Objective First responders experience higher rates of psychological distress than the general population, driven by repeated exposure to traumatic events and limited recovery time. Members of neonatal and pediatric critical care transport teams face additional cumulative stressors related to high-acuity patients and emotionally challenging transports. This study describes the development, implementation, and utilization of a peer-led support program within a hospital-based neonatal and pediatric critical care transport service. Methods Following a 2019 internal survey that identified a preference for peer-based emotional support, the Children’s Mercy Critical Care Transport Team implemented a structured peer support program. Peer Support Persons (PSPs) were selected from a multidisciplinary transport team and completed standardized initial and ongoing training. Peer support was accessed through self-referral, leadership referral, and a confidential QR code (Quick Response Code) request system. Minimal, non-identifiable encounter data were tracked in a secure database. Descriptive analysis was used to evaluate program utilization from March 2023 to August 2025. Results During the study period, 209 peer support encounters were documented, including 11 formal debriefings and 199 informal interactions. Encounters involved registered nurses, respiratory therapists, emergency medical technicians, communication specialists, and other team members, most of which were related to difficult transports, patient deaths, and emotional distress. Program utilization increased over time, demonstrating the integration of peer support into routine team culture. Staff feedback was consistently positive, highlighting the value of timely, confidential, peer-led support. Conclusion A structured, confidential, peer-led support program is feasible and sustainable in a neonatal and pediatric critical care transport setting. This model promotes resilience, reduces stigma, and may serve as a framework for similar first-responder programs.
Helicopter air ambulance (HAA) operations involve shiftwork schedules that put personnel at an increased risk of fatigue. This survey study aimed to provide an updated benchmark for fatigue characteristics and perceptions within US HAA pilots. Pilots across the US HAA industry were invited to complete a survey related to their work and individual sleep-related preferences. Pilots completed the survey, including standardized questionnaires such as the Morningness-Eveningness Questionnaire, the Epworth Sleepiness Scale, and the Pittsburgh Sleep Quality Index, during a larger field study. Our survey of 120 pilots across 21 operators revealed that poor self-reported sleep quality is an issue in more than half (53%) of the sample population. Most participants (71%) felt that fatigue was most prevalent on the return-to-base leg of a trip, and 69% felt that the number of flight requests was the greatest schedule-related contributor to fatigue. One-third of the pilots (34%) reported “nodding off” during a flight, and more than three-quarters (87%) said that their work performance had been affected by sleep inertia. The pilots provided suggestions as to how to mitigate fatigue risk through flight request limits, duty duration maximums, and sleep inertia protections. Overall, the results of this survey can be used to identify areas of fatigue risk to be addressed through operational policies and to highlight areas in need of further research.
Objective Interfacility transports by helicopter air ambulance (IFT-HAAs) are requested for critically ill and injured patients. Requests for patient transport may originate from several settings within the referring facility: the emergency department (ED), procedural areas (such as a cardiac catheterization laboratory), or inpatient units such as an intensive care unit. Existing literature has not clarified the contributions of the ED compared with other facility settings. Methods In this retrospective modeling study, we used data from the Federal Aviation Administration, National Hospital Ambulatory Medical Care Survey, and flight request data from a multicenter convenience sample of 3 nonprofit, hospital-based helicopter air ambulance operators between 2016 and 2018. We used a deterministic model to estimate the proportions of all IFT-HAAs originating from the ED and the proportion of ED patients intended for disposition by IFT-HAA. Results Compared with all other hospital care settings, the ED is the source of more than 75% of all IFT-HAAs in this sample of 3 flight programs. Nationally, IFT-HAA is estimated as the intended disposition for approximately 0.2% of all ED patients; this result seems stable over the 3 years included in this study. Conclusion The intended disposition for 0.2% of ED visits is estimated to be IFT-HAA. Given that ED-dispositioned patients represent more than 75% of all IFT-HAAs in this sample of 3 flight programs, efforts to promote appropriate utilization of IFT-HAA should prioritize engagement with emergency physicians.
