Humanitarian Aeromedical Retrieval using a Long-Range Commercial Aircraft: A Field Report

This field report presents the planning and execution of a large-scale aeromedical refugee retrieval operation amid the on-going Russia-Ukraine crisis. The retrieval was coordinated by the Italian Department of Civil Protection and led by the Centrale Remota Operazioni Soccorso Sanitario (CROSS), a governmental facility overseeing medical assistance. An Airbus A320 was chosen for its capacity of 165 passengers, with one emergency stretcher maintaining maximum seating. The aircraft was equipped with an Advanced Life Support kit, and specific considerations for medical equipment compliance were made. Special cases, including patients with on-going chemotherapy and end-stage kidney disease, underwent fit-to-fly screening. The boarding process in Lublin, Poland involved triage and arrangements for passengers with gastroenteric symptoms. Notably, 22 passengers with recent episodes of illness were isolated. The successful operation, demonstrating the viability of evacuating vulnerable individuals via commercial airlines, underscores the importance of precise planning and coordination in crisis situations.

The shock index predicts in-flight blood transfusion in aeromedical trauma patients

OBJECTIVE

To define the utility of the Triage Revised Trauma Score (TRTS), GCS/Age/arterial Pressure (GAP) score, and shock index (SI) in predicting the need for in-flight blood product administration in civilian trauma patients transported by an aeromedical platform.

METHODS

A retrospective chart review of 3582 aeromedical trauma cases was conducted. An initial TRTS, GAP score and SI were calculated for each patient, and the administration of in-flight blood products was also recorded. Receiver operating characteristic (ROC) curves were used to quantify the predictive discrimination of the TRTS, GAP score and SI on the need for in-flight blood product administration.

RESULTS

The SI showed a superior predictive value compared to the TRTS and GAP score. The SI showed an area under the curve on the ROC curve of 0.85 in both primary and inter-hospital transfer cases, indicating reasonable predictive value.

CONCLUSION

The SI demonstrates favourable test characteristics for predicting the need for in-flight blood product administration. Prospective validation of these results is warranted.

Ventilator-assisted preoxygenation in an aeromedical retrieval setting

OBJECTIVE

Ventilator-assisted preoxygenation (VAPOX) is a method of preoxygenation and apnoeic ventilation which has been tried in hospital setting. We aimed to describe VAPOX during intubation of critically unwell patients in aeromedical retrieval setting.

METHODS

Retrospective observational study of VAPOX performed at LifeFlight Retrieval Medicine (LRM) between January 2018 and December 2022 across Queensland, Australia. Demographic and clinical data were recorded. Descriptive statistics and paired Student's t-tests were used to evaluate the efficacy of VAPOX on oxygen saturation (SpO2 ).

RESULTS

VAPOX was used in 40 patients. Diagnoses included pneumonia (n = 11), COPD (n = 6) and neurological (n = 7). Patients were intubated in hospital (n = 36), in helicopter (n = 2) and ambulance (n = 2). Median VAPOX settings were: positive end-expiratory pressure 6 (IQR 5-9), pressure support 10 (IQR 10-14) and back up respiratory rate 14 (IQR 11-18). Twelve agitated patients underwent delayed sequence induction with ketamine. There was a statistically significant increase in SpO2 after application of VAPOX (P < 0.001), followed by a slight decrease after intubation (P = 0.006). Mean SpO2 were significantly improved after intubation compared with on arrival of LRM (P = 0.016). Hypotension was present prior to VAPOX (n = 13), during VAPOX (n = 2) and post-intubation (n = 15). Two patients had cardiac arrest. Three patients were started on VAPOX but subsequently failed. There were no significant oxygen depletion or aspiration events.

CONCLUSION

VAPOX can be considered for pre-intubation optimisation in the retrieval environment. The incidence of post-intubation critical hypoxia was low, and hypotension was high. Pre-intubation respiratory physiology can be optimised by delivering variable pressure supported minute ventilation, achieving a low incidence of critical hypoxia.

The Impact of Climate Change on Aeromedical Retrieval Services in Remote Northern Australia: Planning for a Hotter Future

It is known that environmental heat is associated with increased morbidity manifesting as increasing demand on acute care health services including pre-hospital transport and emergency departments. These services play a vital role in emergency care, and in rural and remote locations, where resource capacity is limited, aeromedical and other retrieval services are a vital part of healthcare delivery. There is no research examining how heat impacts remote retrieval service delivery. The Northern Territory (NT) of Australia is characterised by very remote communities with limited acute healthcare capacities and is a region subject to regular extreme tropical heat. In this study, we examine the relationship between aeromedical retrievals and hot weather for all NT retrievals between February 2018 and December 2019. A regression analysis was performed on the number of retrievals by clinical reason for retrieval matched to the temperature on the day of retrieval. There was a statistically significant exposure response relationship with increasing retrievals of obstetric emergencies in hotter weather in the humid climate zone and surgical retrievals in the arid zone. Retrieval services appeared to be at capacity at all times of the year. Given that there are no obstetric services in remote communities and that obstetric emergencies are a higher triage category than other emergencies (i.e., more urgent), such an increase will impede overall retrieval service delivery in hot weather. Increasing surgical retrievals in the arid zone may reflect an increase in soft tissue infections occurring in overcrowded houses in the hotter months of the year. Given that retrieval services are at capacity throughout the year, any increase in demand caused by increasing environmental heat will have broad implications for service delivery as the climate warms. Planning for a hotter future must include building resilient communities by optimising local healthcare capacity and addressing housing and other socioeconomic inequities that amplify heat-related illness.

'COVID on Country': an innovative model safely supporting high-risk patients in Central Australia

In January 2022, as the COVID pandemic reached remote communities in Central Australia, The Northern Territory Health Central Australian Regional Health Service and the Royal Flying Doctor Service (RFDS) executed 'COVID on Country', a program designed to triage cases and to implement treatment and clinical review of individuals in their community without the need to be relocated to larger centres for safe provision of care. The program assessed patient factors and community/capacity factors to triage and enact pathways. Remote living people who qualified for the program or who declined aeromedical retrieval, were provided with comprehensive clinical support, including administration of intravenous sotrovimab by daily scheduled visits to all affected communities by a doctor transported on an RFDS plane. Evaluation of the program demonstrated that it was a safe and effective way to provide complex care in a culturally safe manner.