This month, we were live from the Chagrin Valley Fire Department. We discussed air medical care with Kyle Schnarrs, Flight Nurse, and Nathan Brazytis, Flight Paramedic, from the UH AirMed critical care transport system. We talk how to become a flight paramedic/nurse, day-in-the-life, as well as just how much goes on in preparation for flight, plus so much more!
Prehospital Paradigm Podcast
Helicopter Critical Care Transportation - Part of the EMS Team, Part 4
(upbeat rock music) - Hey everybody, welcome back to the pre-hospital paradigm podcast. I'm Scott Woldenheim, we've got Dr. John Hill with us. And our Aeromedical Series this month, we have returning Kyle Schnars. These are our flight RN and for UH Airmen. And down there subbing in for Mr. and A preside us, who actually had to work tonight and didn't get the night off to do podcast things. We have a sub in there. We have a paramedic Andrew Cumberledge down there. So Andrew, thank you for joining us, buddy. We appreciate you getting on here. We are coming to you live from Shagrin Valley Fire Department in Shagrin Falls, Ohio. Gentlemen, ladies, thank you so much for having us here. This is awesome, we got a great turnout. And yeah, so let's, we got a dispense with all of our housekeeping stuff first. And of course, just a reminder to everybody, you now can get free, free Ohio's continuing education for all of the, all of these podcast series. So just hop onto pre-hospitalparadigm.com and our website. Not only will you find there all the show notes, various other little projects that we're working on there, like Dr. Spanner and Dr. Singer does a whole series on great cases, our pharmacy Fridays, all of our other free open access medical pieces. All that's available in pre-hospitalparadigm.com. And then right in the middle on top there, if you click on earn free CE, you can get, you can get all the CE for these, for all of these recordings. The just a quick plug for you guys down there. You guys recently stood up a new website. So that's uhairmed.org. So check that out, that's brand new, all with all the new branding and all the new pieces that reflect UH AirMed and all the UH system. And of course, we are trying to build some audience on YouTube. So however you consume us, whether that's through the website, whether that's audio, whether it's a video product, next time you're poking around on YouTube, if you don't mind hitting that subscribe button. Again, however you can see what's great, but we're trying to build some audience there for some algorithmic things that we're trying to get the computer to behave and get this out to more people. But yeah, we'd love if you hop over YouTube and hit that subscribe button. And like always, not only do we have, we have the onsite crew here from Chagrin Valley. All of you are welcome to hop on either Facebook or YouTube in the comments section, post us a question or a comment for these guys or anybody up here on the team. And we'd absolutely love that if you jumped on. The all of this is brought to you by AT&T FirstNet. So all of this going out into the world, all this goodness going out into the world, it's all going out on the AT&T backbone. So they provide all that service for us. That is the first responders network. And if you're not already on AT&T FirstNet, if you go on, shockingly, pre-hospitalparadimed.com backslashfirstnet, there's a special offer that they've extended to you, through us, which is very gracious of them. In addition to that, all this data's being sent out over a cradle point modem, that is the interface to the network. And that was all that's been provided graciously by CradlePoint. So thank you both FirstNet and CradlePoint for your participation in this series. So guys, welcome back real quick. First, are we as good as we're gonna get? All right, as good as we're gonna get. So hopefully we had to tune down a little bit, make sure we get out to everybody tonight. But guys, thanks for having back in here. We appreciate you coming on. I've got a ton of just great feedback on the episode. And yeah, it's been phenomenal. So the, I guess just a quick little recap on some things. What's, I guess, certainly recap kind of, how did you get in air medicine? And then we've kind of heard a little bit of that on the recorded piece. And then Andrew, we haven't heard your story. How are you lined up here? So Kyle, I'd like to kind of recap what we've already talked and how did you decide to wind up in your medicine? Yeah, so my dad was a nurse. So he got me into nursing and I knew I was gonna be a nurse since middle school. And in high school, I went to the trade school in Trumbull County, and when I was there, I went for a program called Health Science Academy. So I graduated with a pharmacy technician certification and a nurse assistant certification. Also did some pre-nursing stuff. When we were sitting in class one day, a teacher, I just read a paper and said, "Right on what you wanna do." I had no clue what I wanted to do. So she said, "Look around the room for inspiration." So I just picked her on the wall of a flight curtain back to helicopter to work around a patient. So that looks awesome, I wanna do that. So that got me hooked on it. And it's pretty much dead set since then and ended up going to school for nursing and everything I've done since then was to get on a helicopter and here we are. And I understand you recently graduated NP school. - I did. - Yeah, congratulations. Congratulations. What's your story Andrew? How did you wind up on a helicopter? - So I started, I live up in Northeast Ohio, kind of my family's got pretty lengthy public safety background mainly with law enforcement and everything. I wasn't really too interested in the law enforcement side of things. So I decided to kind of venture into volunteer firefighting and then became part, like volunteer firemen ended up going to a trade school kind of the same thing Kyle mentioned and graduated my senior year with my EMT basic certification my level two fire and some hazmat stuff. Got on the local ambulance service still there and throughout my time working on the ambulance kind of worked part time fire for a little while got some experience in the ER some experience in the ICU when they did kind of like a paramedic tech program or paramedic tech position in the ICU did that for a little while. And then mainly just being on the ambulance once I've felt confident in my role as paramedic I didn't really want to just stop there kind of wanted to push what I was able to do and be able to do more. Especially when you're transporting a patient to the hospital, you've done everything you can and they're still sick. I just wanted to be able to go further than what our ground protocols allowed. And then as well as working on the ambulance getting the car accidents or the super sick patients that you elect to fly watching the flight crew come in, do their thing, helping them load, watching them take off. That's kind of what pushed