Objective Etomidate and ketamine are commonly used to facilitate prehospital rapid sequence intubation. We aimed to estimate the association between sedative agents and outcomes in this patient population. Methods We evaluated all adult patients (≥18 years) in the ESO Data Collaborative research dataset during 2023 and 2024 who received ketamine or etomidate and a paralytic agent followed by an intubation attempt for inclusion. Our primary outcome was post-sedative cardiovascular collapse (systolic blood pressure [SBP] < 65 mmHg, vasopressor administration, or cardiac arrest), and secondary outcomes included intubation success and survival to hospital discharge. To compare sedatives, we used multilevel mixed-effects logistic regression with emergency medical services (EMS) agency as a random intercept adjusted for age, sex, pre-sedative airway suction, route (intravenous vs. intraosseous), patient type (trauma vs. medical), paralytic agent used, pre-sedative vital signs (minimum SBP, maximum heart rate, minimum peripheral oxygen saturation), pre-sedative minimum Glasgow coma scale, first-attempt video laryngoscopy use, first-attempt bougie use, and treatment year. Results We analyzed 10,727 patients treated by 703 EMS agencies, of whom 5,505 (51.3%) received ketamine as a sedative before the first endotracheal intubation attempt. Etomidate administration was associated with decreased odds of cardiovascular collapse in comparison with ketamine administration (adjusted odds ratio [aOR], 0.56 [0.48-0.65]; n = 10,703). Sedative agent was not associated with the odds of first-attempt intubation success (aOR, 1.11 [0.97-1.27]; n = 10,703), overall intubation success (aOR, 1.19 [0.98-1.43]; n = 10,703), or mortality (aOR, 0.99 [0.80-1.21]; n = 3,074). Conclusion The use of etomidate as a sedative was associated with lower odds of hemodynamic instability after attempted rapid sequence intubation compared with ketamine.
Objective Endotracheal intubation requires high rates of first-pass success (FPS) to avoid complications. The Universal Stylet Bougie (USB) is a hybrid airway adjunct designed to function as a stylet and a bougie. We aimed to evaluate the usability and educational burden of the USB by evaluating FPS rates and intubation times among flight clinicians in a simulated setting. Methods A total of 24 flight clinicians participated. Each performed 4 intubations on a difficult airway mannequin using the USB in both stylet and bougie configurations before and after viewing a 2-minute instructional video. FPS and time to intubation (TTI) were compared for each configuration before and after instruction using univariate and multivariate analyses. Results Clinicians achieved 100% FPS across all attempts. The instructional video led to a decrease in TTI for both configurations. When used as a stylet, the median TTI decreased from 26.59 seconds (interquartile range [IQR]: 21.72-37.88) to 22.28 (IQR: 17.69-27.44; P = .006). When used as a bougie, the median TTI decreased from 31.96 seconds (IQR: 26.39-40.37) to 28.95 seconds (IQR: 24.01-38.24; P = .05), also demonstrating a significant reduction. Conclusion Our results suggest the USB is easy to use with minimal instruction in a simulated environment. A brief instructional video reduced intubation times in both bougie and stylet configurations. Findings are limited by small sample size and simulation-based design and are influenced by repetition bias. There is a strong indication for future studies to evaluate education retention, direct device comparisons, and patient-centered outcomes to further evaluate safety, efficacy, and clinical utility in prehospital airway management.
Objective This study aimed to characterize flight medical clinician burnout and its impact on flight team safety. Methods A cross-sectional anonymous survey was distributed to flight medical clinicians (May to July 2025) via the Air Medical Physician Association and the Association of Air Medical Services. The survey assessed work-environment safety scenarios and burnout (2-item abbreviated Maslach Burnout Inventory). Safety behaviors were compared across burnout levels using Kruskal-Wallis tests. Results A total of 450 completed responses were received. Respondents were predominantly located in the United States (n = 408; 90.7%); half were nurses (n = 226), and one-third were paramedics (n = 150). A total of 98 respondents (22.7%) screened positive for high emotional exhaustion, and 90 (20.9%) screened positive for high depersonalization. Respondents indicating burnout at least once a week indicated increased frequency of unsafe practices, such as deferring to a coworker’s decision to accept a flight despite not being comfortable with that decision (mean response, 1.98 vs. 1.63; P = .002), ignoring concerning or deteriorating weather conditions due to a need to get to the next destination (1.62 vs. 1.31; P < .001), accepting flights in any weather due to having a good pilot or crew (2.03 vs. 1.58; P < .001), deviating from employer policies to get a job done (2.19 vs. 1.91; P = .002), and decreased frequency in the use of seatbelts during all phases of flight (4.19 vs. 4.53; P < .001). Conclusion Flight medical crew respondents indicated a high degree of burnout, which was associated with work behaviors that conflict with culture of safety practices in health care and aviation.
