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WELCOME. Programme. “When they take care of you like that, you don’t mind fighting” - Wounded Army soldier on his evacuation by air. Air Evacuation of Casualties. Sqn Ldr AVK Raju Chief Medical Officer Indian Aviation Contingent – II MONUC [email protected] Plan.

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“When they take care of you like that, you don’t mind fighting”

- Wounded Army soldier on his evacuation by air


Air Evacuation of Casualties fighting”

SqnLdr AVK Raju

Chief Medical Officer

Indian Aviation Contingent – II

MONUC

[email protected]


Plan fighting”

  • History and evolution of air evacuation

  • Aim

  • Aeromedical issues

  • System specific clinical conditions

  • Practical problems

  • Handy tips

  • Prioritisation

  • Pre flight – In flight – Post flight considerations


History of air evacuation
History of air evacuation… fighting”

  • 1870: Aeromedical evacuation idea conceived

  • 1910: Siege of Paris: 160 soldiers evacuated in hot air balloon

  • 1928: Nicaragua, first US military airlift

  • 1929: Established air evacuation officially

  • 1937: International Aeromedical Association- 62 nations

  • 1936-39: Germans air evacuated soldiers

  • 1941: USAF in WW II

  • 1946: Helicopters used for medical air-evacuation


Death rate of wounded
Death rate of wounded fighting”

  • World War I – 8.5%

  • World War II – 4%

  • Korean War – 2%

  • Vietnam War – 1%

    [ Aeromedical evacuation/Antibiotics/Advances in Medical Science]


Air evacuation
Air Evacuation fighting”

Revolutionised mode of evacuation

  • Helicopters

    • Quick access to trauma sites

    • Land where there are no air strips

  • Fixed wing aircrafts

    • Spacious

    • Comfortable

    • Pressurised


Aim fighting”

  • Overcome adverse terrain

  • Enable early institution of definitive treatment

  • Avoidance of infection

  • Save skilled man power

  • Keep morale of personnel high

  • Keeps communication lines free

  • Economy

  • Safety

  • Comfort


Circumstances of casualty evacuation
Circumstances of Casualty Evacuation fighting”

  • Life saving measures

  • Forward areas to hospitals

  • In between hospitals

  • Errands of mercy


Disadvantage of aero medical evacuation
Disadvantage of Aero-medical evacuation… fighting”

…lack of controlled environment


Aeromedical issues in cas evac
Aeromedical Issues in Cas evac fighting”

  • Hypoxia

  • Expansion of gases

  • Acceleration

  • Vibration

  • Noise

  • Humidity

  • Physical requirements – space, toilets etc


Hypoxia
Hypoxia fighting”

  • Dalton’s Law of Partial Pressures

  • “Hypoxia at altitude”

  • All patients must be on supplemental Oxygen regardless of their clinical condition

  • CVS cases/Ischaemic cases – special precautions


Expansion of gases
Expansion of gases fighting”

  • Boyle’s Law

  • Expansion of gases trapped within the body

  • Special precautions – Pneumothorax, Penetrating head or eye injury, Bowel obstruction, Ruptured Tympanic Membrane


System specific clinical conditions
System Specific fighting”Clinical Conditions


Cardiovascular diseases
Cardiovascular Diseases fighting”

  • Supplemental Oxygen – “Must”

  • Lack of Oxygen – Cardiac catastrophe/Arrythmia

  • AMI – ideally no air evacuation for 06 weeks (?)

  • CPR board


Respiratory system
Respiratory System fighting”

  • Supplemental Oxygen

  • Obstructive Pulmonary Disease – thorough evaluation

  • Untreated Pneumothorax – air evacuation contraindicated in presence of respiratory embarrassment

  • Pulmonary Surgery – air evacuation after proper convalescence

  • Pneumonia – Supplemental Oxygen !


Blood disorders
Blood Disorders fighting”

  • Haemoglobin - < 7 gm%

  • Heamoglobin - < 8.5 gm% ‘or’ Sickle Cell Anaemia


Neurological conditions
Neurological Conditions fighting”

  • Increased intracranial pressure – supplemental Oxygen

  • Head Injury – Position of Head at towards the rear

Acceleration


Neurological conditions1
Neurological Conditions fighting”

  • CSF Leak through nose/ear – air evacuation contraindicated

    [Suction of air/bacteria during descent of aircraft]

  • Seizures – Hypoxia can trigger seizures


Orthopaedic cases
Orthopaedic cases fighting”

  • Sufficient time should have elapsed before air evacuation

  • Pressure changes – soft tissue oedema - ? Vascular compromise

  • Air splint – avoided !

  • Traction equipment – possible missiles !


