Flight care vs. ground care

[LucidResq]

I'm interested in flight nursing.

I keep hearing mentions about the differences between caring for a pt. in a chopper or plane and caring for them on the ground, but no specifics.

So... anyone know exactly what changes? How is physiology affected, and how does that change the care given? What are some difficulties that arise? Are there procedures/treatments that can be given on the ground that should not be given in flight?

I know this may be a complicated topic so just a few examples would be ok.

 

[Ops Paramedic]

Your sources are correct in saying there are differences. Just some general info...

Fixed wing flights tends to be a lot longer than rotory wing flights. Both are used for transfers as well as primary calls. The fixed wing flights out this side go up into africa, it is arranged as a transfer but treated like a primary, whereby often the flight crew has to start from scrath. With these calls you can end up being with a patient for up 12 hours. The heli flights are more reserved for primary calls due to thier range. Thus with regards to care, it is physically draining (Add the jetlag and crossing different time zones to that). Some of the patients are green code, but the majority are fairly ill, so there is no time to read your book!!! Take into consideration that you will most likely be working in a more confined space than usual, for instance to do CPR in some of the aircrafts are impossable. The actual care given to the pt should more or less the same where O2 is still O2, and a ECG is still a ECG.

An important aspect that can cause physiological chages is that of pressure. Should you fly in a pressurised airctraft, as most the of the fixed wings are, they are minor. The helis are not pressurised, but then the altitude that they fly at, should not cause any havoc either. The problem comes in if you fly fixed wing in a non pressurised aircraft. Then you would have to start thinking about the FiO2 of just even the ambient air (Not only for the patient...), the temperature etc. Some people will for instance inflate the cuff of the ETT with H2O, as will not expand or decrease in volume or size, should there be pressure variations. Otherwise ensure to know your respiratory physiology and gas laws well and you should be able to get through.

I am not aware of any procedures that cannot be carried out in the air, barring equipment and space constraints. However it will always be useful to check with the pilot (prior) if he is happy with you using all the electrical equipment, i.e. the defib, cellphones etc. Such devices should be certified and signed off by the CAA to be used on that specific aircraft before it can be used. This is done by doinig scenario based test flights with the equipment on that aircraft, to check fr electrical interferance.

Flying today is generally a safe practise, but has some dangers that we don't have on the road such as you are 35000 ft above ground, and if something goes wrong, there is only one way: down. The tail external tail rotor is not your friend, it bite is leathal. It is a whole lot of fun to fly and should you not get sea sick, you'll enjoy it.

Hoping this info helped a bit.

 

[RWC130]

I live in Peekskill, NY (Westchester County) we use STAT Flight now called LifeNet for Serious Motor Vehicle Accidents with Pin or calls that
require TX to a Trauma Center but might take too long by ground.
It's the call of the EMT Crew Chief to make and if the PT is in bad shape
usually the Medivac is the way to go.

Lifeguard, which is the New York State Police chopper also is available
and has a Paramedic onboard.

If the PT is in Cardiac Arrest some Choppers will NOT take them.
Not a lot of room to do CPR in the Chopper.

Being a Paramedic or Nurse onboard a Chopper you will be busy.

I'd go for your EMT, Paramedic, and or RN. Make sure that you have
ACLS. You should check around your area. Some Medivac's do allow
ride a longs.

I hope this helps a little?

GOOD LUCK!

 

[VentMedic]

The opportunities for the Flight Nurse are numerous. However, it may take a minimum of 5 years in an ICU (preferred) with some ED experience as well as a BSN to get considered for a position.

There are many types of flight programs you could go for including HEMS, interfacility which can be hospital based or not, and international transport. You may also have the option of helicopter or fixed wing. Specialty teams have great options in that they do transport on many different modes and are very self sufficient.

Interfacility does not always equate to "boring" routine calls with "a special drip". Trauma patients can be a big part of their tranpsorts. Many regions do not have HEMS for scene response. The trauma pt is taken to a local hospital ED and a flight team with be called to transport. The hospital may be very good at stabilizing the patient and still may need your assistance in getting the patient flight ready. You will be the one with the special knowledge about what it takes to get a pt safely to another hospital.

ICU transfers can be anything but boring. You will be picking up very complex patients that can have a ventilator, LVAD, balloon pump, chest tubes and 5 or 6 drips all pertaining to BP as well as a couple of different sedation drips. This is where you ICU experience will allow you to manage (not just watch the meds drip) the various medications.

