MEDICAL MANAGEMENT REVIEW

TRAINING MANAGERS IN AIR MEDICINE

The Chinese prospect at the stage of receding pandemic                                                                                      ⚕️

© Petro Rybalchenko 

 



MEMBER OF UKRAINIAN ASSOCIATION OF SINOLOGISTS

FOUNDER OF ASIA-COACH ACADEMY

MBA (MEDICINE)

 

Email for cooperation proposals:

medicine@asia-coach.academy

 

 

The material below can be used for personal & corporate purposes to implement any of the best ideas and practices indicated in this article.

 

INTRODUCTION

 

Both safety of emergency transportation and quality of dispatching control are the core of aviation medicine development and the light of risk management and protocol processing for the global healthcare providers.

One of the key world positions of the use of aircraft for medical purposes is that training specialists in different positions for medical and rescue aviation should have a systemic nature and include many issues related to organizational and medical aspects, navigation, use of radio equipment on board. In economically developed countries, all of which the partners of Ukraine, such as the United States, United Kingdom, Germany, Canada, Italy, Switzerland are quite developed by the system of organizing medical care for patients and victims using helicopters.

Attracting helicopter aviation allows you to quickly deliver medical staff to the crash site, to provide medical care at the scene and when evacuating the wounded, reduce the time of their transportation to specialized hospitals, which will reduce the mortality rate of victims.

In the UK since the beginning of the 80s, the helicopter service system is developing (Helicopter Emergency Medical Services - HEMS) to provides emergency help for victims of accidents in major cities. 

Currently, in almost all administrative centers, the UK has a helicopter service units that use one, less often two helicopters for completing the tasks. According to the recommendations of the British Emergency Association (British Association for Immediate Care), the Helicopter Brigade consists of 1-2 pilots, paramedical brigade and medical equipment. The helicopter is equipped with modern medical equipment, ensures the evacuation of victims from the scene and the provision of medical care during transportation.

Training of paramedics on the provision of emergency rescue forces is carried out in educational and medical institutions according to programs corresponding to European and British standards of medical care.

Another example can be a National Road Safety Improvement Program ("Programm fur mehr Sicherheit im Strassenverkehr") was adopted by the government of Germany in 2001. Within the framework of this program, special attention is paid to the development and providing emergency services and first aid services to persons, victims of an accident.  Helicopter services are an integral part of the services provision of emergency help.  The helicopters have standard equipment and a set of medicines.

In flight, the following can be carried out: emergency monitoring, infusion of plasma substitutes, mechanical ventilation, introduction of antidotes, oxygen therapy, etc. During transportation of a seriously ill patient the team maintains constant radio communication with the medical institution, in which the victim is evacuated, where the doctors on duty prepare in advance for his reception.

Typically, a helicopter crew consists of a pilot, a doctor and a paramedic.

The practice of evacuation victims is dominated by patients with acute coronary pathology, acute cerebrovascular accident, injured in a road traffic accident, patients with burns and poisoning.

With regard to the organization of aircraft departures, some centers organize care for patients with a distance of more than 150 km from the cities or regional centers.  This is necessary in order to meet the therapeutic window when providing care to patients with acute coronary syndrome and acute cerebrovascular accident, as well as taking into account the rule of the "golden hour" i.e.  the period of time after injury and medical help, when the latter is most effective. We can say that in an extreme situation, not only professionalism saves, but also time.  At a distance of up to 150 km.

In the mode of daily activities in the hospital period, the main the tasks of the paramedic manager are the delivery of a specialized medical specialist-consultant (doctor of a licensed medical institution) to a patient, organization and conduct of the need for interhospital sanitary and aviation evacuation.  Preliminary manager assists in clarification of the patient's condition, organizes his preparation for interhospital air ambulance evacuation, controls the collection medical styling and portable medical equipment training, accompanying documentation.  In the process of organizing and conducting medical and aviation evacuation manager needs to know the principles of interaction with the personnel of the airport medical centers, service security, border and customs services of airports, especially if we are talking about multi-stage and international evacuations.

Interaction is carried out on the following issues: coordination with the staff of the airport medical center for admitting the patient on board aircraft;  obtaining a permit for operation on board an air medical equipment vessel, medical oxygen;  organization on on board an aircraft operating a regular flight,  agreement on the list of medicines allowed for transportation on board the aircraft, including narcotic, potent and psychotropic drugs, especially on international flights;  questions compliance with the visa regime, including by the patient and accompanying relatives, etc.

To carry out his duties, the manager must know regulatory legal acts of his country in the field of healthcare in the part concerning the provision of emergency medical care in an emergency form, emergency specialized medical care, legislative basis for medical evacuation of sick and injured persons, including children.  There is a number of specialized knowledge that a manager of aviation medicine must have: general medical and airborne devices, transport for air ambulance evacuation, features of safety precautions when working on aircraft, rules for communicating with dispatcher and team members using special means of communication, questions of the physiology of the body during flight, the influence of altitude factors on the patient's health condition, rules for using medical equipment on board aircraft and a number of other special knowledge.

Regarding the requirements for the qualifications of a manager, we share some expert opinions, confirmed by statistically significant indicators of the fact that these can be specialists with higher professional education in the specialties "General Medicine", additional professionals with education or professional retraining in specialties like "Ambulance".

