and suicidal patients.

High-Level Care
Most important, the medical directors see to it that patients receive high-level care. Although the conditions crew members work in are austere, the technology at their disposal is state-of-the-art. Medical helicopters carry more drugs and equipment than a typical ground ambulance.

“Helicopters are flying critical care units,” Frascone says. Instead of having about 20 drugs on board like a ground ambulance, helicopters carry around 60, along with sophisticated ventilators and blood and plasma, which aren’t normally carried in a ground ambulance. They may also carry intra-aortic assist pumps; ultrasound devices; equipment for inserting chest tubes and monitoring pressure inside central veins, arteries and brains; and portable lab analyzers.

The critical care nurses and paramedics on board have a higher skill level than the typical ground ambulance crew, according to Frascone. Critical care flight nurses are trained and licensed to administer drugs such as vasopressors, dopamine, IV nitroglycerin, and steroids that are normally not administered in a ground ambulance. “These are bright, high-performing people at the top of their fields who are dealing with the sickest of the sick in less-than-ideal conditions,” Frascone says.

Air transport units are especially important in rural Minnesota, where small hospitals may not be staffed or equipped to handle time-critical emergencies such as severe trauma; stroke, where time is brain; or myocardial infarction, where time is muscle. Trauma, heart attacks, strokes, and obstetric/neonatal emergencies are the most common reasons for transports. “Every week our helicopters save a life that probably wouldn’t have been saved without air transport,” Conterato says. He recalls a situation that happened just weeks ago, when an inattentive driver smashed into a parked semi at 60 miles per hour. Both his legs were crushed. “His legs were bleeding heavily and his blood pressure dropping fast. He needed the resources of a Level One trauma center to survive,” Conterato says. “The crew helped apply tourniquets and got him to our trauma center in 35 minutes. He survived.”

Studies show trauma patients transported by helicopter have a 25 percent higher survival rate than those transported by ground ambulance, according to Hankins. “It’s not just the speed of the aircraft that makes the difference. It’s also the equipment on board and the skills of the crew,” he says, adding that helicopters are “very effective at bringing tertiary care to a community hospital setting.” About 80 percent of patients who receive air transport services are picked up at the nearest community hospital, where ground ambulances have taken them, and transported to tertiary care centers. Patients with severe trauma, heart attacks needing catheterization, strokes needing interventional radiology, and complex medical problems with multiple co-morbidities such as respiratory or multiple-organ failure will be transported directly from the scene to a tertiary care center.

An Evolving Subspecialty
Back in the 1980s when civilian air medical transport was new, most air medical directors were emergency doctors who “learned as we went along,” according to Hankins. “It was on-the-job training.” Conterato credits G. Patrick Lilja, M.D., medical director, of North’s ambulance and helicopter services, for teaching him the ropes. He says they still work together to develop protocols and review cases.

Although air medical transport is not officially a subspecialty of emergency medicine, pre-hospital emergency medicine is. In 2007, the Institute of Medicine (IOM) recommended that all medical directors of medical air transport services complete an emergency medicine residency and preferably a fellowship in pre-hospital emergency medicine. Regions Hospital and Hennepin County Medical Center offer such fellowships. Mayo is planning one. “When I first started practicing emergency medicine,” says Conterato, “one or two places in the country offered pre-hospital fellowships. Now around 30 do.”

Subspecialty board certification in pre-hospital emergency medicine will be offered beginning in 2014. Meanwhile, the Air Medical Physician Association (AMPA), which Hankins helped create, has already raised the bar on medical director training. The 400-member organization sponsors a critical care air transport medicine conference each year and has a preconference on how to be an effective air medical director. It also has developed an air medical director core curriculum and published a textbook, Principles and Direction of Air Medical Transport. AMPA seminars are offered as part of other critical care and emergency medical conferences.

Hankins currently serves as president of the Association of Air Medical Services, which provides a forum for personnel from all disciplines involved in helicopter EMS to share information and improve the safety and quality of care.

The increase in educational offerings and training requirements is a commentary on the future of air transport. Helicopters, Hankins says, “will become an increasingly more vital safety net for rural Minnesotans who have time-dependent emergencies that need expeditious care at large referral hospitals.”

Air Transport in Minnesota

In the last 25 years, air medical transport has become an essential part of Minnesota’s emergency medical system. Here’s how it works:

At the scene of an accident, first responders such as a sheriff or the EMS ground crew decide whether to dispatch a helicopter, which helicopter service to call (usually the one with the closest aircraft), and to which hospital to send the patient, according to R.J. Frascone, M.D., medical director for Life Link III. All three of Minnesota’s air transport services—Mayo One, Life Link III, and North Memorial Air Care—base helicopters across the state.

Most air transports involve picking up patients at a community hospital and taking them to a tertiary care center. Patients who must be transported from one hospital to another one more than 200 miles go by medical planes, which don’t do scene-to-hospital transports.

Pilots make the call about whether to fly if the weather is bad. Mayo One cancels about 800 dispatches per year out of 3,000 requests, according to Daniel Hankins, M.D., co-medical director of Mayo One. Hankins says poor visibility and ice on the rotor blades are the biggest weather-related hazards. Mayo pilots now use night vision goggles, he says. And new EMS helicopters with self-deicing blades just became available and will be used in Minnesota as fleets are updated.

At 13 helicopters, Minnesota’s medical air transport fleet is lean and cost-efficient compared with those in other states. Pennsylvania, for example, has 70 helicopters. (Medical helicopters cost $5 million to $6 million each.) “Minnesota has excellent air medical coverage,” Frascone says, “but we don’t tolerate dueling helicopters.”

As for safety, Marc Conterato, M.D., associate medical director of North Memorial Air Care, says Minnesota has never had a fatality or serious injury caused by a medical helicopter accident. “All three helicopter services have outstanding safety records.”—H.B.