Depending on what type of Flight Team you choose, your partner could be another RN, RRT or EMT-P.

For much more information, check out Air & Surface Transport Nurse Association.
http://www.astna.org/

Some excellent teams:

University of Michigan "Survival Flight"
http://www.med.umich.edu/survival_flight/

Florida Hospital Flight 1
http://www.flhosp.org/services/floridaflight1/index.htm

Orlando Regional Medical Center "Air Care"
http://www.orlandoregional.org/Orla.../AirCareTeam/AirCareTeam.aspx?Pid=2496&Wid=20

Bayfront Medical Center "Bayflite" (one that likes to see degreed EMT-Ps )
http://www.bayflite.com/

Calstar - California
http://www.calstar.org/index.html

 

[fma08]

flight is a lot of fun. around here they can do more stuff than the ground crew like they can do chest tubes and RSI where as ground cant. They get some other treatment options as well like hypertonic solutions for head trauma and such. Flight pt's are typically a bit more critical. Tough to do CPR in a chopper as mentioned above. Def. something to look into whether its flight nurse or flight medic.

 

[mikie]

What about protocols? Who establishes the protocols for flight crews?

 

[akflightmedic]

The same type of person that does it for every other paramedic....the medical director.

 

[BossyCow]

The same type of person that does it for every other paramedic....the medical director.

Medical director of the receiving facility.

 

[LucidResq]

I know that the two flight services in my area, AirLife and Flight for Life, are both part of two different hospital companies that operate level one trauma centers. Their medical directors are employed by those hospital companies.

 

[Ridryder911]

I taught flight service Nurses and Paramedics for over three years.

Albeit, I loved it there is some MAJOR misconceptions about flight care.

First, it is a JOB. Yes, love the flight suits and kerosene, but it is really physically demanding and hate the bearer of bad news gets boring at times.

First, one is usually employed because of experience and education. The best as Vent described for nursing is experience in a ICU/CCU and ER. Neonatal/Pediatric experience is a plus, and having prehospital experience is a plus but some flight services do not require such. Flight Paramedics should have the minimum of at least five years in a progressive EMS, hopefully as CCEMT/P experience.

Most patient care is performed on the ground prior to lift off. Due to ambient noise, auscultation is neal to none, even communicating with one to another is usually performed with hand gestures. Sterile cockpit is a must and that means silence. Very little verbal communication with patients is available. As well almost all rotor and even fixed wing are cramped for space. If the back of your ground unit appears small, I can assure you the back of the bird is smaller.

If you are claustrophobic or have an slight hint of of motion sickness, don't even consider such. Remember that it is not like ground where you can pull in and get a soda or something to eat. HBO's at airports may have a restaurant or a vending machine. Stretching the legs (literally) is a highlight, since most have to sit with their legs crossed for the mission. Having a full bladder is not an option as well, remember there is not a place to pull over... and missions can range from a few minutes to a few hours.

Albeit, in EMS we glamorize air medicine, we are about the only ones that do. Some nurses consider it as a lower type nursing similar to a nursing home nurse. Although, again to be one, one has to be a great critical care nurse. Many nurses and medics try it and find out it is nothing similar to what they expected. Remember, that most patients are already intubated, IV's are in place, so most of the care performed by flight teams are supportive only!
I had to schedule clinicals for my staff, because the decrease number of IV's and intubations in the metro area. The reason for so much experience is when & if you do encounter such a patient, you must be able to perform exceptionally (the reason for experience). Most flight services perform innerfacility transfers (they pay) and usually make up most of the flights. If you do not like ICU transfers choose another path...

Now, most of the flight teams do NOT get paid any extra than ground teams. Some may get more pay, again due to the cert.'s and experience.

Safety is the key point of flight care. In actuality patient care comes second to safety. Looking and observing for towers, lines, other aircraft is performed continuously and again safety is first. Continuous watching with a glance looking at your patient to make sure everything is okay.

If you have a fear of dying, consider that at least one flight crew perishes once a month. Even a minor crash will usually leave you with a fractured back, ankles and some form of disability. Not to frighten anyone but this is the truth and continue to increase.

Again, I love flying and flight medicine. It is just so many have expectations that are never met, and unrealistic ideas about the profession.


p.s. most services work under the direction of their medical director not the receiving facility.