At the same time, it is necessary to have work experience in the main specialty at least 3-5 years, which was confirmed by experts.
 

 

1. COMPETENCIES & TRAINING

The training of an aviation medicine manager differs significantly from the targeted training of similar process operational work coordinators in all other markets that have ever existed until now, because

- he cannot read the course of a young fighter in two weeks to get the required result;

- he cannot predict the chain of emergency work algorithms carried out by him for more than 1 minute;

- he is always responsible for the lives of other people with a high risk that something might go wrong;

- he cannot receive his certificate and sleep peacefully resting on his laurels (perhaps the next and next night he will not fall asleep at all);

- he has no time to think about a fixed salary rate and bonuses to it (and he shouldn't, because he must be fully provided with everything for a year in advance!), because he has a completely different task: to save the life and save it to all employees of his team, while strictly observing both the internal regulations and the protocol of aviation medical security);

- if needed to take part in a premature birth, he must also do it with a joyful, balanced smile perfectly well;

- sometimes it is not quite where it is warm and dry, and maybe it also smokes or burns, pours water cats and dogs or is simply too high to think.

This list could be continued further, but that probably says it all, because he is the manager of aviation medicine.

 

 In general, who is this?

This is one and many at the same time: "a combat unit and a holy trinity."  This is the support of the nurse, and the inspired tone of the doctor, this is a gin from the bottle in front of the patient, whose task is to fulfill only three obligatory wishes of the patient: "I want to live, I want to get up, I want to love!"  The other details for now are not specified.

 

 How to learn this and whom to marry for such?

Only in vocation, solid long-term preparation approved by the commission and in a tenfold volume of high-speed random access memory.

 What for?

Because doctors and nurses with a pilot in an embrace are not enough, so someone else is needed to replace them all at the same time with a light sense of humor.

Now in the theses on the content of the updated training of such a manager.  In addition to the ability to know everything, something else is needed: this is a never-closing transcripts record.  It will consist of some basic disciplines and competencies.

In the commonly recognized world practice the key disciplines for formal study & certification of managers of aviation medicine include:

Aviation Physiology, Human Performance, Airport and Travel Health, Clinical Aviation Medicine, Principles of Occupational Medicine, Clinical Occupational Medicine, Medical Logistics in Aeromedical Transport, Operational Aspects of Aeromedical Transport, Aeromedical Studies for Paramedics, Clinical Analysis in Aeromedical Retrieval and Transport, Clinical Care, Organisation of Aeromedical Systems, Managing Occupational Medicine, Health and Industry, International Assistance Operations, Basic aeronautical knowledge, Cardiovascular system, Respiratory system, Digestive system, Metabolic and endocrine systems, Haematology, Genitourinary system, Obstetrics and gynaecology, Musculoskeletal system, Psychiatry, Psychology, Neurology, Visual system and colour vision, Incidents and accidents escape and survival, Medication and flying, Legislation, rules and regulations, Cabin crew working environment, In-flight environment, Space medicine, Practical flying, Human factors in aviation, Incidents and accidents, escape and survival, Tropical medicine, Practical simulator training, Rescue and emergency training.

 

Practical training in

Cardiovascular conditions, Metabolic and endocrine conditions, Respiratory conditions, Ophthalmological conditions, Otorhinolaryngology conditions, Orthopaedic conditions, Neurological and Psychiatric conditions, medical assessment of aviation personnel, risk management of aviation personnel with complex medical conditions for certification, developing clinical protocols for a specific medical condition.

 

Among key competencies managers need to pay a very special attention to:

1. Competency in conducting training for aviation personnel ( Altitude Physiology, High G performance/ Sustained Acceleration, Vibration, Noise and Communication, Spatial Orientation in Flight, Visual Sciences, Crash Dynamics);

2. Competency in conducting practical training for aviation personnel in: (High Altitude Physiology, Night Vision Physiology, Spatial Orientation, High G Performance / Sustained Acceleration, Ejection Dynamics);

3. Competency in prescribing Aviation Physiology Rehabilitation/Treatment methods for ( Aviation personnel with poor G performance of physical conditioning and high G acclimatisation, Aviation personnel with motion sickness, Aviation personnel with barotrauma);

4. Competency in aircraft accident or incident investigation or analysis;

5. Competency in prescribing preventive medicine measures for travel or deployment;

6. Competency in conducting fitness to fly assessment for patients requiring aeromedical transfer;

7. Competency in conducting aeromedical transfer of patients;

8. Possess understanding in the task of flying and the flying environment through first-hand control of aircraft.

 

Supplementary training can be also added in:

1. Languages of international communication (as many as possible) + regional language & medical / aviation English

2. Features and Types of Modern Medical Aircrafts

3. Psychology of operations in extremal environment

4. Rescue decision making

5. Conflictology

6. Physical Training

7. Operating in quarantine conditions

8. Medical ethics

9. Principles of working in aviation medicine brigades.

10. On ground and in air first aid protocols

What should follow for the manager after this training and accreditation? Of course Employment! So let's see how it works on practice.
 

 

1. CHINESE EXPERIENCE

Roads are getting more and more congested, people’s economic conditions are getting better and better, rescue helicopters have gradually begun to be used for the transfer of critically ill patients between hospitals.

