Category:Medevacs and Transport

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OVERVIEW

Weather, patient acuity, commercial plane availability and limited medevac resources can make routine, urgent and emergency medical transportation a tremendous challenge on a daily basis. Health aides and more experienced providers can give you ideas on how to get non-emergency patients into Bethel based on weather, plane schedules and sometimes alternative travel options. YKHC also operates LifeMed, a medevac company that provides services statewide. There is a dedicated Bethel-based crew for local Medevacs and Anchorage/Fairbanks based crews for transporting patients to Anchorage 24/7. Emergency Medevacs require careful coordination and collaboration with LifeMed dispatch, activating physicians and ER physicians. Emergency medevacs are a limited resource and patient acuities in the hospital units and in the villages need to be considered, weighed and prioritized on an ongoing basis.

YKHC owns a medevac service called LifeMed. This is the service that is used for both village to Bethel medevacs and Bethel to Anchorage medevacs. You have to activate the medevac for all patients traveling to Anchorage via LifeMed because ANMC has a different contract for all other sites in Alaska (Guardian.) It is very important that you document very well about why you chose to “roll over” the medevac to Guardian if Lifemed is not available.

Always Consult an experienced provider before you make the decision to transfer or medevac a patient until you become familiar with our system. Generally it requires about 6 months of getting advice before medevacs, unless the medevac is obvious (GSW, trauma, sepsis, respiratory failure, etc.)

Medevac Activation Process

Activate Medevacs as soon as possible to avoid delays in patient’s getting to the higher level of care they need. If you are too busy to activate…get someone else to help you.

This can be done from anywhere in the hospital (outpatient, inpatient, or emergency department) as long as the patient is stable. If the patient is not in the Emergency Department and unstable, please activate a Rapid Response or Code Blue with likely plans to transfer the patient to the Emergency Department for further management while awaiting medevac transport.

Obtain an Accepting Physician

  • When activating from the village, the accepting physician is usually the Emergency Department Physician (E1/E2)
  • For Native (beneficiary) patient’s you must obtain an ANMC accepting physician—even if the patient is going to another facility (during the weekday this is via the ANMC transfer center (*97 or page Transfer Center Coordinator) and on evenings / weekends contact your accepting provider directly and they can contact the house supervisor).
  • For non-native patients you must obtain an accepting physician from a Providence or Alaska Regional ER physician or an on-call specialist.
  • Communicate clearly with the receiving physician the reason for transfer ie deterioration of clinical status, potential surgical intervention, need for diagnostic and specialty care not available in Bethel or need for a higher level of care that is not available in Bethel (this may be nursing).
  • Let the accepting physician know you are calling to transfer the patient to their facility (You are not calling to ask for advice on managing them in Bethel).

NOTE: If you think the patient needs to be transferred to a higher level of care, the on call specialist should not refuse the transfer. If there is any issue with obtaining an accepting physician, page the Clinical Director (CD) on call for assistance.

Complete a Patient Transport Form (PTO)

  • Once you have an accepting provider / facility, complete a PTO and consent the patient for travel. Both of these forms are available on the intranet document library.
  • Send a copy of the completed PTO to the ER (this can be done by walking it over, sending it through the tube system, or scan emailing it to the charge nurse) with pertinent patient information
  • It is important to notify the Emergency Department Physician (E1/E2) about ALL medevacs (Village to Bethel and Bethel to Anchorage) as they help to coordinate all medevac flights.

Activate the Medevac

  • Call Lifemed (*96) and press 1 to get to dispatch. Dispatch will require the following information:
    • patient name, date of birth and weight in kilograms
    • patient diagnosis / reason for transfer
    • your name and facility (transferring facility)
    • patient location (ER, outpatient clinic, Northwing)
    • accepting provider and facility (receiving facility)
    • whether the patient has any special equipment (intubated, NIPPV, pressors)
    • location in receiving facility to deliver patient (e.g. ER, L&D, ICU, etc.)
    • escort information (name and weight in kilos) if applicable

This sounds like a lot of information but it goes quick e.g. “Hello, this is (activating provider), I am calling from the Bethel (ER/ Northwing/ L&D). I am transferring John Doe, date of birth 00/00/00 to Anchorage for (diagnosis). His weight is (kg). He (does / does) not have an escort. He (does / does not) have any special equipment. He will be going to (recieving hospital and unit), care of (accepting provider).”

