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Doctoring at 1,500 feet — during a pandemic

Greg Breining , special to AAMCNews
July 9, 2020

Helicopter teams do dangerous procedures in flight, rescue victims in rough terrain, and land in the middle of roads. That’s always intense and even more so during COVID-19. Here's what it's like to train in the high-flying world of air medical transport.

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A University of Wisconsin Med Flight helicopter team prepares to transport a patient with profound respiratory failure from COVID-19
A University of Wisconsin Med Flight helicopter team prepares to transport a patient with profound respiratory failure from COVID-19.
Credit: Michael Steuerwald, MD

A woman had rammed her car into a cement truck and firefighters were still prying her from its twisted frame when Amanda (Humphries) Ventura, MD, and a flight nurse set down on the side of the highway in a medical transport helicopter from the University of Cincinnati (UC) Medical Center.

When the firefighters finally freed the woman, Ventura, a fourth-year UC emergency medicine resident, intubated her and bundled her onto the helicopter. As the rotor throbbed and the helicopter lifted, Ventura watched in alarm as the woman’s heart rate and oxygen saturation started to fall. She and the nurse checked for a pulse and found none. Straining to communicate above the noise of the engine, they determined that the woman had gone into traumatic cardiac arrest — air trapped between lung membranes was squeezing her heart and preventing the return of blood. Ventura cut through the woman’s chest wall, reached in with her finger and pressed the lung, releasing the trapped air and restoring the woman’s pulse.

“We were actually able to get her back,” says Ventura. “She is doing really well now.”

Ventura is one of scores of emergency medicine residents at approximately 70 programs in the country who climb aboard helicopters to learn about caring for patients in the air.

You might land on the side of the road or right in the middle of the road if it’s the only place to land. Sometimes we’ll have to land in a mountain range or a farmer’s field.”

Scott McIntosh, MD, MPH 
A
ssociate medical director, University of Utah AirMed

Flying patients by helicopter started mostly during the wars in Korea and Vietnam, with civilian flights in the United States becoming more common in the 1970s. Today, most air medical transports involve flights between facilities, usually to bring a seriously ill or injured patient to an academic medical center for more complex care. The rest are “scene calls” to sites of emergencies such as car crashes.

“You might land on the side of the road or right in the middle of the road if it’s the only place to land,” says Scott McIntosh, MD, MPH, associate medical director and flight physician for the University of Utah AirMed. “Sometimes we’ll have to land in a mountain range or a farmer’s field.”

During the first months of the COVID-19 pandemic, medical transports generally decreased as people hunkered down in their homes. There has been “less traffic, less trauma, and also an interesting decrease in things like heart attacks and strokes, which I fear were still occurring but people were just petrified of seeking care in the hospital,” says William Hinckley, MD, air medical director at UC Health Air Care & Mobile Care. Hinckley estimates that flights dropped 40% nationwide during March and April. Now, he says the numbers are heading back up as people begin to venture out of their homes.

Residents in air transport training programs have widely different experiences. In most, they simply observe experienced air medicine providers to learn about “pre-hospital” medicinethe crucial time when a team works to stabilize patients and rush them to care.

“Pre-hospital care is a huge part of emergency medicine, because what happens before [patients] get to us is really critical,” says Nicole Thorndal, MD, a first-year resident at the University of Utah. “I’m not going into air medicine specifically. I’m just happy to have a better understanding of the amazing things our Air Med teams do.”

But in a smaller number of programs, emergency medicine residents get the kind of long-term, hands-on experience that allows them to take charge of a wide range of medical duties in the air. Some go on for additional training in air transport fellowships and then spend part or all of their work life aloft.

Trainees say participation in air transport rescues not only teaches them medical skills but also how to handle high-stress situations. For some, it’s transformative.

Ventura certainly found her calling in the rear of a helicopter. “I knew that I would be flying in the helicopter, and I thought it would be cool,” she says. “I didn’t know that it would become my life’s work.”

Getting airborne

There’s a good deal to learn before heading skyward. Typically, residents spend a day on the ground studying helicopter safety, starting with such basics as buckling up for flight and learning how to avoid the rotor blades.

These days, training also involves the use of appropriate personal protective equipment to avoid possible infection with COVID-19.

“It’s very, very hot working in a black Nomex flight suit covered by a fluid-impervious gown or body suit, mask, face shield, [and] flight helmet in the summer. Even though our aircraft do have air conditioning, heat exhaustion is a significant issue,” says Hinckley. “Thankfully, none of our [crew members] have tested positive or gotten sick to this point, knock on wood.”

Once on board, residents learn from paramedics and flight nurses, although occasionally a physician flies instead of a nurse. “Some of these flight nurses and paramedics, what they can do procedure-wise is really, really impressive,” says Thorndal. “The resources that they have out there are basically whatever they can fit onto the helicopter.” Onboard equipment generally includes such intensive care unit essentials as ventilators, monitors, and IV-medication pumps.

At the University of Utah, all emergency medicine residents — eight per year — ride during a one-month air medicine rotation that includes a two-hour course on topics like the physiological effects of flight on patients. Residents can do some basic procedures, such as starting a medication drip, under the supervision of the flight team, says McIntosh.

“In a big center like ours, [there are] are literally 10 to 12 people in the room to help out. But in the helicopter, it’s just me and a nurse.”