Emergency centers and hospitals in Shanghai and Wuhan ensure the cooperation between the aviation team and the air rescue company has established an "120 air central" platform. Xijing Hospital Affiliated to the Fourth Military Medical University established a professional aviation medical rescue team named Xijing Emergency Flight Doctors.

The development of aviation first aid in China is thriving.  At the beginning of the 21st century, with the improvement of China's economic level and the acceleration of hospital construction, many large hospitals have built helipads/platforms proactively.

In December 2008, Wuhan Emergency Center and Wuhan Helicopter General Aviation Air Co., Ltd. signed an agreement to implement scheduling through "120", to carry out medical emergency services.  Second Affiliated Hospital of Zhejiang University School of Medicine as the roof apron was built in 2005 and transferred in 2009 for myocardial infarction patients from Zhoushan. This is the first time Zhejiang 120" to transfer patients.

However, due to the tens of thousands of transshipment costs and routes of air rescue for control reasons, it was not used again in the following ten years, which made aviation Air rescue more of a news effect under the media spotlight.

 

 Main operating model

From improving efficiency, combining peacetime and wartime, constructing land, sea and air three-dimensional rescue network to enhance the comprehensive emergency rescue capabilities of emergency rescue and disaster relief and to meet different needs/needs and other aspects. In China gradually develops professional or quasi-professional aviation medical rescue.

It must be so.  But from the current profit model of aviation medical assistance, although the air medical rescue market is large, the high cost is personally unacceptable, far from reaching the level of universal use.  There is an urgent need to build a set of aviation medical rescue models that conform to national conditions, the insurance company and the individual share the corresponding expenses.

At present, most of the aircraft used for aviation medical rescue in China for a customer, such as the former Asian emergency companies, European emergency companies and other Major customers.  Because foreign companies’ insurance awareness is relatively strong, they thought they were covered by air medical rescue for their employees in China.

These customers account for 90% of the current air medical rescue market.

Therefore, we can learn from two foreign models.  One is to cooperate with insurance companies in order to incorporate air medical care into commercial insurance, the cost will be paid by the insurance company; the second is to use the membership fee method.  If you pay a certain amount of membership fee each year, you can enjoy the corresponding rescue service for free.

 

 Complementation of Rotary Wing and Fixed Wing Rescue Aircraft 

The "Thirteenth Five-Year Plan for National Emergency Response System Construction" proposes to build a three-dimensional land, sea and air emergency medical rescue network that is integrated with specialist teachers; strengthen long-range aviation delivery capabilities; strengthening the construction of aviation medical rescue and transshipment capabilities; support and encourage general aviation companies to increase helicopters, fixed-wing aircraft, unmanned aerial vehicles and other related professional equipment with emergency rescue capabilities to play their role in the fields of emergency rescue and medical rescue.  Although helicopters have various advantages in emergency rescue, they are still subject to certain restrictions in terms of flight speed, range, endurance, and use area.  Due to space and load limitations, the early helicopters were equipped with only a small amount of medical equipment except for stretchers, and generally did not carry out more complex ambulances on the way, and could only transport critically ill patients with relatively stable conditions; but with more advanced monitoring helicopters  Entering the aviation emergency system can provide on-site emergency and helicopter evacuation with comprehensive medical care like in-hospital ICU wards, and maintain the vital signs of the critically ill.

China's first aviation medical rescue fixed-wing aircraft has joined the 999 emergency center. The aircraft is equipped with a full set of world advanced medical equipment: ECMO extracorporeal membrane lung, monitor/defibrillation integrated machine, ventilator, oxygen supply system, vacuum stretcher, wireless WIFI  digital image transmission systems, etc., can be described as small ICUs in the air.  Prior to this, the 999 Emergency Center had launched special rescue and ambulance aircraft, which were mainly used for transfers between cities when the condition was critical. They used ordinary fixed-wing aircraft (business jets) with a minimum cost of up to 100,000 yuan.

 

 Development trend of aviation first aid

Take the Chiba Kita General Hospital of Japan Medical University as an example. The hospital has three helipads. There are aircraft maintenance equipment on the sides of the apron, and conditions for maintenance are provided. The apron has a specially marked passage to the emergency department of the hospital.  This is related to the remote areas in Japan where it is not convenient to open medical institutions, or the areas where the current hospital scale has been reduced due to the outflow of population and the areas where the emergency department has been abolished have a high degree of dependence on aviation medicine.  With the deepening of the reform of Chinese medical institutions, tertiary hospitals are becoming a trend to cancel general outpatient clinics, and the construction of various medical consortia has entered a phase of materialization. As a result, the rapid and safe transfer of critically ill patients has become an urgent problem. The construction of the aviation medical rescue system once again ushered in the golden period of development.  On August 14, 2016, 13 well-known large hospitals across the country joined hands with Fei Medical Co., Ltd. to establish the "China Air Emergency Hospital Alliance" in Hangzhou. There are currently 68 member units nationwide.  By integrating the high-quality medical resources of the regional medical centers and the aviation emergency resources of CAMC, with the goal of better serving the critically ill patients of the local alliance hospitals, a feasible path has been explored for Chinese aviation emergency.