You will then send the PTO form to Lifemed dispatch. Lifemed dispatch will relay this information to their flight crew who will check on weather. You may or may not receive a call from the flight crew— if it is fairly straightforward (e.g. stable hip fracture), the flight crew may just contact you to report their ETA and not require further patient information. If the patient is complicated you may be directing flight crew with management advice. Once Lifemed lands and leaves YKHC with the patient, update the accepting provider with an ETA as a courtesy, though this is not required.

Provider

Village to Bethel Medevacs

  • sign out to ER doc
  • ER doc will place the medevac on the ER white board
  • ER doc will assume medical control except for OB patients and for some pediatric patients where the pediatrician keeps medical control until the patient arrives in the ER OR the patient has been stabilized and is turned back over to the ER physician for medical control

Bethel to Anchorage Medevacs (stable outpatient/inpatient/OB/ER patients)

  • Talk to med control doctor
  • Notify the YKHC ED physician, they coordinate medevac care and can divert a transport team crew between departments in order to transfer the patient requiring the highest level of care or requiring the most urgent/emergent management that may not be available at YKHC first (e.g. transfer the patient with quickly progressing hand cellulitis requiring orthopedic surgery intervention to the crew that was intended to take a stable intubated patient.
  • Write a detailed transfer note
  • Make sure patient records and health summary are copied and that x-rays are teleraded to ANMC (unless going to another facility) and a disk is made to go with the patient
  • Stay in touch with the medical control physician if needed. Update them on the condition of the patient prior to LifeMed team assuming care if patient’s status has changed.

RN

Once the patient leaves YKHC, the RN taking care of the patient is responsible for calling report to the accepting unit.

Tech

The tech is responsible for putting together a transfer packet. This packet can be found on all inpatient units and in the ER. The things that need to go in the packet are conveniently listed on the outside of the packet. All of these items are related to current visit only! They don’t need to see the last 5 years of labs. The things that need to go in the packet are:

  • provider notes
  • nursing notes
  • CHAP notes
  • lab results
  • vital signs
  • imaging results ; both printout of radiologist read and CD of images made by radiology tech
  • EKGs (copies, not originals)
  • 3 copies of the PTO form
  • 3 copies of patient demographic information

This packet is given to Lifemed on arrival to YKHC.

LifeMed Formulary

A list of medications available in the LifeMed medication box.

Village to Bethel Medevacs

see Medevac Activation Village to Bethel YKHC Guideline

Labor in the Village

  • see Pediatric Village Delivery Orientation and OB RMT: Labor in the Village for more information
  • An OB patient in a village will require a medevac to Bethel if:
    • she is in labor that can not be stopped and if the gestational age is <34 weeks (or unknown)
    • there is a high-risk pregnancy, or
    • there are concerning maternal/fetal signs
  • A family practitioner and a pediatrician will accompany the LifeMed team if there is a considerable risk of the patient delivering in the village or on the plane.
  • The LifeMed team has a full premature/full term delivery kit and a baby warmer for resuscitation and transportation.
  • The family medicine physician must pick up the OB delivery kit and supplies from OB before leaving the hospital.
  • Note: OB medical control remains with the family medicine physician on Northwing until the Family Medicine provider on the flight arrives at the clinic.
  • Sick and preterm newborns that deliver in the village require transfer to ANMC or Providence will benefit from early activation of an Anchorage based PNP/neonatal team to pick up the baby in the village (this occasionally can be arranged with the King Air) OR in Bethel by ramp transfer, if appropriate, or the YKHC nursery.