R/r 911

 

[LucidResq]

Thanks for the insight Rid.

I'm aware of the fact that paramedics have usually intubated and performed most if not all of the interventions that the patients needs by the time flights shows up, but I've heard that flight nurses do chest tubes on a pretty regular basis for trauma scene calls. True?

Also, I've noticed that the flight services around here have special teams for neonates and high-risk OB. Any idea how that works? I know that they have NNPs and specially-trained RNs, but are they on-call or available 24/7 at a facility waiting to be picked up for a call? Would they essentially be doing interfacility transports only? Is this something that other areas have?

I've also noticed that when the weather is bad the flight team may come by ground. How bad does the weather have to be to ground a helicopter?

Oh and also... what is the typical flight crew? I've heard of nurse/nurse, MD/nurse, nurse/medic, nurse/RT...

 

[MSDeltaFlt]

I'm interested in flight nursing.

I keep hearing mentions about the differences between caring for a pt. in a chopper or plane and caring for them on the ground, but no specifics.

So... anyone know exactly what changes? How is physiology affected, and how does that change the care given? What are some difficulties that arise? Are there procedures/treatments that can be given on the ground that should not be given in flight?

I know this may be a complicated topic so just a few examples would be ok.

OK, here's the deal from my perspective as a full time flight medic.

1. Pt care is pt care no matter where you go or what you do.

2. "Flying" does effect pts in different ways; not just in physiology, but also in point of view. With the several different stressors of flight going on at the same time: Boyle's Law, Charles' Law, Dalton's Law, G-forces, noise, vibration, dehydration, and the like are all effecting not just your pt, but also you and your partners as well. For every hour in the air, you will feel the effects of at least 2-3 hours on the ground. Hence why rest is so important.

3. You will also have little room or time to deal with critical pts, so you'll need to be very aggressive very quickly, especially on RW.

4. As far as procedures go, flight crews have more aggressive protocols and are expected to perform them appropriately. My med controls want me to have the point of view that the pt had better prove to me that they DIDN'T need something done or they will rip me a new one come chart review. Remember, the flight crew was called for a reason.

Hope this helps.

 

[Ridryder911]

Alike central lines, chest tubes have been under scrutiny lately. There is a place and time, in regards very FEW services actually allow flight nurses and flight Paramedics to perform such. It is still considered a "surgical procedure" with many risks. Chest decompression is usually allowed similar to ground units. My flight service allowed it in some states and not in other states.

True there are many different "specialty teams" many are also cross trained. No telling what type of mission might come in. Also, it is predicted one will see half the neonate/O.B. teams in the future. There is no study demonstrating the + affect of having a such team that requires a helicopter. Since most teams have a scene time of >1hr. Most of these teams are now being placed on ground transport. Most perform in a regular role or maybe rotated on the team, unless they have a high call volume. I know of many flight nurse/paramedics that have to function in the ER until a flight comes in.

As well, air transport is being very scrutinized for good reasons. Increasing air crashes, increased stress to fly under poor conditions and economical reasons. Especially in metro areas, there is very few justifiable reasons. I predict air services will be less than half within the next five years, after the next medicare and insurance review. Remember the normal flight starts out about $8,000 just for a few miles.

Helicopters costs in the millions, not thousands. Upkeep alone is very costly, after 40 hours routine must be performed, a 24/7 mechanic, pilots cannot fly >8hrs in duration, etc. Many hospital based services have gone to the past..because of the cost issue.

I believe in flight care, when warranted and justified. That means very few times and areas.

The gasses and physiological laws apply but does not usually affect rotor due to the low atmosphere they fly. This is different than fixed wing. One needs to complete formal air aviation training to understand such.

Vibration & noise is definitely a factor, and can be very wearing on the staff.

Again, not trying to point a bleak picture but truthful.

R/r 911

 

[Flight-LP]

Thanks for the insight Rid.

I'm aware of the fact that paramedics have usually intubated and performed most if not all of the interventions that the patients needs by the time flights shows up, but I've heard that flight nurses do chest tubes on a pretty regular basis for trauma scene calls. True?

Also, I've noticed that the flight services around here have special teams for neonates and high-risk OB. Any idea how that works? I know that they have NNPs and specially-trained RNs, but are they on-call or available 24/7 at a facility waiting to be picked up for a call? Would they essentially be doing interfacility transports only? Is this something that other areas have?