Air rescue networking

The establishment of a regional aviation medical rescue system involves military and civil aviation, health, civil affairs, development and reform, land and provincial and municipal people's governments and other departments. It is necessary to establish a regional linkage mechanism and a military and civil aviation coordination mechanism, clarify work responsibilities and procedures, and form work together to coordinate the layout of the three-level aviation medical rescue network nodes in the region and promote the establishment of the network.  In 2017, Beijing began to build the Capital Red Cross aviation medical rescue system, Shanghai was building the Yangtze River Delta regional aviation rescue complex, Henan was building a 24-hour normalized aviation medical rescue ambulance; Hunan was building a golden one-hour rescue network.  Hubei is achieving full coverage of medical helicopter take-offs and landings in all cities in the province; at the end of December 2017, the Second Affiliated Hospital of Guangxi Medical University, as the first helicopter rescue base hospital in the autonomous region, worked together with hospitals in the region to build an air emergency network in Guangxi.  Since August 2016, the Second Affiliated Hospital of Zhejiang University School of Medicine has cooperated with Zhongfei Medical Co., Ltd. to build a “one hour” air emergency network in Zhejiang Province.  AVIC Medical is responsible for providing helicopter rescue services, and the Second Zhejiang Medical Hospital is responsible for medical security services. The two parties will jointly develop the network layout of Zhejiang Air Emergency Hospital, the construction of helipad facilities of the network hospital, the training of flying doctors, flying nurses, and the construction of normalized rescue flight mechanisms.  , Air-ground seamless connection mechanism, etc., to build the first domestic "one-hour" air emergency network in Zhejiang Province, making Zhejiang the only province in the country with normalized helicopter medical rescue capabilities, including the number of flights, coverage.  The difficulty of rescue ranks first in the country.  As in April 2018, the air emergency hospital network has implemented a total of 84 helicopter air ambulances, including 23 cases of charity rescue flights.  Including the country's first helicopter-civil aviation seamless docking of long-distance organ transfer across provinces; the world's first synchronized transmission of medical data for patients on air and ground was completed.  The establishment of the "one-hour" air emergency network in Zhejiang Province will greatly improve the health emergency rescue capabilities of Zhejiang Province, further optimize the distribution of medical resources in Zhejiang Province, and improve the comprehensive treatment capabilities of emergency and critical patients in Zhejiang Province and the people's quality medical services.  Play an important role in terms of accessibility.

 

2.2  Convenient air rescue

The "Several Opinions of the State Council on Promoting the Development of the Civil Aviation Industry" issued in 2012 (Guo Fa [2012] No. 24) clearly stated that the active development of emerging general aviation services such as medical assistance was issued in May 2016.  The "Guiding Opinions on Development" once again proposes to "encourage and strengthen the application of general aviation in disaster relief, medical rescue and other fields."  At the beginning of 2016, the National Health and Family Planning Commission put forward the work requirement of "starting the construction of a three-dimensional emergency medical rescue network for land, sea and air", and officially launched the preparation of the "13th Five-Year Plan for Emergency Medical Rescue".  Taking the Winter Olympics guarantee as an opportunity, the North China Bureau of Civil Aviation is also actively promoting the coordinated development of aviation medical rescue in the Beijing-Tianjin-Hebei region.  In addition, the Ministry of Civil Affairs is also actively promoting the construction of a national aviation emergency rescue network.  Convenient policies provide the foundation and guarantee for the convenience of air rescue.  With the progress of air rescue work, the process of various transfer connections has become more and more convenient. Ruijin Hospital can achieve from the hospital apron to the ward in only 16 seconds. For first aid, time is life, which is also the meaning of air rescue. But to continuously shorten the transit time, behind it is the standardization and optimization of the process.

The focus of developing aviation first aid in China

The systematic construction of aviation rescue is the concrete implementation of rescue network, and it is also a necessary measure to ensure the effectiveness of aviation rescue and patient safety. The systematic construction of aviation rescue should start from the whole process of aviation rescue.  Improve the rescue process from every detail.  Systematic construction should establish an aviation medical rescue command and management system that combines local characteristics and needs, and establish an aviation medical rescue system integrating on-site first aid-air rescue (air ICU)-base hospital treatment for the wounded and the sick, so as to achieve seamless all links convergence.  But even in hospitals such as Tiantan Hospital and Anzhen Hospital that receive more critical patients, helicopters are often parked on the road or nearby sports fields; there are also hospitals’ aprons to the nearest medical building, which are more than 300 meters away, and all mixed routes and hospital roads are all manifestations of the lack of systematic construction of aviation first aid.

Standardized construction of aviation rescue

The standardized base hospitals headed by Shanghai Ruijin Hospital have customized a set of replicable and extendable models in various aspects such as aviation medical emergency equipment and ward equipment, medical rescue teams, and the connection process between inside and outside the hospital.

At present, the standardization of Shanghai's base hospitals has begun to take shape. Ruijin Hospital is not only equipped with professional rescue equipment, but also formed a professional air rescue team, formulated transshipment standards, and a complete set of transshipment mechanisms.  However, building a complete, standardized, and standardized aviation medical emergency rescue system and management mechanism, as well as training professional aviation medical rescue teams will be the focus of the next step, and it will also be a long accumulation process.