me towards the flight side of things. And then got my first job doing fixed wing critical care transport, did that for about a year. - No way. - Did all over the US, Canada, Mexico some of the outlying islands. And then a position at the middle field opened up while they were PHI and I was fortunate enough to get a position there. So, I've loved that ever since. So it's best you have in the world. - Let's talk a little bit about for those maybe didn't watch all the previous episodes and stuff. But just a little bit about what capabilities you all have that separate any aerometrical program from a ground ambulance, what's the advantage? - I think some of the biggest advantages is, especially at AirMed, we carry two units of pecra blood cells with us on every flight. In the event that we need to continue blood from picking up a patient at a facility or if we need to start blood on a patient from a scene. And then the use of mechanical ventilator, the ability to rapid sequence, innovate patients. I know that's kind of spreading more onto the ground side of things, which is good. But primarily, you know, a long time ago, that was like one of the key features of calling an aircraft if you've got a difficult airway and being the RSI procedures. A lot of the advanced hemodynamic monitoring stuff, balloon pumps and pillows, working with those patients. And then just a variety of our medications that we carry in the protocol that allows us to kind of spread beyond what ground protocol allows. I think you're kind of nudging up on a point I wanted to make here in a little bit, which was a lot of the audience being pre-hospital providers, they see the scene flights, they conceptualize the trauma component or the time sensitive medicine component of it, but a large component of your work is actually inter-facility stuff with a lot of very specialized equipment. And you kind of touched on impella and balloon pumps for those who have no idea what those are. I mean, you kind of give a little description on some of that stuff that you wind up having to manage and wind up getting to manage. - Yeah, like Scott was saying, probably about 80% of our calls for our program specifically are gonna be inter-facility. And that varies program with program. But yeah, probably 80%. And as far as these cardiac device capabilities we're talking about, like balloon pump is essentially, it's a balloon. And that balloon sits between the radial artery and the subclavian, and it sits in the aorta. And every time the aortic valve closes, that balloon inflates and it actually pushes blood back into the coronaries. So somebody who tells the STEMI and they have decreased perfusion, decreased oxygenation of the heart, that's actually pushing extra blood back into those coronaries and assisting them with decreased oxygen demand, that sort of thing on your heart and can help them get too definitive care to where they, maybe they need to pull that clot out with whether it's a cabbage or a high-risk PCI and they don't have the capability somewhere else. And then as far as the impeller goes, the easiest way to describe that is it's called impeller 'cause it's an impeller. - An impeller, yeah. - It's basically a, like I said, an impeller device. If you look at like a jet ski pushes water through or what it really looks like is, it looks like a McDonald's straw, or yeah, like a McDonald's straw, the fan in it, spends about 40,000 RPMs and helps push that blood to the rest of the body. They have new ones out that can do up to five liters, six liters, that sort of thing. So they're pretty progressive and there's been a lot of research on them now too that's showing they're pretty helpful and different types of shock and maybe even more beneficial than a balloon pump and a good handful instance. - Right, right, yeah. - Pretty cool to be able to take those-- - Turn buying on a wire. - Yeah, to help with the, it's kind of what it is, right? Then yeah, you kind of touched on all the ventilator management that you guys do and-- - I think that one other cool thing that we do-- - Yeah, absolutely. - That we didn't talk about with some of the surgical stuff. - Yeah, well, I mean, the surgical stuff has become very relevant here lately. It's in the middle of trauma season. - We've been doing surgical airways. - Yeah, even doing a bunch of stuff lately. - Finger Thor costume, he's pretty consistently, so that's pretty big in our repertoire and we train that quite a bit. When it's needed, it's needed and it definitely works, so. - There was a case recently you were just telling me about where they've done a surgical crime. - Yeah, we had a crew did a crime and they did finger Thor costumes on the patient, too. And yeah, it was a pretty intense call for them, so from listening to them talk, they did an excellent job as far as managing that patient and we're actually able to get them to the receiving facility, so. - Yeah, try 'em, so. - Pretty neat, so. - And then, of that care, how much of that, how much of that do you guys do in the air? What, what, like, let's say you show up on a scene flight, how much of that stuff do you reserve for doing on scene versus doing in flight and what kind of is your decision making real time when those things are going on? - I think the biggest decision for scene flight instances is anything having to do with the airway, we'll try and get done on scene, mainly because we've got more hands to help, it's we've got a wider area to work in. In the back of the aircraft, when you've got, sit next to your partner and you've got the patient laying on one side and all of our equipment laying on the other, there's not a whole lot of room to work to drop medications, prepare equipment, position the patient, whereas in the back of an ambulance, you've got ample room to kind of take care of all that. So airway is probably one of the biggest things that we'll try and manage first in the back, and then as well as just being able to reach certain parts of the patient in the back of the aircraft, any type of injury or illness from like the waistline down bilateral lower extremities, we'll try to manage first. Once that patient's loaded up, it's kind of hard to reach the lower legs to take care of anything because they're tucked in. And then, yeah, that's pretty much it. I mean, it's the two biggest thing for all of you. - We were talking earlier when you were doing your presentation before, how much room do you guys have to like, sneak that patient through and then what do you really have access to when you're in the helicopter? - So our tunnel is pretty tight. We fly in an ECE 135 P2 Plus, and our tunnel has the whole avionics deck in the back too, so that's all our electronic controls for that aircraft. And from the top of the cot to the avionics deck is only 14 inches, so it's pretty tight. And even if you include the space down below, even a crawl back there, I mean, it's pretty tough to crawl back there. I've done it on one or two instances