I've also noticed that when the weather is bad the flight team may come by ground. How bad does the weather have to be to ground a helicopter?

True, many flight crews can insert chest tubes. It doesn't have to be the nurse, it can be the medic (or RRT / MD, whoever is on the helicopter).

I think too many people focus on flight services for the wrong reason. The acuity level of the pt. really has little to do with an appropriate decision for air transport. Air crews were designed and implemented, both military and civilian, for one reason; SPEED. I hear sooooo many people talk about the cool stuff that air crews can do and I'll be honest with you, there is a very small difference in the level of care available between a local helicopter and my MICU unit. In fact, the last air medical company I worked for has a LESSER level of care available than my current MICU. You must be cautious when thinking along these lines as most larger companies have "across the board" protocols and are written to the lowest common denominator. So if your air service covers several states, you may have an agressive level of care in your state, but your air service may have protocols written to "less agressive" level for another state. Just a word of caution.................

As far as weather goes, each company has its own policies and the FAR's that dictate what the weather minimums are. An average would be...........

VFR Day Local 3 miles, 1000 feet
VFR Day Cross Country 3 miles, 2000 feet
VFR night 5 miles, 2000 feet

Again, each company sets their own in house policies................

 

[MSDeltaFlt]

"VFR Day Local 3 miles, 1000 feet
VFR Day Cross Country 3 miles, 2000 feet
VFR night 5 miles, 2000 feet"

VFR refers to Visual Flight Rules

The miles refers to the distance in visibility. The feet refers to the ceiling as in cloud cover if any.

Some services also have IFR capabilities or Instrument Flight Rules which lowers their minimums of ceiling and visibility.

 

[mikie]

Oh and also... what is the typical flight crew? I've heard of nurse/nurse, MD/nurse, nurse/medic, nurse/RT...

I know around here (St. Louis) they have a special bird just for neonates. The crew (I believe) is just the primary care providers of the baby.

If you want to read more,
http://www.archairmedical.com/Kid%20Copter%20offers%20care%20for%20the%20smallest%20patients.htm

 

[Summit]

Thanks for the insight Rid.

I'm aware of the fact that paramedics have usually intubated and performed most if not all of the interventions that the patients needs by the time flights shows up

Rid's the man.

Let me add a my little semi-local perspective as a non-flying type (although that would be neat some day). I've seen flight crews intubate patients frequently in both Rural EMS and SAR situations (usually it is an RSI) because there isn't always a medic on hand and ground responses can be as long as flight responses... but that would be a function of what area you serve I'd think. I've seen occasional scared rent-a-docs doing stints in rural "ED"s looking to the experienced flight crew that showed up for direction on treatment (I've also seen these docs occasionally ask the rural EMS medic to place the ET tube in an ED RSI because the MD hasn't tubed lately).

Oh and also... what is the typical flight crew? I've heard of nurse/nurse, MD/nurse, nurse/medic, nurse/RT...

As you know around here it is always RN & P... now they may both hold both certs (been told that its a good idea to have both so they can pick up more shifts)...

 

[AZFF/EMT]

we joke with the crews that they are fed-ex for humans. I would like to eventually get into flying rotor but now I enjoy being first on scene. At our station 1 we house an ALS truck, 2 ALS rescues and a Native Air flight crew and believe me we pick their brains a lot, a lot of very very smart people, bu they do work in a more controlled environment than we do in fire. My brother fly's part-time fixed wing and it can be very boring, like a flying ICU at times.

 

[Outbac1]

Here the flight crew is usually a critical care paramedic and flight nurse. The OB/Neonate specialty teams work at the childrens hosp. they get pulled out if there is a call. There is not enough demand to have them sitting around all the time waiting for a call.

Here its the pilots call as to fly or not. The pilot is not told the nature of the call just that there is one. Their decision to fly or not is then based on facts not emotion for what the mission is. Or so I'm told. Also our helicopter never flys with one pilot, always two. I believe they fly a Sikorsky 76. In talking to some of the pilots, to fly or not is weather dependent at both the pickup destination and final destination. The weather at alternate landing sites also has to be considered.

I have seen the flight crew come by ground for critical care transports if the weather is not fit to fly.

Maybe someday I'll feel I have enough experience to take my flight cert.