Professional construction of air rescue personnel

Helicopter space is limited, and there are also ECG monitors; the cabin is equipped with emergency facilities such as cardiopulmonary resuscitation equipment, trauma kits, respirators, etc., and personnel involved in air rescue should receive professional training to master various skills for rescue in the air.  Ruijin Hospital of Shanghai Ruijin Hospital has established a 30-person air emergency rescue team, which usually works in departments such as surgery, emergency, burns, intensive care, and extracardiac care. Once there is an air rescue mission, it will be called up to perform air rescue missions. Since May 2016, Ruijin Hospital has cooperated with the Shanghai Emergency Office, the emergency center, the police team of the Public Security Bureau and other units to conduct actual flight exercises on this air emergency rescue team every 1 to 2 months.

The Second Affiliated Hospital of Zhejiang University School of Medicine has established an air emergency medical team with first-class professional quality, excellent physical quality, and stable psychological quality. It is composed of 6 doctors and 6 nurses from the emergency center;  The first flight medical personnel training conference of the Air Emergency Hospital Alliance and the Zhejiang Helicopter Medical Rescue Normalization Work Conference" started the training of flight medical personnel; so far, two training sessions have been held and more than 100 flight medical personnel have been professionally trained.

All training is to enable professionals to master the necessary air first aid skills. Only through actual combat exercises can problems be found, and the standardization process of aviation medical rescue is improved, so that the aviation medical rescue mission is no longer a new thing, making it a part of the hospital's routine rescue work. 

The Civil Aviation Medical Center (Civil Aviation General Hospital) was established in 1982 and reintegrated into the Civil Aviation Medical Center in 2010. It includes the Civil Aviation General Hospital, the Civil Aviation Medical Research Institute, the Civil Aviation Personnel Medical Examination and Appraisal Institute, and the Training Department of the Aviation Medicine Department. The institute is a tertiary general hospital with advanced equipment, complete departments, excellent services, integrated medical, teaching, research and prevention, and features aviation medicine. It is also the only tertiary hospital in the country’s civil aviation system. Medical research and training of civil aviation medical examination and appraisal physicians.

       The hospital is located in the east of Chaoyang District, Beijing, with Chaoyang Road in the north, Jingtong Expressway and Metro Batong Line in the south, and the geographical position is superior. The hospital covers an area of ​​50,000 square meters, with a total construction area of ​​160,000 square meters. The new aviation medical building will soon be put into use, with more than 1,000 open beds. At present, the hospital has more than 1,300 employees, 15 wards, 31 clinical medical technology departments, in interventional treatment of cardiovascular disease, hemodialysis and blood purification, diagnosis and treatment of high-risk pregnancy, treatment of intervertebral disc herniation and joint replacement, laparoscopic minimally invasive surgery, The treatment of prostate disease has advanced level. The Department of Internal Medicine has 8 specialties: Cardiovascular Medicine, Respiratory Medicine, Gastroenterology, Neurology, Nephrology, Endocrinology, Hematology Oncology, Geriatrics; 7 majors in Surgery: General Surgery, Hepatobiliary Surgery, Orthopedics, Urology, Neurosurgery, cardiothoracic surgery, plastic surgery; 8 specialties of obstetrics and gynecology: gynecology, obstetrics, family planning, reproductive health and infertility, eugenics, women's health, perinatal health, menopausal health; 9 specialties of pediatrics: pediatrics Digestion, Pediatric Respiration, Pediatric Heart Disease, Pediatric Kidney Disease, Pediatric Hematology, Pediatric Endocrine, Pediatric Infectious Diseases, Pediatric Genetic Disease; Ophthalmology, Otorhinolaryngology Head and Neck Surgery, Stomatology, Dermatology, Traditional Chinese Medicine, Infectious Diseases, Emergency Department, Departments of Anesthesiology, Pain, Rehabilitation and Physiotherapy also have corresponding sub-specialties; 8 medical technical departments, including radiology, nuclear medicine, laboratory, pharmacy, physical diagnosis, pathology, hyperbaric oxygen Division and other departments. It is equipped with large-scale medical equipment and facilities such as 1.5T nuclear magnetic field, 64-slice CT, digital subtraction angiography, SPECT, high and low temperature high and low pressure integrated oxygen chamber, and laminar flow operating room. A number of scientific research projects have been approved for the establishment of civil aviation bureau-level scientific research projects, and have been funded by the first issue fund, the National Natural Science Foundation of China, and the Beijing Natural Science Foundation. The hospital is a civilized unit in the capital, a demonstration hospital for people across the country, a safe unit of the central state agency, and a safe demonstration hospital in the capital.

       The hospital is a clinical teaching hospital of Peking University that has been evaluated by the Ministry of Education. It has been responsible for the teaching and clinical practice of undergraduates and postgraduates majoring in clinical medicine at Peking University Health Science Center, including cardiovascular internal medicine, otolaryngology head and neck surgery, obstetrics and gynecology B-ultrasound, The Department of Laboratory Medicine and the Department of Endocrinology are the training centers for postgraduates of the Peking University School of Medicine. The Department of Surgery and Internal Medicine are the standardized training bases for residents in Beijing. The Dialysis Center is the training base for dialysis techniques in Beijing. The Department of Obstetrics and Gynecology and Radiology are the Maternal Emergency Network Obstetrics Department of Chaoyang District. Hemorrhage fixed-point treatment centers, all disciplines play an important role in the corresponding fields.