Bethel to Anchorage Medevacs

see Medevac Activation Bethel to Anchorage Guideline

Overview

Anchorage and Fairbanks Medevac teams are comprised of two paramedics on a Lear jet. This might be a paramedic and a nurse pair. It takes 1.5 to 3 hours (or longer due to weather or resource availability) to get a plane to Bethel, so activate as soon as you know you need to medevac a patient.

If LifeMed is not able to dispatch a LifeMed crew in a timely fashion, they will make arrangements to send another medevac company’s team out to pick up a patient if appropriate.

OB/Newborn Medevacs

OB medevacs to Anchorage are possible when a patient is not in active labor and the benefit of a transport outweighs the risk of a possible delivery en route. YKHC does not have a nursery, therefore all high risk OB patients and possible preterm deliveries would benefit from being delivered at a higher level of care for both mother and baby. The FP and the pediatrician can consult with the high risk OB doctor on call, accepting OB physician and the peri-natologist if needed in extremely difficult cases.

Newborn medevacs from YKHC to ANMC or Providence may be done by regular medevac if the baby is very stable and is not expected to require resuscitation, intubation or any specialty care. For babies that are unstable in any way, a NICU PNP with accompany the medevac team to Bethel

Reverse Medevacs

  • ANMC to Bethel Inpatient Unit and Bethel Inpatient Unit to village Medevacs.
  • These are unusual occurrences and they must be evaluated and approved on a case-by-case basis.
  • Occasionally, ANMC will request a patient return to YKHC inpatient unit to finish up a prolonged course of treatment or an end-of-life YKHC inpatient may want to return to a village and is not able to travel commercially. If this request is made by ANMC or a YKHC inpatient physician, the medevac request will have to be reviewed and pre-approved by YKHC and LifeMed administrators. These medevacs do not require emergency care and are not eligible for reimbursement.

Lifemed Detailed Information for medevac roadblocks and alternative options

Lifemed Dispatch, the crew and experienced providers may work together to get patients directly from a village or Subregional Clinic (SRC) to Anchorage without coming to the Bethel ER. In some cases the Bethel-based team will fly to the village and care for the patient until an Anchorage team gets to the village OR a ramp transfer may be arranged at a SRC or Bethel airport. Below are some options and limitations…

Runway Lights

Most of the villages in the YK Delta have runway lights, which are pilot-controlled. Kwigillingok and Newtok do not have pilot-controlled runway lights, however they do have portable runway lights that are FAA approved for fixed wing aircraft. Legally, we are no longer allowed to land our aircraft in the dark at an airport that does not have FAA approved runway lights. Crooked Creek, Lime Village, Red Devil and Stony River do not have any form of FAA approved runway lights, so we can land our aircraft there only during daylight hours.

Emergency Military Transport

See Activating Emergency Military Transport YKHC Guideline

If LifeMed is unable to complete a medevac, the Rescue Coordination Center (RCC) can help find a military medevac aircraft. If the Bethel Based Army National Guard is available, the Bethel Lifemed Med Crew may fly with them on their aircraft to complete the medevac. If the Bethel Guard Helicopter is not available, RCC will dispatch an aircraft from somewhere else in the state, usually from the 210 or 211 Rescue Squadron based in Anchorage. LifeMed Dispatch will take care of all of those transportation arrangements for you.

NOTE:

  • If Lifemed cannot travel due to weather, then Lifemed and YK staff cannot travel with the National Guard.
  • If a patient needs surgical intervention or care that cannot be provided in the village (ie compartment syndrome or fracture related vascular compromise), then the risks and benefits must be carefully weighed, consult "CD on Call," and record good documentation about the decision.