and it's not fun. But I mean, it's manageable, but it's not fun. So if we have the chance to prep the patient beforehand and not have to crawl back there, I'm all about it. - I think that kind of ties in with the first question here and we've got online. Danny asks, what are the key differences in clinical practice and operational challenges between working as a flight nurse and as a ground paramedic and how do you adapt those skills to meet those demands in the air? - So some of that we kind of already touched on, but I mean, think about your time on the ground versus both of you and I know you've worked a critical care ground as well. - I think the biggest thing, at least on my side and the paramedic side, going from ground to air, is I didn't have a whole lot of experience with like, even just little things like medication pumps, learning how to program medications when it comes to concentration, dosage, weight-based dosage, getting the pumps figured out. A lot of EMS and paramedics, we're good at the trauma stuff, we're good at the airway stuff. That's kind of like our bread and butter, but in terms of, you know, with 80% of our volume being inter-facilities, unless you're a paramedic that has hospital experience working in an ER or on a floor somewhere, you don't really, that's where the nurses, the expertise kind of comes into play is to get report from the other nurses, certain key things that they look for that we may not think of yet is kind of the biggest thing, at least from my perspective. - I guess let's talk to that a little bit, is that relationship between providers, right? That nurse medic, you know, is there a hierarchy here? How does this role on, you know, you pointed out, yeah, a nurse might be better equipped for some of these things, but then conversely, I'm sure, on a scene, you know, on a scene up, medic may be more for some things, but what's that nurse medic relationship like in this program? I mean, I understand it differs in many, but-- - For sure, so with our program, we pretty much hold each other to the same standard. There's no ones better than the other, and I think we all have something to bring, and if we're not learning from each other, then we're not doing this job the right way. - Right. - So we hold each other to the same standards, as far as skills and capabilities go. Andrew can do the same thing as me, and I can do the same thing as Andrew, whether that's inhibiting a patient or starting a drip. There are some nuances with the states that-- - That law? - Yeah, that required-- - No, we may or may not be working on changing. - Yeah, so there's certain things that the state requires for the nurses to do, but it's one or two things, and it's minimal, but otherwise, I mean, we're expected to all be able to do the same job, and all be able to do it at the same level, so it's really, like I said in the recorded ones, is if you were to stick us next to each other and have us do the same job, we should be doing it exactly the same. - Exactly the same, yeah. - Yeah, that's really awesome. So we've got another question here from the interwebs. Cassie asks, "Because of the noise in the helicopter "it's being so loud, how do you monitor the development "of any potential chemo and pneumo with thoraxes?" - Yeah, so that one's an interesting one. That was actually something else I was gonna bring up when one of that first question was, "It's loud." So listening to the patient is not really much of the name. It's pretty tough. I mean, they do make electronic stethoscopes you can use and put them on your helmet and that sort of thing, and they work, but they're not the best. A lot of times these patients that do end up with these hemoneumos, they're always maybe managed. So we can watch the vent settings and watch their static compliance and their pips and their plateau pressures and that sort of thing to see what's going on. And really just keeping an eye on the patients, the ones that aren't tube, the patients that aren't tube, that sort of thing. We're continuously talking to them, how you feel and what's going on. Do you get any pain or you get any discomfort? Are you having a difficult time breathing? And I mean, our eyes are on that patient the whole time. That's one cool thing with critical care transport and EMS that as a nurse, you don't really get to see when you're working in an ER, you take care of four or five, six patients or even in the cardiac ICU, take care of two, three patients sometimes at a time. So you're jumping back and forth. This, we're right there. Eyes are on the patient the whole time, we're watching, we're looking for that increase in worker breathing, we're watching them breathe faster, we're watching them, maybe win some pain or discomfort and watching those vitals pretty much every second. So it definitely makes it easier to catch that sort of thing for sure. - Yeah, I guess that would be different from a nursing perspective, coming out of the hospital as you have, you know, a multi-patient to one ratio and now you've got, well, let me know. In your case, in the critical care space, almost exclusively two to one patient care ratio. So yeah, you've got a bunch of eyes on all the time. Yeah. - You talked about doing between intubated and non-intubated. What, and I think with this, we talked about in the recorded show, what decisions going to you deciding 'cause we always think that, oh, we're gonna call the helicopter and they're gonna intubate. - Yeah, we did talk about that, yeah. - Yeah. - So what goes into your decision making of when to intubate a patient, when not to intubate a patient, what's your thought process behind that? - Yeah, so as far as that goes, obviously not everybody needs to intubate it. Is it gonna be more harmful to that patient to put a tube down their throat? The risk of morbidity and mortality increases tenfold when you throw a tube in somebody. So that's something we're considering the whole time. Are they really, is there really something that's gonna make it worth it? Like me and Dr. Hill had that conversation before and we talked about it in the recorded tube was, in this job, it's not the decision to do something. Sometimes it's the decision to not do something that really makes a difference. And that's kind of how we decide that, I guess. - Yeah. - I think obviously we wanna secure airway for transport. If there's a question about that airway, the default is to go to secure it. There's definitely caveats and minutiae in there. When to intubate, when not to intubate. If someone's breathing 30 times a minute, we can't really reproduce that on a ventilator. So we wanna let their intrinsic drive them, right? And in recent practice, probably since you started practicing, we're transporting less patients intubated 'cause we have other tools. We have non-invasive tools, we have non-invasive positive pressure ventilation, whether that's in the pre-hostile space, CPAP. You guys probably do BIPAP, right? - Yeah. - We've