       The center is a member unit of the International Association of Aeronautics and Astronautics. The Civil Aviation Personnel Examination and Appraisal Institute is the only three-level medical examination and appraisal institution for aviation personnel in the whole civil aviation. It is a training base for the national civil aviation personnel medical examination and appraisal physicians. It is the important task of perfecting the construction of China's aviation medical system and ensuring the safety of civil aviation flight. The Institute of Aviation Medicine is responsible for the psychological testing of civil aviation personnel, drug testing, aviation environmental sanitation and pest testing. Among them, the two laboratories of aviation toxicology and pharmacology and aviation sanitation have obtained national accreditation (CNAS) and laboratory certification (CMA). ). There are currently 13 research projects, and the funding for research projects has reached more than 10 million yuan. It has state-level advanced laboratory equipment and facilities, and has a very professional and high-quality research team.

In accordance with the center's 2020 training plan, the Department of Civil Aviation Medicine has implemented medical basic knowledge training courses and civil aviation medical professional knowledge training courses (A series). To ensure the safety of epidemic prevention and control, this training is be conducted in the form of online live broadcast.

The relevant matters are hereby notified as follows:

Training content 

1. Civil Aviation Medicine Basic Knowledge Training Course. The content includes: International Civil Aviation Organization and International Civil Aviation Convention, China Civil Aviation Administration System, Civil Aviation Laws and Regulations System, Civil Aviation Hygiene-related Regulations and Normative Documents, Civil Aviation Knowledge, Aviation Physiology, Emergency  Civil aviation emergency prevention and control of public health incidents, aircraft accident medical investigation, aviation psychology basics, first aid knowledge, etc., applicable to all civil aviation health workers.

2. Civil aviation medical professional knowledge training courses (A series). The content includes: CCAR  -67, CCAR-121, CCAR-183, Civil Aviation Medical Examination and Appraisal Principles and Clinical Aviation Medicine, Aviation Information System Construction and Health Data, Aviation Hygiene and Health Promotion, Aviation Nutrition and Food Hygiene, Aviation Pharmacology,  Aviation psychology, civil aircraft public health, etc. It is suitable for civil aviation personnel medical examiners, aviation physicians, aviation sanitation professional inspectors and other personnel engaged in aviation sanitation management, aviation personnel health management.

Participants 

1. Not through aviation  Medically-trained inspector of aviation health profession;

2. Aviation health professional and technical personnel of various units who have not received aviation medicine training;

3. Other relevant personnel who need to participate in aviation medicine training.

 

 

1. PARAMEDICAL COORDINATION SPECIFICS OF MEDICAL AVIATION BRIGADES

Medical transportation is organized by helicopters, regular and private planes, accompanied by a trained medical team (including paramedics).  In each such flight, depending on the complexity of the patient's condition and the specifics of the disease, only a specialized group of doctors and paramedics takes part.  Paramedics have specialized skills to assist in flight conditions within their specialization.  Therefore, all planned actions and the resolution of emergency situations are under the vigilant control of specialists.

 

 Types of brigades in the ambulance

The choice of medical air transportation can be justified by the fact that the evacuation of the patient by another type of transport, within the limits of the settlement, is impossible.  Or there is no time to get to the remote institutions.  And also, turning to air ambulance services may be the only way out, in the absence of the required medical care in the local region.

If necessary, carry out a planned or emergency evacuation of a person and his subsequent transportation to hospital, an institution, a specialized company sends a sanitary team to call.  The composition of doctors and paramedics who are able to provide specialized assistance in a particular case is preliminarily formed.

In case of an emergency, the sanitary group, having arrived at the site, conducts basic medical procedures to save the victim's life, and then contacts the receiving clinic to evacuate the patient.  Scheduled transportation usually takes place as usual, and communication with the receiving hospital through paramedics and company dispatchers who act as case managers in critical conditions.  The receiving institution is notified out in advance.

 

Neurosurgical team

Such a team serves patients with a broken spine, head brain tumors, various abscesses, traumatic brain injuries, and other injuries.  Such patients are transported to neurosurgical and oncological centers.  The medical staff on board consists of a neurosurgeon and a medical assistant.

 

Resuscitation team (general type)

Serves patients with electric current injuries, strokes, symptoms of poisoning, in a state of coma or clinical death.  The team consists of a resuscitation doctor-anesthesiologist and a resuscitation nurse.  Doctors provide resuscitation measures during evacuation and during air transportation.

 

Obstetric and gynecological team

Such a team serves pregnant women who have just given birth, with various pathologies and bleeding.  A group of doctors, consisting of an obstetrician-gynecologist, an anesthesiologist and an obstetrician, who can receive delivery.  On board, among other equipment, there is an incubator for newborns.

 

Pediatric team

It transports children of different ages, including newborns in an incubator, with which you can conduct accurate monitoring of the baby's condition.  Accompanying group: paramedic and neonatologist with resuscitation skills.  Beforehand, they undergo specialized training in order to provide any, even the most difficult, assistance in flight.

 

 Equipment for aviation medical transportation

On all ambulance flights, only specialized and high-quality equipment is used that can withstand the flight load and function without failures.  The peculiarity of the equipment for aviation medical transportation is its compactness, vibration and moisture resistance.  All medical devices on board, in the event of force majeure situations, operate from an autonomous power source.

Restrictions and prohibitions on sanitary transportation by air prescribe that the following patients are not allowed to medical transportation by aircraft:

with acute asthma;

with cardiac arrest, exacerbated by pulmonary edema;

with embolism;

with intestinal obstruction;

with anemia;

other diseases.