Jordan Imoehl, MD
Emergency medicine resident, University of Wisconsin

The University of Wisconsin (UW) is one of a few schools that train residents to become more robust helicopter team members. There, the 12 emergency medicine residents in each class year have the option to fly. Most do. And a few opt for additional training to become a flight’s full-fledged onboard physician. “We do that through a graduated responsibility model,” says Andrew Cathers, MD, associate medical director for UW Med Flight. “We run through cases and review things one-on-one to really make sure they’re at the appropriate level before we let them care for people on their own.” Of course, he explains, attending physicians are always available to assist by radio.

Jordan Imoehl, MD, had “essentially no interest” in air medical transport when he started his emergency medicine residency at UW, but he was so taken by it that he’s now started a one-year fellowship there, where he will spend half his time in the emergency department and half airborne.

Imoehl appreciates the intense training helicopter experiences have offered him. He recalls one recent case in which a rock climber had tumbled about 30 feet and landed on a steep wooded slope. First, a team of rappelers, park rangers, and others had to carefully maneuver the victim — who suffered severe head and pelvic injuries — to where Imoehl could stabilize him. Then he and the team had to carry the man by stretcher to an ambulance, which then ferried him to the helicopter for a fast ride to the hospital.

Imoehl highlights the need for resourcefulness when trying to save a life in mid-air.

“In a big center like ours at the University of Wisconsin — let’s say it’s a bad traffic accident — we have a trauma team, we have a pharmacist, we have two nurses, we have an IV technician. There are literally 10 to 12 people in the room to help out. But in the helicopter, it’s just me and a nurse.”

Mountain rescue

Sometimes, medical air transport involves rescuing hikers, climbers, and other outdoor adventurers who’ve been injured in dangerously remote or rugged regions.

Jason Williams, director of the University of New Mexico (UNM) International Mountain Medicine Center, reports a small uptick in mountain injuries in his region as people increased their outdoor recreational activities during the pandemic. “We typically get a lot of rescues on the weekends, and now we’re seeing more rescues during the week,” he says.

A resident trainee at the University of New Mexico International Mountain Medicine Center practices a helicopter hoist rescue maneuver
A resident trainee at the University of New Mexico International Mountain Medicine Center practices a helicopter hoist rescue maneuver.
Courtesy: University of New Mexico International Mountain Medicine Center

Each year, Williams helps prepare some 40 residents, paramedics, and others for complex, remote rescues in extreme environments. After roughly 200 hours of training, graduates earn a diploma in mountain medicine from the center, which is one of only three such programs in the United States.

Two of the program’s 18 days are devoted to air transport training. Students first attend ground school orientation, which includes lessons in setting up landing zones in rough terrain. “Then we load them all up into the helicopter and do some flight time,” says Williams. “That evolves into some medical scenarios.” The training includes how to hoist a patient aboard with a winch as well as “short-hauling” someone on a long rope beneath a helicopter to a nearby landing site.

Risa Garcia, MD, earned the diploma in mountain medicine as an emergency medicine resident and now is completing a wilderness medicine fellowship at UNM.

Along the way, she’s had some dramatic experiences. Once, she helped treat someone who was having trouble breathing at an ultramarathon in Texas’ Big Bend National Park. The patient ultimately was fine with simple treatment and didn’t need evacuation. Less lucky was a man who was struck by lightning while hiking on high ground in New Mexico. The strike blew the man’s shoes straight off, and he was confused and in some pain. The crew flew in, examined him on-site, bundled him aboard, and quickly transported him to the hospital, where he recuperated well. Garcia says such experiences “only whetted my appetite for more.”

Full-fledged flyers

The U.S. program with perhaps the most extensive focus on air medical transport is UC’s, where all emergency medicine residents fly.

During their first year, UC’s emergency medicine residents spend a significant amount of time observing. “After you get about two or three flights under your belt … the flight nurse and the senior flight doc may start bringing you into the clinical decision-making and any procedures that need to be done,” says Hinckley.

Residents who pass a series of tests at the end of year one are “ready to be a full-fledged flight team member,” says Hinckley. Then, they spend time over the next three years as the chief doctor on missions. “On average, our residents are graduating with 80 patient flight missions over the course of their residency.

Ventura, the UC resident who rescued the car wreck victim, has logged 131 flights. “I am very proud of that number,” she says. “It definitely represents some of my most profound and powerful patient encounters — some of the most hair-raising but definitely some of the most rewarding.”

Like several other residents, Ventura points out that stress comes not from the flight itself — “Flying does not bother me at all,” she says — but from the need for fast thinking and self-reliance. Now in her final year of residency, Ventura is a resident assistant medical director, helping to instill those skills in the 14 new residents who join the program each year.

Next up, Ventura has opted to enter a one-year emergency medicine fellowship at UNM. “There are multiple right ways of doing things,” she says. “I’m looking forward to seeing how they practice in a different aircraft and very different terrain.” One day, she hopes to get a job as a helicopter emergency medical services medical director.

Ventura says she’s been drawn to the field’s fast pace, diagnostic challenges, and opportunities to resuscitate deathly ill patients. But, she adds, “I think that what really got me hooked is I really enjoy and value that small-unit teamwork. It’s you and your nurse. Its [the two of you and] your own four hands doing everything that needs to be done,” she says. “That is satisfaction that I’ve been unable to replicate anywhere else in medicine.”

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