got air-voe now that can do high flow oxygen, just via the nasal cannula. So we have a lot more tools now that we're not taking a lot. We're innovating less patients, which is actually good for patient care. - You talked about the patient breathing over 30 times a minute. We just had one three nights ago out of an outside facility that we got there and they had a Montgomery T2. Never seen it before, but very interesting. It's basically, yeah, it's for trachial stenosis. It looks like a trach, but it goes in and actually goes up and down. And the referring facility was trying to BIPAP this patient through this and they had the lady's head wrap like a mummy and we're trying to close her mouth and her nose to be able to get it to work. And it was a hot mess, but when we got there, we took her off everything 'cause she didn't eat it. She just, she needed to breathe on her own. She was a decay patient, her blood sugar was 1467, or decay, which is through the roof. So they were given her meds and we let her work herself out 'cause she was compensating well, just breathing on her own. But that's, again, one of those situations where are we gonna put this patient on the vent? Are we gonna take their intrinsic drive because in that case, we would have taken that and slowed their rate. Dainty probably would have killed himself. - Yeah, absolutely. All right, we got another question. Any questions? - In the room. - In the room. Caleb's not circulating. Caleb's hiding in the corner. - You gotta like, you gotta like... - Listen, my ankle's all stung up. I can't hold this. - Oh, it's such a suck of wuss. Okay. So, walking off his boo boo. - Hold it. So, from what I'm listening to, it really sounds like these guys and you need to take care of a lot of things before you put them into the chopper. So, including that question regarding the hemo pneumothorax, that would be something that you would think that you'd want to take care of before you're in the air. Is that accurate? - Yeah, 100% if we have somebody with that, we're definitely going to try to manage it beforehand. Sometimes it does happen where it develops in flight and we have to manage it. But most of the time we get on scene and somebody's got a tension new mo and we're going to decompress it in the back of the squad and if we have to finger-thore cost me and we're going to do it in the back of the squad, it's definitely not ideal to do it in the back of the aircraft. So, to kind of go along with that, with our equipment and stuff, you said there's only 14 inches to get them in there. Lucas is obviously can't get in there. Is there certain stuff that you don't want us putting on him and he said stuff to do? What do you stuff you don't want us to do? - I don't think in terms of equipment size, there's anything, Lucas devices are obviously one thing that won't fit in our aircraft. So, if we're coming to a scene and the patients in a traumatic arrest, typically what we'll do is we'll stay on scene with you guys, do what we can help stabilize the patient and then more often than not, we'll just ground transport with you to the hospital unless the, you know, unless Rosca's obtained, we can pop the Lucas off and then load them at that point and take care of them in the air. The unfortunate thing is if they arrest again in the air, then, you know, we've got to do CPR in the aircraft and that's, you know, that's something we have to deal with then on our end. - It's a tight squeeze, yeah. Very tight squeeze. So, I've done it once. We did it for 25 minutes from Ash to Biola County and it was not fun. It was very coordinated, but it was not fun, especially two people in the back bouncing around, trying to get it done, but. - You got another one? All right. And on landing, do you guys recommend us pulling a line and having water available and ready to extinguish if we need it to? - Of course comes to worst. Yeah, if you first see any issues or anything like that, yeah, it's definitely not, we're definitely not going to frown upon that by any means. I've actually gone to landing zones for PR events where they've done that for us. So, definitely not a bad idea if you have. - Well, it's a cool kind of thing to do is always have a line around you. - Yeah, totally, not everybody does it anymore, but I mean, we're definitely not going to give you a hard time about it or anything like that. - It's definitely not going to hurt. - AOK in our books, so yeah. - We got a couple more questions online here. So, I got that drawn up there. And this kind of plays in with what Dr. Spanner said and what we're talking about development of hemo-numo authorities. How much is atmospheric pressure play in part the treatment during flight? - Good question. - Yeah. - I think with the altitudes that we fly at around here in Northeast Ohio, it's definitely a factor to keep in the back of your mind. I wouldn't say it's a huge determinant of how you're going to base your treatment off of. A lot of the times, even just flying around local area, going from wherever we're going to, and then going up to Cleveland, we're usually not typically, most of the times not going above 3,000 feet, maybe. We may be going a little higher if we're doing IFR flights because the weather's kind of iffy. We'll fly a little bit higher if we're doing a longer transport, if we're going down to Columbus or - Marietta. - Marietta, places like that. To get there, we'll climb an altitude from three to 4,000 to 5,000 feet. But with patient leg, we usually don't stay that high. So I wouldn't say it plays a huge factor in monitoring certain things closer than another. - Your previous experience on fixed wing was-- - Yeah, my fixed wing experience, it was definitely a factor that we had to take into consideration. So we flew the Learjet 35 and 45s. So typically, even on our short flights, we were going anywhere from 30 to 45,000 feet. And then maintaining a cabin altitude of a certain, whatever the pilots deem necessary. If we've got a certain patient that requires a lower altitude, they would usually accommodate to just fly at a lower altitude to help us out. But then you have to worry about like, we're going to be flying at 45,000 feet so do we have to take the air out of the ET tube and put water in it type of thing. - Stuff like that. - I've personally never had to do that. Some of my coworkers from my past job, you had to do that a couple times just because going from San Bernadino to upstate Maine, on their flying at 45,000 feet for four or five hours. And then, on descent, once you get to a regular altitude, so to speak, just replacing the water with them with air. - With air. - I think another caveat to that with, that's a really good question. Another caveat to that would be small patients, neonates and pediatric patients that are really young. That pressure is going to affect them a lot more than it's going to affect an adult. So that's something we'll consider. And like Andrew said, in his past job that the pilots