Objective Inter-hospital land-based patient transfers on continuous positive airway pressure (CPAP) have traditionally been avoided owing to potentially serious risks to both the patient and transfer staff. Patients with respiratory failure may be intubated to mitigate these risks and facilitate the required transfer. Methods We developed a standard operating procedure for the interhospital transfer of patients on CPAP and present a case series of patients over a 12-month period. All cases were identified at the point of referral, and outcomes were measured retrospectively. Outcomes included key time events, physiological deterioration, and adverse events associated with the transfer. We also assessed intubation and/or mortality at 7 and 30 days. Results A total of 10 patients, with an average age of 47 years, were transferred on CPAP. Most were male (70.0%), and the most common cause of respiratory failure was coronavirus disease 2019 (COVID-19) pneumonitis (60.0%). We identified no physiological deterioration or adverse events attributable to the transfer process 48 hours after transfer. There was a small increase in mission durations, including time taken to prepare for transfer. Approximately a third of the patients (30.0%) subsequently required intubation within 7 days of the transfer and died within 30 days—all had a confirmed COVID-19 pneumonitis. Conclusion This case series supports the safe and efficient use of CPAP during land-based interhospital transfer for critically unwell patients with respiratory failure, including COVID and non-COVID cases.
Objective Neonatal interfacility transport of critically ill infants with severe respiratory failure is challenging. Although high-frequency ventilation is maintstay in the neonatal intensive care unit, its use during transport has been historically limited by equipment size and complexity. The TXP-2D ventilator delivers high-frequency percussive ventilation, a hybrid modality potentially offering greater stability during transport. This study aimed to evaluate the safety, feasibility, and operational stability of the TXP-2D ventilator during neonatal transport. Methods We conducted a retrospective descriptive study of infants transported by a specialized neonatal transport team between January 2023 and December 2025. Demographic data, clinical diagnoses, physiological parameters, and ventilator settings were analyzed before, during, and after transport. The primary outcomes were stability during transport and the frequency of required ventilator adjustments. Results Thirteen infants were transported on TXP-2D. Most (69%) required high-frequency oscillatory ventilation or high-frequency jet ventilation upon admission. Physiological parameters, including heart rate, mean blood pressure, and oxygen saturation, remained stable throughout transport. Most transports required zero ventilator adjustments after initiation; only 4 infants required a single setting change. No device malfunctions or unplanned extubations occurred. One patient experienced admission hypocarbia, but no transport-related mortalities were observed. Conclusion The use of the TXP-2D for HFV during neonatal ground transport is safe and feasible. The modality provides significant operational stability, requiring minimal intervention from the transport team. This “low-intervention” profile, supported by a standardized protocol, may reduce cognitive load and enhance safety during high-acuity transfers.
BACKGROUND:Dexmedetomidine is a commonly used sedative agent for both intubated and nonintubated patients. Despite its frequent in-hospital use, the description of its use in the critical care transport (CCT) environment is limited. OBJECTIVE:This study aimed to describe the use of dexmedetomidine during CCT. METHODS:This was a multicenter, retrospective review of patients transported by 2 hospital-based CCT agencies from January 4, 2024, to January 3, 2026. Transport modality (air or ground), patient information (age, sex, airway status, mode of ventilation, and Richmond agitation sedation scale [RASS]), clinical impression, and the use of additional sedatives were compiled. Descriptive statistics were then performed for each category. RESULTS:A total of 185 patients were administered dexmedetomidine. The median age was 40 years [interquartile range (IQR), 5-62], and 64% were male. Two-thirds (122; 66%) were mechanically ventilated, 34 (18%) received noninvasive ventilation, 13 (7%) received only supplemental oxygen, and 14 (8%) were on ambient air. Pediatrics were more likely to have patent airways (63% vs. 20%; P < .001). The median starting infusion rate was 0.6 mcg/kg/h [IQR, 0.3-0.9] and was titrated in 78% of cases. Additional sedative medications were administered to 59% of patients. No noninvasive ventilation patients required intubation. The infusion was initiated by the transport team in 39 cases (21%) with a median change in RASS of -2 [IQR, -3 to 0]. CONCLUSIONS:Dexmedetomidine seems to be an effective sedative in the CCT environment to facilitate both invasive and noninvasive ventilation in adult and pediatric patients. Further prospective studies are warranted to compare its safety and effectiveness with other commonly used sedation strategies.