Helicopter Destinations: When a military helicopter transports the patient to Anchorage, they can land only at Providence, Alaska Regional, Elmendorf AFB, and Mat-Su Regional Medical Center. ANMC does not have a helipad, therefore a helicopter cannot land on the ANMC campus. It is an EMTALA violation to have the patient transported directly from the helicopter to ANMC via ground transportation without the receiving hospital doing an initial evaluation of the patient. Therefore, if a patient is sent from the YK Delta to Anchorage on a helicopter, the patient must be seen initially by the hospital the helicopter landed at. Arrangements can then be made between the receiving hospital and ANMC to have the patient transferred to ANMC via ground transportation.

LifeMed Pilots

LifeMed Pilots make the decision to fly based solely on aviation, weather and runway condition factors. They are not provided any information about the patients in order to prevent them from feeling any pressure to fly based on a patient’s condition. They know only the pick-up point, weight and destination of the patient. The dispatchers will not allow you to speak with a pilot regarding the medevac. If you want to know the reason for a pilot’s decision (i.e. weather, runway condition, etc.), the dispatcher can provide you with that information.

Medical Crews on Standby

There are times when either the Bethel-based Caravan crew or the requesting physician place the Anchorage-based Lear Jet on standby. This moves the pilots and medical crew to the hangar to prepare at that time. The pilot can check weather and determine how much fuel will be needed and the medical crew can assemble any additional medical supplies they will need for that medevac. The crew will then be standing by awaiting the call to launch or cancel. Putting the crew on standby will decrease response time by 40-60 minutes because the crew has the aircraft ready to go. Putting the Lear Jet crew on standby allows more patients to be ramp transferred and transported directly to Anchorage without having to be seen at YKHC.

Contacting Medical Crew

Please contact the medical crews thru Dispatch. They know where the crews are in their sleep cycle and whether they are on crew rest. For non-urgent communications, you can contact the crews on the Base Quarter’s phone at 543-5036. The crews turn the ringer off when they are on crew rest.

Medevacs for the ER Provider

  1. The ED doc is the med control for all medevacs that arrive in Bethel from the surrounding villages. This is often 2-3 per day.
  2. The exception to this is our OB medevacs when we send a Family Med doc and a pediatrician along. Med control is then with the doc on the plane.
  3. The ED doc should also know about every single medevac that is going out of Bethel to Anchorage, regardless of the location of the patient. For example, if OB is medevacing an OB patient, the ED doc needs to know about the medevac and at least a cursory clinical knowledge of the patient. This is for purposes of triage. If a sicker patient comes into the ED, the plane may need to be diverted to get the sicker patient.
  4. Once the inpatient doc tells you about the patient being medevac’s in from the village, you assume medical control. This means that you talk to the Health Aide when he/she calls and you document in the record any interventions and changes in condition. You can either start your own note or add to the RMT note already started by the CHA and the inpatient doc. Just right click and modify the document.
  5. All weather delays must be clearly documented in the patient’s chart, as well as all other delays. For example if another medevac is already underway in another village, this should be noted in the chart (not the details obviously, just that the medevac team and plane are in another village and unavailable.)
  6. Our hard-working medics will occasionally time out because of too many hours of continuously flying. They will then go on “red” status meaning they can’t fly for at least 8 hours. If they are on “yellow” status, it generally means that whatever flight you send them on is the last flight before they go on “red.” When this happens, sometimes LifeMed can put another plane and team in Bethel to perform the village flights and sometimes the plane from Anchorage can go directly to the village to pick up the patients. Creative problem solving is key in these situations. Clear documentation in the chart as to what is going on is key in these situations as well.
  7. In general, do not activate a medevac for CPR in progress in a village. The CHAs can only do BLS and return of spontaneous circulation is rare. The exception to this is cold water drowning in a child with high-quality CPR on-going since they were taken out of the water. It may be appropriate to send the plane out in these situations. Consult with peds in these cases.
  8. If you transfer a meningitis patient to ANMC, send an extra tube of CSF with the patient to ANMC for faster turnaround on identification of the causative agent.

return to the Emergency Department Main Page

Medevacs for Inpatient Pediatricians

Notify the ED doc about every single medevac that is going out of Bethel to Anchorage, regardless of the location of the patient.

