Peter V.R. Tilney

Blast lung injury in a 20-year-old man after a home explosion

A large family home exploded after a propane leak ignited. Initial reports from the scene noted that 11 people were injured, with many sustaining critical injuries. Immediately, multiple helicopter emergency medical services aircraft were dispatched to respond to the scene, and ground emergency medical services (EMS) providers were en route. Of the five aircraft requested, only two were available to respond; one aircraft was out for maintenance, and two others were committed to other missions.

Thoracic aortic dissection in a 38-year-old man.

A few days before Christmas, a flight team was activated for an interfacility transfer of a 38-year-old man with a history of hypertension and spinal stenosis diagnosed with a thoracic aortic dissection. The patient was presented to a local community hospital complaining of nearly 5 days of left-sided rib pain. This afternoon when he stood up from a chair, he experienced a near-syncopal episode. Concurrently, he had an abrupt onset of a tearing sensation in his chest that radiated to thoracic spine in the region between his shoulder blades. Ground emergency medical services (EMS) was called, and the patient was transported to the community hospital. During the initial transport and evaluation by the emergency department (ED) staff, the patient was noted to be hypertensive, with a systolic blood pressure greater than 180 mmHg. In the ED, the patient received aspirin, morphine, and Lopressor. He underwent a chest x-ray (Figure 1) and computed tomography (CT) scan and was diagnosed with a type B thoracic aorta dissection, which was noted to start on the descending thoracic aorta distal to the left subclavian artery and extend to the level of the celiac trunk (Figure 2). Despite the initial beta blockade, the patient was noted to be profoundly hypertensive, with initial blood pressure greater than 190 mmHg systolic. The flight team was activated for hemodynamic management and rapid transport to a facility capable of vascular and cardiothoracic surgery.

Cold Hearts :A Case Study of Therapeutic Hypothermia in Helicopter Emergency Medical Services (HEMS)

A 36-year-old white man hit a home run in the seventh inning of a community baseball game. The patient ran the bases successfully and returned to home plate. As he was bending over to pick up the bat, he suddenly collapsed. Bystander cardiopulmonary resuscitation (CPR) was immediately initiated, and defibrillation occurred within 5 minutes per the local emergency medical services (EMS) service. The automated external defibrillator (AED) shocked the patient a total of three times, and he was transported to a local hospital at the basic life support level. Helicopter emergency service (HEMS) was activated by local medical control, and LifeFlight of Maine responded to transfer this patient to a tertiary care center.

An 11-Year-Old Who Suffered Multiple Traumatic Injuries Secondary to a House Explosion

On a 40 degree late winter day, a house occupied by 5 children and 2 adults exploded secondary to a propane leak. The air medical helicopter was dispatched by ground emergency medical services to assist with patient transport to the appropriate trauma center. The initial dispatch information was for an injured child of 5 years of age requiring treatment and transfer. Upon arrival, the air medical team noted that the entire house was destroyed. The roof had collapsed with chunks of rubble that contained cement, wood, and drywall. Debris was found across the road and into the neighbors yard. Firefighters and ground emergency medical service personnel were sifting through the rubble looking for a child who was still reported missing. Medical providers on scene alerted the air medical critical care team that the missing child had been located and his injuries were extensive. As it turns out, the team arrived to find an 11-year-oldmale whowasmoaningwith obvious long bone fractures. The Advanced Trauma Life Support (ATLS) primary survey was initiated. The airway was evaluated. The patient had burns to his face with singed hair. The paramedic did a jaw thrust to open the airway. There was soot and pooled secretions in his mouth. Because of the patients inability to maintain his own airway, it was determined that rapid sequence induction for endotracheal intubation needed to be performed. Broselow Tape (eBroselow Products, Blacksburg, VA) was used, and the patient measured green (30-36 kg). The critical care crew elected to use ketamine 80 mg and rocuronium 40 mg. These medications were given intravenously per protocol. The paramedic used a video laryngoscope for intubation.

