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Introduction: Caring for an infectious patient in the air medical environment presents a special challenge to all air crew members (ACMs) involved. The purpose of this study was to survey the infectious disease control practices of air medical programs (AMPs) that are members of the Association of Air Medical Services., Methods: A structured telephone survey was designed to gather data. Using one interviewer (an undergraduate student) with no knowledge of the study's goal minimized experimental bias. AMPs from 151 geographically selected areas were called between June and August 1996. Only the programs' chief flight nurses (CFNs) were targeted as respondents., Results: The response rate was 91% (138 of 151). Although no program refused to participate, 13 CFNs were unavailable to be interviewed. Mission profile was 32% scene and 68% interhospital with an annual average of 950 patient transports per program. Transport type was 61% rotor-wing aircraft, 17% fixed-wing, and 22% both. Flight physicals for ACMs were required by 57% of the AMPs. Pre-employment screenings for rubella, tuberculosis (TB), and varicella were noted. Interestingly, 17% of the AMPs reported pre-employment HIV testing. Immunization was mandated by 57% of AMPs, including hepatitis B virus, measles, rubella, and tetanus. Nine percent of the respondents refused to accept a transport with specific contagious conditions, primarily TB. A formal decontamination policy was in effect at 88% of the AMPs, and OSHA-approved filter masks were available at 70%. Pathogen exposure reporting was required by 97%., Conclusion: A current, comprehensive infection control program, continuing education, and 100% compliance with standard precautions will help reduce the possibility of accidental exposures. These strategies to reduce transmission also can be extended during training sessions to the prehospital and hospital personnel with whom the air medical program serves.

Introduction: The safety and efficacy of medications stored on air medical helicopters may be adversely affected by extreme temperatures. The purpose of this study was to determine whether temperatures inside an air medical helicopter drug box were within the U.S. Pharmacopeia recommendations for controlled room temperature. This is defined as a temperature between 15 degrees and 30 degrees C (59 degrees and 86 degrees F) with a mean kinetic temperature of less than 25 degrees C (77 degrees F). An additional goal was to determine whether time/temperature indicator labels can reliably monitor mean kinetic temperatures., Methods: Temperatures were monitored with miniature electronic temperature recorders and color-changing time/temperature indicator labels., Results: The mean kinetic temperatures for the summer and winter periods were 25.1 degrees C (77.2 degrees F) and 12.7 degrees C (54.8 degrees F), respectively. In the summer, the electronic recorders logged temperatures exceeding 25 degrees C (59 degrees F) 37% of the time and more than 30 degrees C (86 degrees F) 6% of the time. In the winter, temperatures less than 15 degrees C (59 degrees F) were recorded 83% of the time. The mean kinetic temperatures obtained from the electronic recorder and the time/temperature indicator labels differed by less than 0.7 degree C (1.3 degrees F). The results show that medications on an air medical helicopter are subject to temperatures out of the recommended range and that time/temperature indicator labels can reliably monitor mean kinetic temperatures.

Introduction: As health care evolves, air medical program (AMP) interhospital transfers will come under increasing scrutiny. The object of this study was to evaluate various components of the interhospital transfer policies of AMPs across the country., Methods: A structured telephone interview of the chief flight nurse (CFN) or administrator of 90 geographically selected AMPs was conducted by a college-educated research assistant using a scripted questionnaire., Results: Seventy-seven (86%) of the AMPs contacted agreed to answer the questionnaire. CFN or administrator unavailability was the reason for nonresponse. The mean number of flights performed per year was 1046: 29% scence and 71% interhospital missions. Mission profile ranged from fixed-wing (19), rotor-wing (45), and both (13). Forty-five percent of respondents require prior administrative approval and 31% require prior medical approval before accepting an interhospital mission. Financial approval or long distance transport was the most common reason for requiring approval. Ninety-four percent of programs transferred patients to facilities other than the AMPs' host hospital; two-thirds of these programs required medical (30%) or administrative (35%) authorization before accepting missions., Conclusion: This survey indicates that most AMPs use some form of screening mechanism for interhospital flight requests. With managed care requiring health care delivery systems to examine the use of resources, AMPs should continue to stay ahead of trends that affect the industry.

Introduction: Many helicopter emergency medical services can transport either one (singles) or two (doubles) patients. The purpose of this study was to investigate whether the additional patient in the doubles flight had an adverse impact on patient care because of the deceased provider-to-patient ratio., Setting: Patients were flown by a Level 1 trauma center-based helicopter emergency medical service staffed by a nurse and paramedic. METHOD. A retrospective record and trauma registry review comparing 124 randomly selected scene trauma singles frequency-matched to 100 doubles (1/89 through 6/92) was performed. Data collected included patient demographics, Injury Severity Score, Glasgow Coma Scale, Revised Trauma Score, mechanism of injury, scene time, and ground ALS and helicopter emergency medical services procedures performed., Results: Doubles accounted for 6.5% of all on-scene helicopter emergency medical service trauma patient transports. Paired comparison of Glasgow Coma Scale, Revised Trauma Score, and Injury Severity Score revealed that only one of the doubles patients had a field Glasgow Coma Scale as low, or a Injury Severity Score as high as the average singles. Revised trauma scores were equivalent. Although more procedures were performed during doubles missions, no procedures were performed in most singles missions (58%) and a substantial minority of doubles missions (41%). No differences were found between the groups in change in Glasgow Coma Scale during flight., Conclusion: Only of the two patients during doubles missions was as severely injured as the average patient in a singles transport. The decreased ratio of helicopter emergency medical service crew to patients in doubles missions does not jeopardize patient care because few procedures were performed during either singles or doubles missions.