would accommodate, our pilots are good for, if we tell them, "Hey, we need you to fly at a little bit lower out to fly at 900AGL compared to, I don't know, 1500AGL, then they're more than happy to do it and make things work for us for the patient, so. - No, that's awesome. That was a great question. Then we have another here. Anybody else? Oh, we got one in, yeah. - And what's the difference in care capabilities between you guys and Metro? - Oh, okay. Yeah, no, that's cool. That's a good question. So differences in care capabilities. I'll be honest, I'm not 100% sure on all of Metro's capabilities. I know Metro flies, I just listened to a, it was a lecture series with one of the NPs that flies for Metro. And he was talking about some of their capabilities and that sort of thing and their crew configurations. And Metro flies with a nurse, nurse practitioner configuration. So they do bring a provider, which I think is beneficial, especially in inter-facility transports. If you get somewhere and somebody needs a central line or an art line or something like that, instead of maybe burdening that on the emergency physician or ICU physician, they have the capabilities to do that sort of thing. They also can do chest tubes. We do finger-thoracostinies, they do chest tubes. So that's one difference there. The only difference between that is putting the tube in and not putting the tube in. Both are gonna help the patient. One's gonna be better for monitoring long-term, but otherwise, that's pretty much it for the most part. I've heard of Metro doing some, like, emergent on-scene C-section sort of thing, but that's very few and far between too. So otherwise, capabilities are pretty much the same for the most part, yeah. Got one, good one. - We were just talking about altitude and how it affects patients. - How much do you guys, as medical personnel, need to know about the flying aspects? - Ooh, that's super important. - Yeah, yeah, I'll let you kind of go on. - So the, in terms of moving from the ground to air transport, a lot of the employees, such as the paramedics and nurses, we all have to go through courses that pertain to flight physiology. So you learn about all your different gas laws, how altitude affects different patient populations and things like that. So a lot of it is, I'm losing my train of thought here. - You take over to see if it comes back up. - You're saying like the flight physiology and that sort of thing. - Yeah, so they, as far as like aspects of flight, flight physiology, understanding weather patterns is big. Some of the, the physics of the aircraft are big. We talked about that in recorded session. - Yeah, absolutely. - Things like vortex ring states, it's, you want to know your winds. So like, us being able to look out and say, hey, our winds coming out of this direction, you might want to come in this other way, 'cause you want to come into the wind because you don't want that wind recirculating, you get that dead air. The dead air will actually kind of drop you out of sky. So knowing that sort of thing, being able to anticipate things that the pilot's going to do. So that way, we're not bouncing around in the back of that aircraft, we're trying to take care of a patient. On top of that, we fly single pilot. So one of us is in the front with that pilot. And we're helping with radios. We're helping with, you know, looking out for other aircraft. And that's, you know, that's something they teach us too, is, you know, scanning and all that sort of thing. Making emergency calls, assisting with IFR checklists, assisting with emergency procedure checklists. So really they expect us to know a lot of it. So it's pretty important. - Yeah. - Well. Anything else? - The, we've got a-- - How often are you on IFR? - So that's a, that's an interesting question. We train it pretty regularly. It's difficult in this area because everything's so close that doing an IFR flight compared to transporting somebody by ground is not always justified 'cause it may take longer. One misconception about IFR is that we can just pick up at a hospital and land it at another hospital. Unless there's some sort of pins approach, such as like, the Cleveland Clinic has a pins approach or Asheville County Medical Center has a pins approach where we can specifically bring our GPS, or use our GPS to bring us right to that pad. We can't do that to most other hospitals. So if we're doing an IFR transport, a lot of times we're picking up at one airport and transporting to another airport, whether that be Burke Lakefront or Youngstown, Warren Regional. And so it does extend our time a little bit. And then we have to have ground transport on either end of that to get the patient from the airport to the receiving facility. So we do it, but it's not super common. But we do have the capabilities to do it and it's been helpful in the recent years since we've transitioned to an IFR program. So yeah. - Can you, for the sum of us, explain what IFR is and what other types of flight might be? - Yeah, yeah. So IFR stands for instrument flight rules. Any time we're not flying IFR, we're flying what's called VFR visual flight rules. It basically just means that clear blue 72 outside, picture perfect day, you're able to just lift, go to your scene, go to your hospital, pick up the patient, fly to the receiving, land at the receiving drop the patient off. And you're good to go with flying IFR. Basically the weather is hanging around what we call minimums. So when we go to do an IFR flight, it takes a lot more planning on the pilot side because not only do they have to figure out everything on their side of the house, but now we have to schedule to have an ambulance, pick us up somewhere around the referring location. And then once we land at the hospital that we're gonna pick the patient up from, we land at the airport, go to the hospital, pick them up, bring them back. And then we have to do that exact same thing on the receiving side. So like Kyle said, landing at Burke or Youngstown Warren or Cuyahoga County, wherever. And then now we have to get back in an ambulance and drive to the receiving hospital. But IFR is basically where super cloudy outside and you're flying in the clouds the entire time. So it's basically in terms of trying to imagine it. If you're sitting up front in the helicopter and someone just puts a giant white sheet over the windscreen and you're basically just sitting inside a white ball. And you can't, you can't really, it kind of looks like nothing's moving sometimes depending on how dense the clouds are. Sometimes you're able to see if the clouds are patchy, flying between the clouds. Most of the time it's basically just like sitting in a white ball and you're looking at the GPS and you're watching yourself track across to where you're supposed to go. But it also just kind of feels like you're sitting and they're not moving. - The pilots up there looking at all their controls and they're looking at their artificial