An 89-Year-Old Man Hanging in a Remote Location

I have been writing the case column series for a decade with more than 50 different case presentations. Each of these transports has had its own intricacies, medical challenges, and varying patient outcomes. From all of these cases, I have seen a variety of transport programs, medical personnel configurations, and indications for air medical transport. From reviewing cases around the country, I have discovered that the air medical transport industry uses many indications to determine if a patient is appropriate for transfer. Indications include the use of highly trained medical personnel (ie, neonatal transfers, extracorporeal membrane oxygenation, and intra-aortic balloon pump patients), the need for rapid transport (ie, patient’s with time-critical diagnoses including STsegment elevation myocardial infarction and cerebrovascular accidents requiring intervention), and the need to access remote regions. In some of these latter cases, the teams may even act as the primary responding units. With all of these indications for flight, teams are regularly called upon to have a diverse skill set in order to meet the need of an increasingly complex population of patients. The case below illustrates the diverse nature of care provided by crews in helicopter emergency medical services (EMS) and air medical transport in general. A local flight team had just completed a complex flight to a tertiary center for a patient with a hemorrhagic cerebral vascular accident when they were activated for an 89-year-old male patient reported to have hung himself. En route, the dispatcher noted that the team would be responding to an isolated community that had difficult access. Neighbors had apparently heard shouting several hours earlier

A 56-Year-Old Man With an Asthma Exacerbation

pH 6.96 PCO2 94 PO2 81 HCO3 22 A local flight team was activated for an interfacility transfer of a 56-year-old man with a history of asthma from a local community hospital to a tertiary care center for respiratory failure. The patient had a history of severe asthma in the past that had been not been well controlled. He had been admitted multiple times to this particular local hospital in the past and had required intubation on several of those occasions. On this particular date, he had been admitted with increased work of breathing and dyspnea that had progressed since the night before. He reported that during the last several days he had a cough and concurrent typical upper respiratory symptoms necessitating the use of his daily albuterol inhaler. Once in the hospital, staff noted that his respiratory condition worsened despite aggressive albuterol therapy, corticosteroids, and magnesium sulfate. Thus, an arterial blood gas test was completed, which immediately showed a severe respiratory and concomitant metabolic acidosis with a pH less than 7.0 (Table 1). Because of the imminent respiratory failure, the patient was subsequently intubated for increasing hypoxia as well as respiratory failure by the staff at the sending hospital before the flight teams arrival. He was intubated with standard doses of ketamine and succinylcholine, and sedation was continued with intravenous propofol. While the crew was en route to the scene, a variety of ventilation modalities were attempted without significant success. The patient remained tachypneic and hypoxic and had elevated plateau pressures that were greater than 30 mm Hg. In fact, the sending physician became so concerned about the patients acidosis that she initiated a sodium bicarbonate bolus and drip before the teams arrival. The

A 20-Year-Old-Male with Hemorrhagic Shock

Hemorrhagic shock from trauma is a leading cause of morbidity and mortality and commonly encountered by HEMS agencies. Understanding of the management of patients in hemorrhagic shock transported from the scene and interfacility transfers is important for all critical care providers.

A 47-Year-Old Man With a Spinal Cord Injury After a Parachute Jump

A 47-year-old man was participating in a parachute demonstration when he became tangled with another member of the demonstration team and suffered a free fall of approximately 20 to 25 feet. On the initial jump, the patients parachute deployed without incident. Unfortunately, however, the chute opened immediately before landing and tangled with another team member. The patient sustained a direct fall, landing feet first on a grass field. Subsequently, he then fell backwards. Ground emergency medical services were on-site for the event and immediately assessed the patient. He was unable to ambulate and complained of left foot pain and back pain. He was wearing a helmet and denied loss of consciousness. The patient initially had a blood pressure of 147/ 87, heart rate of 83, and an oxygen saturation of 98% on room air. Once assessed, the patient had a cervical collar placed, and he was secured to a backboard. He received several doses of fentanyl for pain. He remained hemodynamically stable without additional complaints and was taken to the closest level III trauma center for further evaluation without incident. On arrival, the provider assessed his critical systems, and they were not altered. However, during the neurologic examination, he was noted to be able to dorsiflex and plantarflex without compromise of his strength in the right lower extremity but was unable to raise his right leg off the bed. On the left lower extremity, the patient had a deformity to the ankle, and he had no movement to the left lower extremity. The left foot had no palpable dorsalis pedis or posterior tibial pulse, and the toes were dusky. His bilateral upper extremities were