Introduction: There is a paucity of data comparing injured pediatric patients transported by helicopter emergency medical services (HEMS) with patients transported by ground ambulance. The purpose of this study was to compare HEMS pediatric trauma patients to: 1) pediatric patients transported by ground to an urban level-1 trauma center (TC), and; 2) a similar cohort of adult patients. The managed-care consequences of these comparisons are highlighted., Methods: All trauma patients flown directly from the scene by HEMS from January 1, 1990, to April 30, 1993, were compared to a cohort of trauma patients arriving by ground advanced life support (ALS). All patients were transported to the same level-1 TC. The data collected included the mechanism of injury and the prehospital procedures performed, the injury severity score (ISS), and outcome., Results: There was no difference in the ISS between the HEMS (n = 216) and ground ALS (n = 355) pediatric patients (16.8 vs 17.1; p = 0.55). Adult HEMS patients (n = 202) had significantly higher ISS than did injured adults (n = 1652) transported by ground (18.0 vs 13.6; p < 0.0001). Overall, trauma patients transported by air directly from the scene have a higher ISS than patients transported by ground (17.5 vs 13.6; p < 0.001)., Conclusions: Pediatric patients transported by HEMS were as severely injured as those transported by ground, in contrast to adult patients. We conjecture that since trauma triage schemes classically focus on adults, ground personnel are more selective about which patients are flown to a TC, and less selective for pediatric patients. Trauma centers and HEMS programs should develop pediatric trauma triage protocols that do not overemphasize physiologic parameters.

Study Objective: To compare the effectiveness and incidence of adverse reactions with three treatment regimens for asthma in adults in the prehospital setting., Design: Prospective, randomized clinical study., Setting: Inner-city emergency medical service system providing basic and advanced life support and transport to 14 urban area hospital emergency departments., Participants: One hundred fifty-four adult asthmatic patients, 18 to 50 years old, who presented to paramedics with shortness of breath and wheezing., Results: Eligible patients were randomly assigned by the base station physician to one of three treatment groups: subcutaneous epinephrine, nebulized metaproterenol, or subcutaneous epinephrine and nebulized metaproterenol. Peak expiratory flow rate (PEFR), blood pressure, heart rate, and respiratory rate were measured before and after treatment in each patient. During a 9-month period (October 1992 through June 1993), 154 patients were enrolled in the study; 53 (34%) received epinephrine, 49 (32%) received metaproterenol, and 52 (34%) received both. There were no significant differences in patient demographics, initial vital signs, or pretreatment PEFR among the three groups. The mean difference between pretreatment and posttreatment PEFR was 73 L/min and did not significantly differ among the treatment groups. Significant changes in vital signs were seen in no treatment group., Conclusion: Nebulized metaproterenol is as effective as subcutaneous epinephrine in the prehospital treatment of adult patients with acute asthma. The combination of these two treatments offered no additional clinical benefit in the patients we studied.

Background: Health care costs continue to spiral; aggregate costs for 1992 are $850 billion, 13.6% of the U.S. gross national product. The issue has assumed national proportions, and change appears to be on the federal agenda. Great interest in surgical expenditures exists, which comprise 30.1% of all health care outlays., Methods: We analyzed 13,600 general surgical patients in eight teaching hospitals in New Jersey during 1988. Hospital resource consumption was measured for hospital length of stay, hospital cost per patient, race, gender, diagnoses and procedures, and mortality rate., Results: Surgical patients at these medical centers had a mean hospital cost per patient of $8,193, mean hospital length of stay of 12.4 days, an emergency admission rate of 40.4%, and a mortality rate of 6.0%. Emergency admissions had higher costs compared with nonemergencies ($11,717 vs $5,804, p < 0.001) and a poorer outcome (11.2% mortality rate vs 2.6%, p < 0.01). Patients who died had a higher hospital cost per patient compared with survivors ($29,314 vs $6,837, p < 0.001) and a higher emergency admission rate (74.7% vs 38.2%, p < 0.001)., Conclusions: Changes to the surgical delivery system will occur during the next decade. This study showed factors associated with higher hospital costs for surgical patients; changing reimbursement systems must recognize these characteristics for surgical patients in teaching hospitals. Factors associated with emergency admission and mortality, once identified, could be used to improve the health delivery system that affects surgical patients.

Severe hypothermia with cardiopulmonary arrest often requires prolonged resuscitation while rewarming procedures are implemented. A 63-year-old male in cardiopulmonary arrest with a core body temperature of 23.7 C was resuscitated successfully after core rewarming by means of a two-chest-tube continuous thoracostomy lavage procedure. This lavage procedure resulted in effective and rapid rewarming after other conventional rewarming methods had failed.