horizon and their altitude and that sort of thing. So they're not looking out, they're looking straight down and that's not what they're looking at. So you could pretty much blackout everything in front of them and they can fly that thing from one spot to another. A big piece of that is whether we're gonna be able to break out or not. And that's what Andrew's talking about minimums is we have to be able to, we follow an approach and that approach there's different points so where you need to be a different altitude. And when you get to a certain point in that approach you need to have broken out of the clouds. So gotten out of the clouds and were able to see the ground, see what's in front of you. And if you can't do that, you have to go back up and you have to find somewhere else to go. So definitely can be a hindrance and a transport for sure. - Awesome. We have another online question here. This is from Eric. This is what does your debrief post call look like? - So a lot of our debriefs, that's a good question. When we come back after a mission and we're landing back at the airport, one thing we always kind of say to our comms is we're down back at base negative debrief. And I believe a lot of that negative debrief started with COVID in terms of whether or not we were gonna be on a little bit of a delay so that we could clean and sanitize the aircraft. But if we've had a lot of our debrief, I would say is between the pilot and the medical crew, once we're done, we get restocked, get the aircraft ready to accept the next mission. We go inside and our crews are really good with it. Our pilots are really good at being included with it. Our mechanics too, on some of them, is we'll all just kind of huddle in our office where we do our charting and everything. And there's no formal process I would say that we go through. It's more of just everybody kind of expresses how they think everything went, maybe things that could have gone better, things that maybe one person caught that the other person didn't, things that maybe have been missed entirely. And then we just kind of bounce ideas back and forth. Like how can we do better next time? Or what can we do to maybe avoid a certain situation, maybe take care of this from now on at the referring facility before we get in the air? Just so it's one less thing to worry about. But, and then a lot of our formal, I haven't been part of any formal debrief with AirMed yet, is then we would go through UH to do any type of formal debriefing scenarios if it were due to a bad patient outcome or an injury or something like that. And that's, I've been through a couple of those for some pretty intense calls. As far as the formal process goes, generally within hours somebody's calling us, hey, I heard you guys had a tough call. What went good? What went bad? How can we help you? Do you guys need to talk about things? Do you need a break? So we do have a lot of support on that end as far as dealing with difficult calls and that sort of thing. And fortunately they're really good about reaching out to referring facilities and EMS providers that were on the call with us too. - Yeah, yeah. - One specific area to go is we had a really bad call for a pediatric patient with a shard and flyer in Geauga's emergency department. And within hours we were getting called, we were getting texts, we were getting everything under the sun. And the same thing happened with Geauga's ER and shard and fire. And they had grief counselors at the ER, they had grief counselors at the fire department. So we do get a lot of support in that sense as far as the debriefs for that sort of thing go. - So that was a question specific to the debrief. But we'll talk a little bit about what you guys brief on at the beginning every day. And then when you get a fresh pilot because your pilot doesn't work 24 hours like you did. - Yeah, for sure. So our pilots are 12 hour shifts, their max timeout is 14 hours. So we get two pilots a day in the morning and at change shift for the pilots, we always do a debrief. And this is after we check all our equipment, make sure everything's good. - It was an accident, but that ran out. - All of us as a crew get together, we'll talk about weather, we'll talk about our current fuel status, how far we can go, the size patient, we can take our oxygen that we have on the aircraft. We'll discuss, we have a specific topic every week that we discuss, whether it be like a brownout or a whiteout or ditching over water or any number of things, wires. We always have a safety topic we discuss. We'll go over any sort of temporary flight restrictions in any areas, any issues that are happening somewhere with something or another. If there's any maintenance that's going on, a lot of times in the hospitals and that sort of thing, we'll send out notifications if there's cranes in the area working on a building or something of that sort. So we'll talk about all that, just to kind of prepare us for the days, the way we're ready for anything that comes at us. That was our call counter getting thrown up there. They got their first call they were guaranteed to have. - Oh boy. - Everybody gets one during a live show, it's a guarantee. So we have just come off of this outrageously hot heat bubble that's been camping over northeastern Ohio. How does that affect, let's do this in two parts, aircraft performance and then human performance on your behalf. - I want you to start on the aircraft performance. - So the, obviously we take a new account more than just the heat, we take a new account, the humidity as well, density, altitude, those are things that the pilots look at. This last week when it's been super hot and then an even higher heat index, it affects the aircraft's ability to perform in terms of depending on how hot it is, how humid it is, what the density altitude is and how much fuel we have on board currently plus the pilots will plug in the crew member's weight plus the pilot's weight into a total weight and then it gives out an available weight that we're able to pick up from the pad where we're at. The aircraft performs, it doesn't perform as well in hotter altitudes than it does in cooler altitudes. The aircraft loves colder altitudes, it performs a lot better. So when it's been hot and humid, we're not able to take as much weight and along with that, we're not able to take as much fuel either, just because of the whole weight travel and burn off and everything, right. So the cooler it gets, the more weight we can carry, the more fuel we can carry and things like that. When it's hot and humid, our two biggest concerns is our fuel weight and our patient weight. And then obviously as we're in the air, going to a referring facility or for a scene, the more fuel we burn off allows for a heavier patient. If we get on scene and we're at a point where, you know, we can't accommodate the patient because we've got too much fuel, the pilots will actually lift from the scene and orbit for a little