The only medevacs the pediatricians go out on are for high risk or premie (less than 36 week) village deliveries. There is limited space on these medevacs so only one pediatrican can go out at a time. This makes it difficult to orient new staff for this part of your job. It is important to review the links below and talk with other pediatricians about their experiences on medevacs. Your assigned back up pediatrician during orientation (or any pediatrician at any time will be happy to help you) can talk to you before you go out and after you get to the village to help coach and help you.

Medevacs are one of the scariest things we do. We don’t do them often; we can’t have another pediatrician by our side and there are limited resources in the village. BUT the medevac crews are great. We have phone and video conferencing capability and even new pediatricians will be surprised at how well they can do with good preparation ☺

You need to review the following information before going on your first medevac. It would be good to have a copy of these handouts available to review or print when you go out on your first medevac.

Resources

NOTE: Pediatricians do not go on any Anchorage medevacs. Our medevac crews are good and can handle very sick pediatric patients and infants.

Pediatrics Main Page

Medevacs/Transfers for OB

In consultation with HROB and the ANMC OB on-call physician, OB patients with a serious but stable medical condition may need transport to a higher level of care (ANMC or other). Once an accepting physician is identified, LifeMED should be activated and the patient should discharged pending medevac team arrival. Essential documentation should include a transfer summary and three papers from the “Transport Pack” completed by hand:

  • PTO
  • Signed consent form
  • Diagnostic imaging request form for studies to be loaded on a CD
  • Discharge summary, which you should do before LifeMed team arrives.

As soon as it is obvious that a mom or baby needs to be transferred (in some cases this is before the baby delivers i.e. when there is a known maternal or infant problem that necessitates a NICU or higher level of care for mother and/or infant during labor and/or delivery).

  • Call ANMC and get an accepting physician for mom, if she has not delivered, or for baby if baby has delivered…if a patient is non-native the accepting physician should be from Providence NICU.
  • Complete the Patient Transport Order (PTO) and other paper work in the transport packet
  • Notify the ED doc about the medevac.
  • Complete the Admit Orders and Medication Reconciliation
  • Continue to monitor and stabilize the infant
  • Complete the Newborn Discharge/Transfer Summary and add updates as needed. You can create your own transfer template or you can use McClure’s shared template and modify and save it for your own use.
  • Update Diagnoses and Problem List
  • Complete and E&M charge
  • Complete the Medication Reconciliation

see Labor in the Village for a detailed discussion about a reason to medevac from a village to Bethel

OB & Newborn Main Page

Transportation/Transports

Stable patients, that do not require a medevac, can usually be transferred from villages, outpatient clinics, ER, the inpatient unit and the OB/Newborn unit to a higher level of care via commercial flights. These transfers are often needed to obtain diagnostic evaluations not available in a village, SRC or Bethel and to be closer to surgical and intensive care resources if needed.

Commercial Flights From Village to Bethel

  • Patients can be sent to Bethel via regular commercial flights. These flights are expensive. Only patients who are covered by Medicaid or Denali Kid Care have their travel, meals and housing covered. Some patients have medical insurance, but often they have to get reimbursed for travel and there is no coverage for meals and housing.
  • The CHAs and village clinic office staff complete patient travel from village to Bethel.
  • Reminder: Have CHAs remind patients to bring money, extra cloths, diapers, medications, neb machines, ID etc. in case they have a prolonged stay in Bethel.
  • For patients without insurance:
    • If a patient is sick but stable, they must pay their own way in or be managed in the village.
    • If a patient is sick and you feel the patient needs to get to Bethel, the administrator on call may be paged to authorize one-way travel to Bethel. If admin approves travel, the patient will need money for food, cabs and the hostel (or have a place to stay).
    • If urgent or emergency travel is required (and the patient is stable enough for a commercial flight), the inpatient or ER physician may approve one way travel to the ER without paging the administrator on call.

