Helicopter On-Scene Response Program Instructor Notes Air Ambulance Helicopter On-Scene Response Program Emergency Health Services Air Ambulance Section Introduce Program overview of new policies related to Helicopter On-Scene Response updates to initial program of 1997 Review Learner Objectives Provide overview of delivery lecture with large group discussion to highlight key points and application of Policies 4.7-4.10 introduction of Trauma Triage Guidelines final question and answer period Regional Training Network

Roles and Responsibilities Helicopter On-Scene Response Program Instructor Notes Roles and Responsibilities Caller CACC Dispatcher MATC Dispatcher EMA/Paramedic Flight Paramedic Flight Crew Discuss all those who could be involved in helicopter on-scene response decisions Concentrate on roles of land paramedic determination of travel and patient preparation times (including extrication time) to the most appropriate facility identification of operational and clinical guidelines that would indicate a helicopter on-scene response advising CACC of the need for helicopter on-scene response, or canceling an already dispatched helicopter if assessment of situation warrants it designating a “Landing Site Coordinator” working safely around helicopters knowing the limitations of on-scene responses

Ontario’s Air Ambulance System Helicopter On-Scene Response Program Instructor Notes Ontario’s Air Ambulance System Provide brief overview of Ontario’s Air Ambulance System specifically highlight new Preferred Provider Bases - replaces the previous Standing Offer Agreement (SOA) rotary wing charter air carriers - specify air bases in your area new Preferred Provider Bases in London, Ottawa, Moosonee, and Kenora preferred air bases provide Advanced Care Flight Paramedics, dedicated air bases provide Critical Care Flight Paramedics. may still see isolated SOA fixed wing response in remote northern areas - all certified to Primary Care Flight paramedic level - SAED and SR This program deals with helicopter on-scene response calls, as per policy 4.7 Dedicated Air Ambulance Preferred Provider SOA Charter Air Carriers

Policies Related to On-Scene Response Helicopter On-Scene Response Program Instructor Notes Policies Related to On-Scene Response Tell class: These are the policies applicable to Helicopter On-Scene response Confirm everyone in class has personal copy of this policy - part of learner package Policy approval and implementation date: Will be announced by EHS - training of CACC’s must also take place. This will be happening in near future. Policy 4.7 - Preferable Mode of Emergency Response Policy 4.8 - Landing Air Ambulance Policy 4.9 - On-Scene Limitations Policy 4.10 - Joint Land/Air Emergency Response

Helicopter On-Scene Response Program Instructor Notes On-Scene Requests Operational Guidelines Clinical Guidelines Judgement! Requests for on-scene helicopter response should meet at least one Operational Guideline, and one Clinical Guideline However - use judgement - if appropriate under current circumstances, helicopter on-scene response should be requested even if operational and/or clinical guidelines have not been met. This review of the guidelines will enable EMAs/Paramedics to make sound decisions based on reliable indicators.

Operational Guidelines Helicopter On-Scene Response Program Instructor Notes Operational Guidelines Land response to scene >30 min. Land response to hosp. > 30 min. land and air response >30 min., but ALS required - not available on land Multi-Casualty Incidents Patient Accessibility Judgement! Review Operational Guidelines Point 1 request helicopter if land response to scene is greater than 30 minutes, and air can reach the scene quicker. Point 2 “closest appropriate hospital” now more clearly defined for trauma patients. 30 minute transport time includes extrication time, traffic and road/weather conditions, and those factors which affect response/transport time but cannot be predetermined Point 3 both land and air response greater than 30 minutes, but approximately equal, and patient needs advanced paramedic level care which cannot be provided by responding land ambulance. Points 4 and 5 multiple patients who meet guidelines and local land ambulance resources are overwhelmed access issues include ravines, valleys, large park/conservation areas, etc ** CACC’s may establish geographical zones as opposed to time guidelines - see policy 4.7 page 3). ** Judgement - even if no operational guideline met, helicopter on-scene response can be requested if the current circumstances warrant. ** Land ambulance that has patient ready for transport will not wait for helicopter unless it can be seen on final approach (Policy 4.7, page 5). In this situation, land ambulance will proceed to closest hospital with an emergency department - air ambulance will proceed to that hospital (see policy for complete details).