A Traumatic Epidural Hematoma in a 15-Year-Old Male

A 15-year-old male was brought into the emergency department via an air medical helicopter. Hewas riding his bicyclewithout a helmet when he was struck by a motorcycle traveling at an unknown rate of speed. Witnesses reported that the patient was thrown from his bike. The distance he traveled was not quantified. He was ambulatory on scene for a brief period. Upon emergency medical service arrival, the patient became less responsive and was only responding to repeated painful stimuli. He continued to become more unresponsive and required assistance with ventilations via a bag mask. Upon flight crew arrival, he was subsequently intubated using rapid sequence induction using standard doses of succinylcholine, etomidate, and vecuronium per the teams out-of-hospital guideline. There were no complications. During the course of transport, he did not receive any additional analgesic or sedativemedications because he showed no purposeful movement or significant pain response. His initial vital signs upon flight crew arrival included blood pressure of 138/80, temperature of 94.4 F, heart rate of 54 beats per minute, respiratory rate of 16 breaths per minute, and SaO2 of 100%. The physical examination showed an unresponsive, intubated youngmale with a Glasgow Coma Scale (GCS) of 3T (verbal: 1, eye: 1, and motor: 1). He hadmultiple abrasions to both sides of the scalp as well as a large hematoma to the frontal and right parietal region without any significant external bleeding. There was no periorbital ecchymosis, battle signs, or hemotympanumnoted. There were no facial fractures or deformities appreciated. His pupils were 3 mm bilaterally and minimally reactive to light. The only other significant finding was that his pulses were

A 77-Year-Old Man With Large Vessel Acute Ischemic Stroke

Air Medical Journal 34:5 A 77-year-old man with a past medical history significant for hypertension, coronary artery disease on aspirin, congestive heart failure, a remote history of deep vein thrombosis formerly on warfarin (noncurrently), and an old right-sided ischemic stroke with residual tremor in his left lower extremity for which he takes levetiracitam presented to a rural emergency department after developing acute-onset left-sided hemiplegia. Local emergency medical services was called to the patient’s home after his family noted the deficits shortly after dinner. He was found sitting on the couch in the family living room after having shared an evening meal with the rest of his family. The paramedic noted complete left-sided hemiplegia, including left-sided facial droop and gaze deviation to the right, and marked dysarthria. During transport, the ground team reported stable vital signs and a blood glucose level of 158 mg/dL. Upon arrival to the emergency department, the patient was “last seen normal” 1 hour 15 minutes before. On examination, he was awake and alert but had 0/5 strength to his left upper and lower extremities, including significant left-sided facial droop. He had a rightward gaze deviation with dense left-sided neglect and significant dysarthria with aphasia. His National Institutes of Health Stroke Scale score was 18. He was rapidly taken for a noncontrasted head computed tomographic (CT) scan and a CT angiogram of the head and neck. The noncontrasted head CT scan showed a right-sided hyperdense area of ischemia noted to be a middle cerebral artery (MCA) sign (Fig. 1) suggestive of large proximal MCA thrombus with no evidence of acute hemorrhage. The CT angiogram showed a right-sided M1 distribution occlusion or cutoff (Fig. 2). Laboratory values were obtained, and an electrocardiogram showed new-onset atrial fibrillation. The regional stroke team was consulted using a telemedicine robot terminal with bidirectional cameras and speakers. The patient was deemed a candidate for thrombolytic therapy and was treated with an intravenous (IV) tissue plasminogen activator (tPA) bolus followed by a 1-hour infusion 1 hour 53 minutes from “last seen normal.” Rotor wing critical care transport was contacted to transport the patient to a neurointervention suite at the receiving facility. The patient spent a total of 1 hour 17 minutes in the emergency department before helicopter emergency medical services (HEMS) transport. On HEMS arrival, the patient was found to be hemo dynamically stable with a blood pressure of 143/66, a heart rate of 67, and an oxygen saturation of 96% on a 2-L nasal cannula. The patient was placed on the transport stretcher, transferred to the transport monitor, and tPA infusion was continued. The patient’s systolic blood pressure remained under 180 systolic, and no blood pressure management was required throughout the flight. The patient was taken directly to angiography, and care was transferred without incident. Upon arrival to the receiving facility, the patient had aspiration thrombectomy of the right M1 artery occlusion with reperfusion shown intraprocedure at 3 hours 58 minutes from the “last seen normal” time (Figs. 3 and 4). The patient initially had some improvement in his neurologic examination demonstrated by some movement in his left upper and lower extremity but went on to have a hospital course complicated by left-sided anterior cerebral artery ischemic stroke and a urinary tract infection. He was discharged to a skilled nursing facility on hospital day 13.