Objective UK helicopter emergency medical services (HEMS) are often tasked to nontraumatic brain pathology (NTBP) patients, yet national provision and triage practices are unclear. Methods Cross-sectional online survey using REDCap software of UK HEMS distributed via the National HEMS Research and Audit Forum. Survey data were summarized descriptively. Results Fourteen of a potential 21 UK HEMS responded (67%). All respondents (14 of 14; 100%) reported attending to patients with NTBP. Bypass to specialist neurocenters was reported by 7 of 14 (50%); 4 of 14 (28%) had direct admission pathways to stroke thrombectomy services. Dedicated standard operating procedures/pathways existed in 3 of 14 (21%), a formal triage tool or rule-based criteria in 1 of 14 (7%), and a commissioned pathway in 1 of 14 (7%). Clinician judgment guided bypass in 4 of 14 cases (28%); 1 service cited factors such as functional status, time since onset, Glasgow coma scale, age, frailty, or comorbidities. Core interventions were widely available: hypertonic saline, rapid sequence induction/prehospital emergency anesthesia, sedation, and vasoactive support (14 of 14; 100%) and levetiracetam and neuroprotective-ventilator strategies (13 of 14; 93%). Adjunct diagnostic methods were used infrequently, accounting for only 1 of 14 instances (7%) for each modality. These methods included biomarker point-of-care tests, ultrasound (such as transcranial color-coded duplex and optic nerve sheath assessment), pupillometry, and blood gas analysis. Reported systemic barriers encompassed variability among networks and restricted access to helipads. Conclusions NTBP care is routine within UK HEMS, but triage decisions are heterogeneous and infrequently supported by formal pathways or commissioned networks. Standardized, network-supported bypass criteria that potentially incorporate point-of-care diagnostics and biomarkers could be developed and evaluated. Broader, multiagency studies capturing case volume and outcomes are needed to inform national guidance.
OBJECTIVE:Current guidelines recommend achieving a first medical contact-to-percutaneous coronary intervention time of ≤ 120 minutes and a door-to-balloon (D2B) time of ≤ 90 minutes in patients with acute coronary syndrome (ACS) requiring urgent reperfusion. Although prehospital electrocardiography (ECG) in ambulances has been shown to reduce mortality and D2B time in patients with ACS, its effectiveness in helicopter emergency medical service (HEMS) remains unclear. This study aimed to assess the impact of prehospital ECG on time to cardiac catheterization, mortality, and prehospital treatment by flight physicians in patients with ACS transported via HEMS. METHODS:Using data from the Japan Society for Aviation Medicine Doctor Helicopter National Case Registry System, we retrospectively analyzed patients transported by physician-crewed HEMS between April 2020 and March 2023, who were suspected of ACS and underwent coronary angiography. RESULTS:Of 499 eligible patients, 204 (41%) were in the non-ECG group and 295 (59%) were in the prehospital ECG group. Prehospital ECG was significantly associated with a shorter time from hospital arrival to cardiac catheterization (risk difference, -9.1 minutes; 95% confidence interval [CI], -17.5 to -0.8 minutes), despite a slightly longer time at the scene (risk difference, 1.09 minutes; 95% CI, 0.11-2.09). Nitrate administration was more frequent in the prehospital ECG group (odds ratio, 2.70; 1.40-5.10), whereas all-cause mortality did not differ significantly. CONCLUSION:Prehospital ECG in HEMS was associated with a shorter time to cardiac catheterization, potentially improving ACS management.
