Best of Med Flight

Landing Zone Preparation &

CommunicationsWhy is this so important?

Undesignated / Spontaneous LZs

• High risk –espc at night

• Obstacles on approach Wires Cell Towers

• Ground hazards – signs, poles debris

• LZ security – people vehicles

• How well was it scouted out –we are 100% dependent on your eyes

Alternate LZs.You don’t have to land the helicopter

exactly at the accident scene

That’s why God put wheels on the ambulance

Designated LZs

Communication

• MF dispatch 608-263-3258

• Your county 911 dispatch

• Cell contact on scene

Initial Info

• Location – street and cross street

• Relationship to city, well known landmark

• Contact agency

• Cell contact on scene

• Contact frequency – Typically Marc 2

• Incident type and basic patient info

• Do you need more than 1 helicopter?

Radio contact

• MARC 2

• 5-10 minutes out

• Use vehicle radios – handheld have limited range

• Our #1 interest – LZ information

• VERY brief patient update

What to do if no radio contact ?

Common LZ Problems

• Personnel “marking” the LZ

• Personnel approaching aircraft before blades stop turning

• LZ security once helicopter lands

• LZ has to be secured 5 minutes prior to landing until 2 minutes after takeoff

• No vehicle, regardless of height within 50 ft of aircraft. Especially ambulances

Brownout / Whiteout

Large Patients

Im not afraid of heights

Im afraid of widths

Meanwhile in Germany…

A Slippery Slope..

• Car 1 looses control on ice at highway speeds

• Collides with car 2. Both go over 30 degree embankment

• Car 1 slides sideways, impacts tree into drivers door

• Car 2 T-bones Car 1 into passenger side

• 2 occupants of car 2 self extricate –minor injuries

• EMS arrives – Extensive damage toCar 1. Driver is obviously pinned. Talking but confused

• Walmart parking lot 200 yrds from scene

• Med Flight called – Landed within 15 minutes

• Significant intrusion on both passenger and driver doors

• Pt alert, confused, slightly agitated. Pinned by legs

• Complaining of chest/abd pain

• Collar placed. IV established, O2

• Initial VS 150/80 100 18

Wisconsin EMS Rule 11a

If it is Saturday night and you respond to an accident scene after

10pm and do not find a drunk-

Keep looking because you are missing a patient

CAR 1

CAR 2

Initial Approach

• Car 2 winched up towards highway exposing passenger side of Car 1

• Plan is to remove passenger door and top

Additional support personnel beamed down

from the Enterprise

The concept of “Holding the C-Spine”

Passenger side is no go

• Now at 50 minutes post incident

• Outside temp 35 F

• Patient becoming more agitated-yelling

• BP dropping 100/70

• Lets hold things for a minute..

Medical Interventions

•Given Ketamine 50 mg IVP

•IO placed in L humeral head

•Concern re internal bleeding –TXA

•Started PRBCs

• Pt BP improves slightly

• Dissociated state –protecting airway

• T= 50 mins Tree cut away

• Top removed

• Pt starts to vomit and vomit and vomit

EMS rules regarding vomit

• The volume of vomit always exceeds the size of the container be a factor of 2

• Standard suction is useless for Saturday night puke ( consists of McNuggets & partially chewed burritos pressurized by a pitcher of Milwaukee's Best) –you need a shop vac

• Always point the pt at the person you like least

Tailoring the Extrication (speed/spinal

precautions) to the patients condition &

environmental issues

Situation a little more urgent

• Pt quickly put in a KED

• Lifted out – put on long board

• Transferred to ambulance

Why don’t you just put him in the helicopter

and go?

In the Ambulance

• Initial GCS 13 –now 7

• Pt intubated using Glidescope

• Given 2 units of PRBCs

• 10 minute flight

• To the trauma bay….

In The Emergency Dept

• BP 90-100 systolic

• Labs –hgb 8.5 Etoh 0.19

• FAST exam with ultrasound positive

• CT scan of head/neck – negative

• CT Scan of abd/pelvis – extensive splenic laceration

What is a FAST exam?Focused Assessment by Sonography for Trauma

Taken to the OR

• Uneventful splenectomy

• Transfused total of 4 units PRBCs

• Discharged to home POD 5

Case #3

16 y/o healthy female

• Alone in the lap pool at waterpark

• Found unresponsive in 4 ft of water

• Immediately picked up on security video

• Submerged 3-4 mins MAX

• Park EMTs pull her from water, no pulse

• 911 called

• Start CPR, AED applied, shock advised

• Immobilized, C-collar

We have a pulse

• Local paramedic service arrives

• VS 110/60 HR 120 irreg

• Bagged on 100% O2 sats 85%

• No evidence of trauma

• Frothy sputum, bilat rales

• GCS 6-7 Pupils 4-5mm reactive

• IVs x 2

Prior to MF

• Pt intubated, high airway pressures

• Freq suctioning,

• 12 lead –freq multifocal PVCs, no STEMI

• MF lands at hospital helipad as ambulance arrives

Handoff

• Vital signs and Neuro status unchanged

• Pt sedated, paralyzed put on ventilator

• What is the history again??

• Uneventful flight Home

• Handoff to ED

• Evaluated in ED – head CT NL

• CXR – pulmonary edema

• Most labs and studies c/w drowning

• Admitted to PICU

• Its just another tragic drowning..

Whats the history again?

• 16 y/o healthy 5’ 7”

• No etoh, drugs, trauma

• Lap pool is 4’ deep

• Call to the water park – Can you pull the security videos?

• What about the initial AED?

Torsades de Pointes

• Polymorphic Ventricular Tachycardia

• Caused by:

• Congenital mutation of cardiac electrical system

• Electrolyte abnormalities

• Drugs

Radically changes treatment

• Not just a drowning

• It’s a drowning caused by syncope caused by cardiac arrhythmia

• Drowning similar to geriatric falls- What caused it? Primary vs secondary

Secondary Drowning

• Trauma / CHI

• Seizure

• Drugs/ETOH

• Cardiac Syncope

• Hot Tub issues

ICU Course

• Aggressive pulmonary support

• No electrolyte abnormalities

• Neuro status improved quickly

• Extubated on day #4

• No neuro deficits

• Cardiology consult

Electrophysiology Studies - EPS

Found to be at high risk for malignant arrhythmiasNext Step

AICD – Automatic Internal Cardiac Defibrillator

Discharged to home

• No Meds

• Normal activities

• No restrictions

In closing, Just two words

Altruism

Awesome

This is the official “You Are Awesome” notification from the UW Emergency Care Conference staff

indicating how awesome you actually are

Fini . .

@FLTDOC1

ma2@medicine.wisc.edu