while to burn off fuel to accommodate for that patient, yep. - And what's your burn rate for the helicopter? - I guess three gallons per-- - So we burn a gallon a minute. - A gallon a minute, yeah. - So a gallon a minute, a gallon is seven pounds. So if you think about that, we fly around for 10 minutes, we burn 10 gallons at 70 pounds, and we just added that we can lift. So it makes a pretty good difference and in this hotter weather, it's definitely more likely we'll do it. Done it a couple of times this year already and it definitely helps, so. - And then the human performance thing. - Yeah. - 'Cause you got great air conditioning, right? - Actually it is, it's pretty good. So we have good AC, but as you guys are all probably well aware, trauma patients that are bleeding, they need to be warm. So we try to keep that AC down to a minimum, if not on at all, so it does get hot and sweaty in the back of the aircraft. And that'll tire you out pretty quick. So definitely want to keep hydrated, that sort of thing. Yeah, it makes for long days. - It's a great way to lose a few pounds every shift. - Yeah, absolutely. (laughs) - Do you guys use those jiffy pot bags that we used in the military to keep them warm in the choppers? - So we do keep hot packs to keep our patients warm. Like I said, we'll turn the AC off if we need to turn the heat on for any reason, especially in the fall when it's starting to get a little cooler, of course in the winter. We have a very good heater in there. And also we have blood warmers that can do both blood and fluids. So we can give them warm fluids, that sort of thing. We use a special wrap on our cot to keep the patients warm and we'll put them as a main blink 'cause we possibly can't keep them warm too. - So we got another online question here. Does your entire crew follow the go, don't go, 100% crew agreement? - Absolutely. - Yep. - That was a standard with PHI that's come across as we've become UH employees too. - The motto. - Nobody understands, yeah. - Yeah, so the whole motto is three to go and one to say no. And you'll find that pretty much every flight program in the United States is gonna follow this is you know, everybody's gonna be in a green so we're gonna go somewhere and as soon as one person says no, we're not doing it, we're not doing it. And that's just a big safety factor. And of course we're gonna debrief that if somebody decides that they're uncomfortable and they don't wanna do a call for any sort of reason, we're gonna ask them, hey, what's your rationale for it? And there's no pressure to it. We're big on no pressure in flight because that's how accidents happen of course. And so we'll sit down and we'll talk about it and maybe that person just needs some educationists to, you know, hey, you know, I know you're concerned about this weather but this is really no issue because we have these capabilities or that sort of thing. So then we can maybe make a decision that way or if there really is something they're still uncomfortable then. That's rather be safe than sorry and so would everybody else on the team. It even goes as far as if a flight request comes in and it's, you know, if it's clear blue 72 or if the weather's marginal or it just looks kind of weird is, you know, we'll kind of all go into the pilot's office and the pilot's got their screens up of their weather radars and future forecasts and all this kind of stuff. And a couple of our pilots are even to the point to where if we're standing around and nobody's, you know, we're just kind of him on a little bit thinking about it. If we're thinking about it for more than 20, 30 seconds, trying to justify in our head before we say something, we'll call it right there. - It's an automatic note. - Yeah. - Another question here. Are the pilots trained in medical to help out? - So are pilots, at least to mine, I mean, to work for the program, I do not believe that they need to have any medical training. I'm sure maybe they'll hold like a AHA like CPR card or BLS, maybe if that pertains to some other part of their job. But in order to fly, they don't need any, they don't have any medical background. - So as far as I goes to, a lot of times they don't want the pilots to have that medical background. And the rationale behind that is the more information, you know, the more that's going to cause your judgment. So those pilots, their jobs to fly that aircraft, their job's not to take care of the patient. So same difference is why when we get a call, we only get told, the patient wait and where we're going is because we don't want that to clot our judgment and say, oh, well, that's a kid, we need to hurry up and go do that or, you know, or, you know, something like that, that we don't want that clotting their judgment and do it something risky in the aircraft. So they're pretty much non-medical for the most part. So that way it doesn't clot their judgment. - Although one cue, okay, it tips you off. - Yeah, that's true, that's true. - There are hints. - Yeah, it's, there are caveats to that for sure. - And then, and you get a question back there, fantastic. - If we request a helicopter for a scene run, how is it determined which call a company for lack of a better word is going to show up? - Yeah, so I think that really depends. A lot of times it depends on the dispatch for who you're calling. So like, if you're calling a geographic county and geographic county dispatch is going to decide that, a lot of times they're going to look at the closest appropriate aircraft to see who's the closest and available for that call. And if that aircraft is available, then they'll call the next aircraft. So like specifically for here, the closest aircraft is likely going to be our aircraft at a middle field. And if we're unavailable, the next closest aircraft is going to be the Cleveland Clinic's aircraft. So they would be the next one to come up for the call. So in the long run, that's going to be the most beneficial for the patient for sure. That's getting that care to the patient the fastest and having the closest aircraft is definitely best for that patient. And I would take no offense on, if we were further away and they called somebody else from the area, whether it'd be live in clinic or a metro, I would hope that they would call that closer aircraft to go do that call for the sake of that patient. Do what's best for them. So, man, go ahead. - So when you get on scene, I'm expecting, or I'm assuming you are expecting a report from us, but what else are you expecting from us to do to help you? Do you want us to follow you? Do you want us to just give you the patient? What are your expectations? - So the biggest thing coming into a scene is we'll try to make radio contact you. We'll make radio contact with you as soon as we lift, just to give you an ETA as to how far it's going or how long it's going to take for us to actually land at your scene. Once you've made contact back with us, we'll ask for an LZ update and