Helicopter On-Scene Response Program Instructor Notes Trauma Centres For trauma patients only, the “closest appropriate facility” has been more clearly defined consideration of time to hospital should be based on pt. arrival at a Lead Trauma Hospital See Policy 4.7 - Definition Studies prove that morbidity and mortality rates increase if patient is not taken directly to a Lead Trauma Hospital Define Closest Appropriate Facility for Trauma Patients designated Lead Trauma Hospitals assigned in conjunction with local BH direction Does not apply to patients meeting clinical criteria other than trauma e.g. medical, environmental, obstetrical, MOI these patients may still meet guidelines for on-scene response, but time estimates based on travel to “closest appropriate facility”

Helicopter On-Scene Response Program Instructor Notes Clinical Guidelines Trauma* Medical Category Environmental Category Obstetrical Category Mechanism Of Injury Category Judgement! Review guidelines for each category except Trauma - this will be highlighted in Trauma Triage Guidelines - pages 6 to 8 in Policy 4.7. Remind class that in these categories (all but trauma), the closest appropriate facility has not changed from current practice requests for on-scene response in these situations still includes “patient extrication time, traffic and road/weather conditions, and other factors which affect response/transport time” guideline of more than approximately 30 minutes to closest appropriate facility, and only if air can be faster

Trauma Triage Guidelines Helicopter On-Scene Response Program Instructor Notes Trauma Triage Guidelines Clinical guidelines for Trauma patients are now more clearly defined in the Field Trauma Triage Guidelines - Policy 4.7 page 6 Composed of three sections - anatomical, physiological, and incident criteria Trauma patients meeting any one characteristic in any of the three categories should be transported to the closest lead trauma hospital Remember diversion to closest ER department possible in judgement of paramedic Review the trauma triage guidelines with learners ** land ambulance is not to delay patient transport by waiting for the helicopter, unless it is seen on final approach. Transport to closest local hospital with ER - helicopter will proceed to that hospital - Policy 4.7 page 5 ** Land ambulance will bypass other hospitals to go to lead trauma hospital if the closest lead trauma hospital is less than 30 minutes away by land ambulance. However, if at any time the EMA/Paramedic is uncomfortable with the safety of the patient during transport to the closest lead trauma hospital and bypassing other hospitals, the EMA/Paramedic may divert to the closest hospital with an emergency department - Policy 4.7 page 3. **local direction can come from BH Medical Director Anatomical Criteria Physiological Criteria (>16 yrs) Incident Criteria

Paediatric Trauma Guidelines Helicopter On-Scene Response Program Instructor Notes Paediatric Trauma Guidelines To be used for patients under the age of 16 years, or when unknown, in the absence of secondary sexual characteristics (judgement) 6 item scoring system - if patient scores 8 or less, they should be transported to the closest lead trauma hospital, provided it is less than 30 minutes away, and you do not suspect that the patient will not survive the extra transport time. transport by air or land, which ever is appropriate using the operational guidelines and EMA/Paramedic judgement in consultation with CACC paediatric trauma is relatively rare - may be useful to have this scoring system located in convenient place for future reference, e.g. pocket card, zip pack, patient compartment of ambulance ** Alternate BP measurement - Radial/Brachial Pulse present scores +2, femoral pulse present scores +1, and no pulse scores -1. ** Scoring of patient must be done in all six areas - one score per component - total the score for each of six components to achieve overall trauma score.

Helicopter On-Scene Response Program Instructor Notes Landing a Helicopter Safety Landing Site Site Safety Working around a Helicopter Review key points of policies 4.7 helicopter pilot will determine landing site from the air landing site coordinator will work in harmony and under the direction of pilot

Response Limitations and Joint Response Helicopter On-Scene Response Program Instructor Notes Response Limitations and Joint Response Night Calls Reassignment Search/Rescue Joint Land/Air Emergency Response Review Policy 4.9 and 4.10 EHS helicopters are not permitted to respond to night calls which require a landing at other than night licensed airports, helipads, or night approved remote landing sites. Diversion of helicopter from calls to on-scene calls must receive approval from MATC Base Hospital physician. Land EMA/Paramedics will still request in appropriate situations - availability will be determined through communication between CACC and MATC. ** Do not delay transport waiting for helicopter on-scene. EHS helicopters are not permitted to take part in search and rescue calls CACC may initiate both land ambulance for tiered response with air response crew reaching the scene first is responsible for triage and scene management highest medically trained personnel on-scene will normally be authority in patient/medical matters if both land and air are ALS, the transporting crew will have authority over medical/patient matters