Burns
Burns fighting”

  • Pulmonary burns to be ascertained before air transportation

  • Air evacuation of patient with pulmonary burns – fatal

  • Pre flight Chest X-ray – mandatory

  • Stabilisation of patient – patency of airway, adequate ventilation, Oxygenation and fluid resuscitation


Gastro intestinal cases
Gastro Intestinal Cases fighting”

  • Recent Adbominal Surgery cases – extra care

  • Gas in abdomen – expansion - ? Pain/Bowel circulation compromise/ ? rupture of sutures


Neuro psychiatry cases
Neuro Psychiatry Cases fighting”

  • Adequate observation prior to air transportation

  • Kept adequately sedated

  • Availability of restraint system


Pregnancy
Pregnancy fighting”

  • Active labour – only contraindication

  • High risk obstetric cases – safe

  • Placental insufficiency – supplemental Oxygen

  • Altitude restriction – 5000’ (abdominal gas distension)



Prior to any air evacuation
Prior to any air evacuation…. fighting”

Ponder over the following questions:

  • Is the risk to the patient being transferred less than the risk of not being moved?

  • Is the patient adequately stabilised?

  • Do the benefits of the move justify the clinical and fiscal costs?

  • Is the move medically necessary or driven by emotion or family based concern?

  • Is the move based on necessity or convenience?


Practical problems
Practical problems ! fighting”

  • BP monitoring/checking of pulse difficult

  • Auscultation is difficult

  • Difficult to establish IV line

  • Difficult to pass Naso Gastric tube, catheterise

  • Nearly impossible to Intubate

  • CPR is difficult

  • Motion Sickness – vertigo/vomiting - ? Airway compromise

  • Electro Medical equipment – may interfere with the flight instruments


Handy tips
Handy tips... fighting”

  • Electronic BP and HR monitor

  • 2 x wide bore IV canulas in place, syringes filled with drugs

  • If needed, Intubate with ET tube before the sortie

  • NG tube, catheterisation pre flight procedure

  • All catheters to be filled with Normal Saline

  • For Air Sickness: Tab of Cinnarizine – 30 min before air evacuation sortie & low flow Oxygen

  • Tab Pseudoephidrine/Vasoconstrictor Nasal Drops – prevents OtiticBarotrauma

  • CPR board

  • Humidified Oxygen


Relative contraindications
Relative contraindications fighting”

  • Infectious diseases

  • Moribund patient

  • Offensive patient

  • Decompression sickness


Priorities of evacuation
Priorities of evacuation fighting”

Priority 1. Patient whose transfer by quickest means is necessary as a life saving measureor to avoid serious permanent disability

Priority 2. Patient whose condition is likely to be adversely affected unless they are speedily evacuated or who need early specialized treatment

Priority 3. Patients whose immediate treatment are with in the powers of local medical units, but whose progress would benefit from movement by air rather than by surface transport

Priority 4. Patients for whom movement by air is a matter of convenience rather than a medical requirement


Preflight procedures
Preflight Procedures fighting”

‘Understand the case well’

Briefing of pilot & crew

1. Height limitations required

2. Intermediate stops

3. Precaution in transfer of special cases

4.The aircraft for use for Evacuation should be fitted with proper equipment.

5. Communication facilities with departure intermediate & destination air field

6. Captain of aircraft in charge of over all discipline


Inflight
Inflight fighting”

  • Fluid management

  • Oxygen/ IV line management

  • Medicines intake

  • Brief cabin/ aircrew for any changes from planned

  • Prevent exacerbation deterioration in clinical condition

  • Manage emergencies


Post flight
Post flight fighting”

  • Make a note of problems encountered

  • Brief the Hospital who are receiving the patient

  • Brief the Hospital who have demanded air evacuation

  • Share your experiences and suggestions on ‘Lotus’


Mi - 17 fighting”


IV Fluids fighting”

Resuscitation equipment

including

Oxygen Apparatus

Doctor’s Bag

Oxygen Mask

Physiological Monitor & Defibrillator

Spinal Board

Ortho Scoop stretcher + splints

Stretcher

Suction Apparatus

Urine/Vomitus/Stool Receptacles can be kept under the seats


Loading of patient fighting”

from the rear

Patient being monitored and being rendered medical treatment



To summarise special precautions
To fighting”summarise…. Special precautions

I. Condition susceptible to pressure change

1. CNS

Air in CNS due to surgery or trauma, CSF Rhinorrhoea

2. Eye- Perforating Injury

3. Ear

ASOM/ Mastoiditis/ Eustachian tube stenosis, Sinusitis

4. Respiratory System

Pneumothorax/ Mediastinal Emphysema/ Sucking Wounds/ Open case of TB


5. GIT fighting”

Hernias/ Gangrenous Appendicitis/ Penetrating Perforating Wounds/ Post Operative Cases/ Colostomies/ Liver Abscess

6. Skin

Gas Gangrene/ Subcutaneous Emphysema

7. Maxillofacial injuries

Till wires are removed

8. Decompression sickness


Cases requiring special attention
Cases requiring special attention fighting”

II.Condition susceptible to hypoxia

1. CNS

Head injury & epilepsy

2. Eye

Ocular injuries/ Post Surgical Cases/ Glaucomatous Eye

3. RS

Reduced vital capacity/ Pulmonary HT/Pul surgery

4. CVS

Angina/ MI/ HT/ CCF/ Cardiac arrhythmia

Require supplemental oxygen

5. Blood

Anemia less than 7 gm%


Remember
Remember...... fighting”

Murphy’s Law: “If anything has to go wrong, it will go wrong”

“If you are prepared for the worst..

the worst seldom happens;

If not prepared….

the worst is guaranteed to happen”


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