OBJECTIVE:Helicopter emergency medical services (HEMS) and search and rescue operations represent the intersection of aviation complexity and clinical criticality. Despite technological advances in simulation, most training programs remain fragmented across aviation and medical domains, failing to integrate the human factors that determine mission success. This program report describes the longitudinal development of an integrated HEMS simulation training system, from early low-fidelity cabin prototypes to contemporary multi-sensory and hybrid simulation environments, and proposes a systems architecture framework applicable to next-generation air medical crew training. METHODS:We describe the staged development of a longitudinal HEMS simulation training initiative in multiple years, evaluate relevant regulatory and competency-based training frameworks, review international centers of excellence, and synthesize lessons learned into an architectural proposal for integrated air medical training systems. RESULTS:Early multi-sensory simulation incorporating cabin noise, smoke, temperature changes, and communication systems demonstrated that clinical performance degrades significantly under operational stress-a finding now validated by evidence-based training frameworks. The September 2024 European Union Aviation Safety Agency regulatory update removing Full Flight Simulator mandates for helicopters, combined with virtual and mixed reality qualification milestones, creates unprecedented opportunity for hybrid training architectures. CONCLUSION:HEMS training requires systems thinking-not isolated course development. Organizations designing next-generation programs need professionals who can integrate competency frameworks, immersive technologies, behavioral assessment tools, and clinical-operational training into unified ecosystems. This report provides an architectural blueprint applicable to HEMS, search and rescue, and critical care transport.
OBJECTIVE:Rapid sequence intubation (RSI) in helicopter emergency medical services (HEMS) is conventionally performed at the scene before transport, potentially delaying time to definitive care. The feasibility of performing RSI during flight in civilian HEMS operations has not been established in the United Kingdom. We evaluate the feasibility, safety, and temporal efficiency of performing simulated in-flight RSI in an AW169 helicopter under operational flight conditions. METHODS:A prospective proof-of-concept study using high-fidelity simulation was conducted across 2 phases (May 2023, January 2025) at the Air Ambulance Charity Kent Surrey Sussex. Eight simulations were completed by 4 distinct clinical teams comprising operationally experienced HEMS physicians and paramedics. Scenarios replicated a standardized traumatic brain injury scenario requiring RSI during the return transit phase. The primary outcome was time from RSI checklist initiation to confirmed intubation. Secondary outcomes included overall mission times, safety events, and crew-perceived feasibility assessed via post-scenario questionnaires. RESULTS:All simulations (8/8, 100%) achieved successful first-pass intubation. Median time from checklist initiation to confirmed intubation was 5 minutes (interquartile range [IQR]: 5-7). Median total mission time from base departure to RSI completion was 42 minutes (IQR 40-44). No safety events, procedural complications, or communication failures occurred. Crew questionnaires (93% response rate) confirmed unanimous perceived feasibility, with participants identifying adequate workspace, effective communication, and manageable equipment accessibility. CONCLUSION:High-fidelity simulation demonstrates that in-flight RSI is technically feasible in an AW169 helicopter, with consistent procedural times and no safety events. These findings may support further evaluation of in-flight RSI as a complementary strategy for time-critical patients where scene-based airway management may delay definitive care.
Objective Out-of-hospital cardiac arrests (OOHCAs) occur at sporting events. In the United Kingdom (UK), the outcomes remain unclear. This study aimed to perform a systematic literature review to establish the outcomes of OOHCA associated with sports in the UK, alongside a literature search of online media. Methods PubMed, ISI Web of Knowledge, and Embase were searched from inception to March 2025 (PROSPERO CRD42024557120). Data were extracted relating to demographics, sports, medical care received, and outcomes. A quality review was undertaken with the Newcastle-Ottawa scale. In addition, an online media search of Google News and BBC News between June 2021 and October 2025 was performed, with similar data extracted. Results From 10,026 studies, 12 studies were included, totaling 578 patients. Most were male (91%), with a mean age of 43.2 years. Limited data were presented regarding the actual OOHCA event, for example, presenting rhythm. Twelve patients were detailed as having a full neurological recovery. Postmortem data suggested that cardiomyopathy and sudden arrhythmic death syndrome were common causes. In addition, 82 OOHCAs (95% male) were identified from the media search, with 29% younger than 40 years and an estimated survival rate of 62%. Conclusion The exact outcomes of OOHCA associated with sports in the UK are difficult to establish, with the incidence potentially under-reported. Survival rates do seem to be higher than the general population, based mainly on online media evidence. A prospective data collection tool would allow a greater understanding of the outcomes, incidence, and contributing factors for a UK population, to help plan prehospital medical input.