 

In order to safely transport such patients, they must first undergo medical treatment that will help stabilize exacerbated conditions.  In any case, it is important to ask all the questions to the consulting expert in order to determine the degree of transportability of the patient and the occurrence of possible complications during the flight.

 

TAIWAN CASE

In the islands of Taiwan such as Kinmen, Matsu, Penghu, Nansha, Dongsha, etc. the injuries who need to return to the island for further treatment, or want to return from Taiwan in  township, or residents of outlying islands who return to outlying islands to receive long-term care, as appropriate can apply for air injury transfer through relevant channels.

The 439 team takes on this important task and uses the C-130H transport aircraft to transfer the injured. The Jinmen area has routine transfers every Tuesday and Friday.  The unit flies more than 300 sorties a year and evacuates nearly 600 patients. At present, the brigade has a total of five aviation nursing officers and five aviation medical supervisors with EMT-2 or higher qualifications  required for each attendance. A group of manpower (an aviation nursing officer with an aviation medical supervisor), silently guards the outer islands in the air.

There are complete ambulance equipment in the hospital, but if the same ambulance equipment is in an airplane there are many factors to consider in terms of power supply, for example, it’s a very large power supply.

The difference is that patients who use ventilator generally rely on electricity in the hospital, but in the case of lack of electricity on the plane, they will use pneumatic ventilator (commonly known as elf, without the function of storing electricity), the oxygen cylinder. Then, the brigade uses the pressure difference to help the patient breathe.  The on-board environment cannot be peaceful compared with the surface, the high-altitude environment will also cause the physiological changes of the patient, where mainly the problems are: low pressure, hypoxia, low temperature, vibration, noise, and related symptoms:

1. Low pressure: According to Boyle’s law of PV=K, low pressure at high altitude will cause the gas swells, so if you encounter a patient with tension pneumothorax, you must first need decompression; if you encounter hemothorax patients, you must have a chest tube after getting on the plane, so remember to fix the chest tube and bottle.

2. Hypoxia: Although the engine room will be pressurized, the air is still thinner, so if the patient oppresses force changes are more sensitive, and oxygen is usually given. Then the situation will change for the good.

3. Low temperature: low temperature at high altitude, usually keep the blanket warm.

4. Vibration: There will be a large tilt angle and vibration during takeoff and landing, so you will need relevant instruments, oxygen cylinders, drip solutions, etc. require ropes, devil felt, and tape. Wait to fix it to avoid sliding.

5. Noise: usually put a cotton ball in your ears to avoid the noise caused by the voyage.

In addition, it is necessary to remind the injured, patients and family members of the precautions related to the voyage in advance.

For example, do not eat foods that will cause gas before getting on the plane, such as cola, tofu, milk etc.; if the aircraft takes off and landed, due to the unbalanced pressure inside and outside the ears, sometimes there will be ears dinging occurs, which can be improved by swallowing saliva, pinching the nose and inflating the nose.

The detailed description of the nursing care can reduce the anxiety and uncertainty of the injury and family members who may participate in the voyage.

The manager receives notice the day before, which of the injured patients raised under the doctor’s treatment, applies for the transfer service, gives a summary of the medical record and a review form, and then actually visits to understand the condition of the transferred patient, the injured and their family members for this return to Taiwan or leave. Then fills in relevant forms and evaluates whether it can be transferred or need to apply for resources, such as which drips and medicines to bring, how much piping should be left, the amount of oxygen cylinders, etc., because of different situations.

There will be different needs for supplies and care during the voyage, all of which need to be pre-conceived, so the manager reports to the hospital to apply for material and equipment requirements.

Before take-off, the manager makes task reminders with the crew and checks the materials and equipment it is complete, whether the storage capacity of the instrument is sufficient, etc., and start transporting the injured, so when reviewing and evaluating the injured again, the accompanying aviation medical supervisor will assist in carrying the stretcher and carry the injured to the flight according to the loading plan drawn up by the aviation nursing officer. The latter fixes the stretcher with wounded patient according to the arranged position, and assists in fixing the instruments such as drip, oxygen cylinder, chest tube, etc.; in addition,  he also assists in the repair of instruments and meters.

For calibration and maintenance, aviation medical supervisors are undoubtedly an indispensable help for aviation nursing officers.

 

 

 

 

 Voyage care during the transfer of the injured

During the flight, it is necessary to ensure the stability of the vital signs of the injured during the air transfer process, and record the physiological changes of each injured patient during the air transfer process, and use limited resources and equipment to ensure that the injured and their families have comfort throughout the voyage.  Of course, in various emergency situations in the air, it is sometimes necessary to perform cardiopulmonary resuscitation or advanced cardiac life-saving for corresponding treatments, and notify the captain and crew members. If possible, make an emergency landing or turn over to enable the injured  Transfer to the hospital faster for treatment and rescue.

 

 

 Tracking and reporting of injuries after transfer

 

When the plane arrives at the destination, the ambulance will be parked on the apron. After confirming the identity of the injured with the ambulance staff, and briefly handing over the condition of the patient, the family will accompany the injured to the hospital where they applied for medical treatment for follow-up treatment and care.