Commercial Flights From ER/Inpatient/Outpatient to Anchorage

  • Patients may need to take a commercial flight from Bethel to Anchorage after being discharged from the ER, OB or the inpatient unit.
  • The patient may be going to a specialist f/u appointment the next day, to ANMC ER for re-admission or for further evaluation or the patient might be a direct admission to the pediatric unit, etc.
  • These patients have been discharged from our facility, but YKHC has assisted in the patient’s travel and there is an accepting physician at the next facility expecting the patient with an agreed upon plan of care.
  • Complete a Patient Transport Form (PTO) for all urgent (within 24 hours) commercial travel from Bethel to Anchorage
  • For patients traveling commercially to Anchorage without Medical Insurance, the travel payment and authorization protocol is the same as it is for the village patients. YKHC travel makes the travel arrangements. Patients will still need funds for cabs plus food and lodging if they are not admitted. Sometimes ANMC can assist the patient with housing on campus once they arrive.

Behavioral Health

The Behavioral Health department and clinicians will arrange for patients who are medically stable to travel from village to Bethel and from Bethel to Anchorage.

BH inpatients that require psychiatric hospitalization will be transferred with a BH escort via a commercial flight to Alaska Psychiatric Institute (API) after they are medically cleared.

Urgent Charters

Urgent Charters should only be considered when

  • a patient is stable
  • there are no commercial flights available
  • transport is urgent and there are no reasonable options for transporting a patient into an SRC, Bethel or Anchorage.

This is an option when the patient needs to be evaluated by a higher level of care within 12-24 hours but there are no other options.

Process for obtaining an urgent charter

  1. Contact the Administrator On Call for payment approval.
  2. Let CHA know a charter has been admin approved
  3. CHA will work with Medicaid/patient travel to arrange the charter using Medicaid or YK pay
  4. Ask CHA to let you know if and when the charter has been arranged and approximate time of arrival at destination
  5. Make sure patient is stable before getting on charter
  6. Make sure the patient is expected at destination and there is good documentation of why the patient is being transported.
  7. Ask CHA to notify the provider if the patient is not able to get a charter, the charter is held up by weather, the patient does not make to charter or if the patient gets worse before getting on charter.

Urgent charters can only be arranged on weekdays and weekends, but not holidays or after hours. Usually they are arranged from village to Bethel or SRC, but occasionally they can be arranged from Bethel or SRC to Anchorage.

Creative Alternative Transports

When weather is down or there are no flights available, a stable patient might come in to Bethel or an SRC by boat, snow machine, snowmobile, river cab or private vehicle on the ice highway.

In extreme situations, a CHA may accompany a very sick patient to another close-by village for more help/supplies/medevac access OR bring them to Bethel if able. Having a CHA leave the village to accompany a patient requires approval of the Community Health Aide Administrator on call (a CHA must not leave the village without appropriate health aide coverage)

Medevac Ride Along/Observers

Ride-a-longs are scheduled on a first-come first-serve basis. A Medevac Ride Along Form (Online Medevac Ride-along Participant Application) must be filled out prior to a medevac.

Fill out the form online and someone from Lifemed will contact you within 2 weeks.

The medevac team will call you when they get a call and you have 15-20 minutes to make it to the hangar. You must be ready to get in a cab and go the first time to the hangar without going home for rain gear or other gear. After you know where it is, you can drive out there and leave your truck there during the medevac. They will not wait if you are not there when they are ready for takeoff since by definition, the patient waiting is in an emergency situation.

If you are in the ED this process is much easier and you may get a ride from one of the techs.

The most important tip is to come prepared. You may be riding in a boat, snow machine or ATV from the village airport to the clinic. You may also have to spend lots of time outside and so if it is cold, bring the gear. A headlamp is helpful.

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