patient status or patient condition. Followed that, usually what we're looking for is, if you're giving us landing zone information, it's information such as we've prepared a, we're gonna have you land in a field 100 foot by 100 foot cleared open space, no immediate obstructions, or you've got power lines to the North, tree line to the West. And then, as we get closer to the scene, like Kyle was mentioning earlier, we'll do our orbits. So we'll do a high orbit and a low orbit, and that's basically just us taking the information that you gave us and trying to match that with where you described it. And then also looking for any obstructions that maybe we can see from the air that maybe you guys can't see from the ground. In terms of patient condition, we don't really need like a whole laundry list, I guess, of diagnoses or problems or interventions. Our biggest thing we're looking for is patient age, how much they weigh, the mechanism in which they were injured, and then really any interventions you've done thus farce, you know, and then current set of vital signs. And other than that, that's really all we need to know before we get on the ground. 'Cause what that does on our end is it kind of gets our gear spinning as to, okay, well, they've described a potentially unstable airway, so we may have to intubate them. So when we get out, instead of leaving the ventilator in the aircraft, maybe let's bring that with us just in case. And then, you know, I mean, worse comes to worse, we go back out and get it. That's fine if something took an unexpected turn. But once we're on the ground, you know, obviously, if we can get, you know, patient demographics that we can pass on to the receiving hospital, and then maybe a little bit more detailed. Information as to, you know, what you were called for, what you were presented with, what you've done thus far, and how the patient's reacting to your treatments. - Yeah, as far as the assistance on scene too, I don't think any of us would ever turn down any help, whether it be, you know, even something as little as spiking an IV bag or helping to get extra IVs. So we're always grateful for that help. Yeah, I don't think we'd ever turn down anything like that. So that's always helpful as far as that goes. We're gonna put them on our own monitor, of course, and kind of get them squared away in that sense. We may ask, hey, are you able to get a blood sugar for us? Are you able to drop some Zofran? We can give this patient something like that. And otherwise, yeah, we're definitely grateful for the help. And like I said earlier, when I was talking about our LZ stuff, that all of our EMS in this area in Northeast Ohio is just excellent. And patients are always so well-managed and well-prepared, and we're super grateful for that around here. So, that's awesome. All right, got two more, two more rapid fire questions, and then we'll round out our hour. So the first is really pertaining to training. Kind of question is kind of what's the dropout success right of students attending Air Medical School? And I guess let's chop this up a little bit, you know, is there a formal Air Medical School? Technically no. So yeah, no, there's really no formal Air Medical School per se, it's pretty much you get your paramedic license or get your nursing license, start working in that field and get your experience to get on the aircraft. And really you don't have to have the certification to get on, but most programs, if not all programs, are gonna be looking for that. And they're gonna require it within two years, procamed standards. It's especially in Northeast Ohio. It's so hard to get on an aircraft as a job. That came standards as three years experience, but pretty much anywhere you look in this area, it's gonna be a minimum of five years to get on. So having that certification is huge and super helpful. Pass rates on the tests for those, I think are like mid 70s, I believe. So it's definitely a more difficult test, but if you put your nose down and get at it, it's doable for you. And there's resources out there, of course, to prep courses and that sort of thing, so yeah. - All right, last one as we round out the night here, how long does it take to turn the aircraft around in between flights? - Ooh, that's actually a pretty good question. - Yeah, so I would say, I would say nine times out of 10, we're usually pretty quick when we drop land up Cleveland or whatever receiving facility we're going to, our turnaround time is pretty quick. We'll go down, kind of do our thing, transfer the patient care from us to the receiving, give them kind of a detailed rundown of everything that's gone on. And then make the cot restock at what we can, come back up. I would say from the time we land, the time we lift to go either back to base or to another flight is 30 minutes. - 30 minutes, yeah. - And 30 minutes is probably on the high end. I mean, there's some patients, especially if we're taking a device, whether it's a balloon pump or an impeller, we may be a little bit more time at bedside, just 'cause obviously we don't want to rush with that stuff. But if we're, I would say a lot of our patients were usually able to get down and get back up pretty quick. - That's another nice thing with being UH employees now is we do have a stock room there, so we can get all our stuff there and we're ready to go as soon as we get back up. And pilots generally go over to Brook Lakefront and they'll get fuel. - They'll take down fuel, yeah. - When we get back, pretty much the same time we're coming back up and we're ready to go for the next one, so. - Awesome. - What's the most flights you've done in 24 hours? - Ooh, myself personally, I believe is six. I've seen people do seven or eight, and that's running pretty good. If you think about it from the time of dispatch or the time of drop off is at least an hour to two hours and then we get back and since we can't really use our phones or the internet much in the back of the aircraft with FAA regulations and that sort of thing, normally you're spending an hour or two charting afterwards, so minimum, some of these charts get really involved especially if we're doing these surgical skills and airway management and a bunch of titrations on medications and ventilator titrations, so we could be charting for four hours, so it gets to be quite a bit, but yeah. - Yeah, somebody was recently behind on a bunch of insurance. - Oh yeah, oh yeah. - All right, we have one last job for you before we break for the evening and here Dr. Hill is gonna pass this over. We need one of you to pick where we're going next. - That's all you saw. - So, all right, Andrew is going to tell us where we are gonna wind up for our next-- - We're going live podcast. - See you. - Where's my chicken scratch that's sending us? - Willoughby. - We're on a willoughby, all right. Willoughby, we'll see you in a month for the next pre-doctoral paradigm live. Thank you all for watching and we'll catch you next time.