 

 

 The process of transferring the injured

 

In addition, from the understanding of the situation of the transferred patient, it can be used as a reference for the next transfer of the same patient.  In addition, some hospitals have specially set up service windows for outlying island residents to give priority to various services in order to shorten the time that residents staying in the medical center and waiting for treatment.

 

The manager first confirms with the obstetrician and pediatrician about the maternal condition and the reason for the transfer. Whether the condition of the mother or the newborn cannot be dealt with. If it is the condition of the newborn, priority will be given to transfer; but if it is the condition of the mother and it is not suitable for transfer, then they tend to ask doctors on the island to fly over to the outer islands to assist in treatment. This is also a flexible way.

 

There is a high-risk pregnant woman from an outlying island who applied for transfer. If you were an aviation nursing officer (tutor), what would you do?

 

 

 

 All-inclusive-administrative communication and coordination skills

 

On an airplane, aviation paramedic has a medical professional role, which is different from the general clinical environment. The people who need to communicate are not only the injured, the family members, and the crew; how to make non-medical professionals understand the importance of the injury and illness,  like many aircrews who are worried when they hear about heart failure, there are several levels of heart failure, so when the flight attendant explains in detail, the aircrew will understand that they will not be overly nervous.  The pilot flies the plane in the front cabin, and our aviation nursing officer takes care of the injured in the rear cabin. If the injured is in stable condition, follow the normal flight plan, but if the injured suddenly changes in illness, it may sometimes require an emergency landing or diverting to other airports. Therefore, the role of an aviation care officer must not only ensure the safety of the injured and their families during the voyage, but also pay attention to the concept of flight safety and risk management, so that the entire task process can be completed.

 

 The bitter talk of the aviation nursing officer and a gamble with death

 

Whether the injured patient can be transferred will be judged according to the relevant regulations of the air ambulance operation manual, and the decision is left to the aviation nursing officer. Some serious injuries (such as injection of several blood pressure drugs, the blood pressure has not risen or the body has too much internal bleeding, etc.) cannot be transferred, because it may die during the voyage, causing unnecessary waste of resources or disputes, but how to communicate with family members is actually a big deal to learn. The managers often experience a lot of entanglements and struggles in their hearts. One can realize and understand that what patients' family members are longing for what is a "miracle", what they want is the "hope" of being able to return to the island of Taiwan for further treatment, and want time and life from God.  But sometimes the god of death will not let go. At this time, the aviation nursing officer can only communicate with his family members constantly, and often communicate until midnight in the middle of the night. This is a common thing, and sometimes the manager gambles with the god of death, and people are longing for miracles!

 

A young patient with a ruptured spleen and internal bleeding has been transferred to the intensive care unit on an outlying island for a few days, but the family members have been hoping to come to the island for treatment.  That time the manager was very impressed because he prepared a lot of oxygen cylinders, a lot of blood pressure drugs, and even blood bags on the plane. Although the experience was very hard, he heard that the patient came back to life afterwards, and he was about to leave. 

 

When the aviation nursing officer returned to school for a master’s degree, the manager learned that he was almost recovered. It was really exciting news. Looking back on the hard work, everything is worth of efforts, because what is saved is a precious life.

 

 

 Non-redirection principle

 

According to the air ambulance operation manual, there are several principles that should not be transferred:

 

1. Those who are seriously ill and have no vital signs should not be transferred.

 

2. Legally infectious diseases who have not been effectively isolated.

 

3. The mother has signs of premature delivery (such as contractions, redness, broken water), or has been pregnant for more than 240 days.

 

4. The test value is too low, such as hemoglobin, red blood cells, white blood cells and other related indexes are too low.

 

5. Other persons who are deemed unsuitable for air transfer by a doctor or aviation nursing officer.

 

 

 Transfer?  Not forwarded?  ──The myth of big hospitals

 

The air ambulance operation manual currently only stipulates that patients who are too serious should not be transferred, but there is no restriction that those with minor illnesses cannot be transferred. Therefore, sometimes there may be cases of abuse of air patient transfer resources. At this time, aviation nurses will have some frustration and helplessness.  Managers encounter some patients with pneumonia. The general course of pneumonia treatment requires 7 days of antibiotics. At that time, the course of treatment may reach the 4th day and the symptoms have been relieved. However, the family members still ask the doctor to go to the island for medical treatment. After the communication fails,  the manager has nothing but to apply.  When he visits, assesses the injured, he sees this situation. He sincerely communicates with the injured and their families again and again.

 

 

CONCLUSION & PERSPECTIVES

The institution of Aviation Medicine Paramedics is developing in parallel with medicine itself.  The tasks that fall on the shoulders of medical supervisors and other employees involved in air ambulance teams are continually becoming more complex.  In particular, the situation around the areas most affected by the receding epidemic in individual countries and regions of the world requires an increase in the highly tactical response of the health care system in the process of providing first aid to the population in remote areas.

The development and implementation of a service management system in the field of aviation medicine requires not only high-quality training of medical and technical personnel with subsequent accreditation, but also an internship in leading international schools in the world.

Cooperation in this area is mainly possible at three key levels:

- training of personnel for introduction into the aviation medicine segment;

- technical equipment of clinics with high-tech flight transport, equipment from leading countries in this industry;

- conducting expert research and conducting programs of international cooperation in this area.

We invite a competent and interested Western audience to conduct active contacts and projects in East Asia.

 

December 20, 2020

Tirana, Albania