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Pre-Flight Considerations

When patients are transported from one site to another using an aircraft or a helicopter, this is referred to as aeromedical retrieval and transfer. An airplane or helicopter can be used for either fixed-wing or rotor-wing transport. This method was historically employed during World War I to transport wounded soldiers from one location to another. This system is used by both in the contemporary day globe. Emergencies in both the medical and surgical fields qualify as justifications for utilizing this type of intervention. Acute cardiac crises, acute vascular emergencies, and severely unwell patients, such as those suffering from sepsis, are only a few examples of medical interventions. The focus of this presentation will be on the aeromedical transfer of a patient who has developed urosepsis. urosepsis is a clinically obvious severe urinary tract infection that is typically preceded by a complex Urinary Tract Infection (UTI). The clinical pre-flight concerns for this patient, as well as the first assessment and management at the referring facility, will be the primary focus of the evaluation of the aeromedical transfer and retrieval of this patient.

Pre-flight considerations are typically aimed toward assessment and stabilization, as well as preparation for in-flight management and monitoring, among other things Patients who are critically ill require a high degree of care in both an emergency and non-emergency setting, regardless of their location. It is necessary to ensure that these patients receive high-quality care. There are a number of prerequisites that must be completed in order for this to occur. First and foremost, there must be the most basic clinical equipment available. Pulse oximeters, electrocardiogram equipment, and blood pressure monitors are all recommended as basic equipment for aeromedical delivery. Capnography equipment, tracheostomy kits, backup oxygen tanks, cannulas, defibrillators with pads, and so on and so forth.

The requirement for resuscitation and stabilization is extremely dependent on and case-specific since it is influenced by a variety of elements such as the clinical, environmental, and logistical circumstances of the individual. Aspects of logistics that must be considered at this stage of preparation for a flight include the following: preparing for the worst-case scenario in transportation Pre-flight clinical considerations include the necessity for resuscitation and stabilization, as well as the possibility of a medical emergency. The transfer team is the first and most important. The members of the team who will be involved in the transfer of the patient should be knowledgeable and skilled in the aeromedical evacuation of a patient suffering from urosepsis, as well as in the transfer of other patients. Specifically, it is because this ailment is a critical condition that has a significant mortality rate when there is an inadequate management strategy. Multiple organ failure and circulatory failure are two of the leading causes of death in the disease. Circulatory shock and failure are common concerns among patients who are presenting with sepsis in a clinical setup.

Another important preflight consideration is ensuring that there is the supply of equipment that is required for monitoring this patient. In making sure that this is fulfilled. Having an efficient power supply in the pre-hospital environment is of utmost importance. The monitor/defibrillator unit, ventilator, and syringe driver are the three important pieces of equipment that need a reliable power supply. A patient with urosepsis is at risk of tipping into septic shock therefore these instruments are essential. The first and most important consideration is the type of aircraft being used. The type of aircraft that is utilized to transport the patient can have a significant impact on the clinical outcome of the condition. If you are using an aircraft to transport a patient, you will undoubtedly face a number of challenges, including concerns about safety, noise, vibration, acceleration, and deceleration, as well as restrictions on your ability to get to the patient. Notable is that pressurized jet/turboprop aircraft have numerous advantages over unpressurized piston aircraft in a variety of situations. This is due to the fact that pressurized jets fly at higher altitudes than piston aircraft due to independent cabin conditioning; as a result, they are often quieter than piston aircraft. Pressurization will allow humans to fly above 50000 feet without experiencing any obvious symptomatology at high altitudes, these planes may be subjected to clear air turbulence, which means that there will be a vibration reduction. Due to the numerous implications of vibration on a patient's clinical outcome, it is critical to reduce or eliminate vibration from the environment. This can be linked to the fact that vibration, especially at low frequencies, frequently causes emotional sickness, blurred vision, shortness of breath, and chest and stomach pain, among other side effects . Vibration has also been linked to increased metabolic rate, tachycardia, elevated blood pressure, and peripheral vasoconstriction, to name a few effects. It also makes it difficult to monitor the patient, such as by placing blood pressure cuffs and ECG leads on the patient.

Team Qualifications and Equipment

Other Considerations determining appropriate aircraft Distance Helicopters and unpressurized fixed-wing aircraft are suitable for shorter distance missions, ranging to large commercial or military aircraft for long haul international scale retrievals. Accommodation Access to the patient for medical team Space for medical equipment Luggage and escorts Loading/unloading requirements Fixed-wing aircraft inevitably require an inter-vehicle transfer of patients and secondary transfers by road from airfields; helicopters may be able to land on designated hospital landing sites negating the need for secondary transfers. Ease of loading-unloading varies: some aircraft have systems to facilitate this reducing need for manual lifting and reducing risk to patients and crew. The cost will depend on contractual arrangements with the aircraft operator. Mile for mile costs of rotary-wing flights is greater than fixed-wing.

There should be an initial evaluation of the patient. This should be conducted using tools to predict the clinical outcome of the patient. This can be done using assessment tools like qSOFA and SIRS o rule out organ failure and any onset of septic shock. By doing so it necessitates any form of resuscitation and further management that the patient is warranted for.

Another important thing to be performed at the referring location is the collection of the relevant microbial samples. Samples required for microbial confirmation include urine, blood, and drainage of any discharges General principles in the management of sepsis are obtaining specimens for microbiological testing as soon as practical, commencing appropriate antibiotics, and obtaining source control. There should also be the establishment that there is adequate fluid resuscitation, commence other organ support as required, and Prevention of secondary complications.

Initiation of empirical antibiotics. This should be administered to the patient at the referring location because of the administration of empirical antibiotics The antibiotics should be administered in higher doses. Other adjunct measures that can be initiated at referring location include fluid therapy, particularly with steroids, this should be the administration of crystalloids. Crystalloids should be administered to patients with sepsis because they act as volume expanders and can therefore increase blood pressure. During fluid therapy, there should also be concurrent administration of vasopressors such as norepinephrine or dobutamine when there is the anticipation of myocardial dysfunction

If the patient is unstable at this point there should be stabilization of the patient, this can be conducted using the ABC assessment of the patient. This will encompass the airway, breathing, and circulation. Once the patient is stabilized, then their aeromedical transfer can be initiated.

It is important that the medical team attending to the patient should be cognizant and knowledgeable of aviation physiology. This is because aviation physiology will instruct careful attention that needs to be afforded in monitoring and management of this patient. First and foremost, it is important to note that the composition of environmental gases remains the same inspire of altitude. However, it is important to highlight that even when the composition of these gases remains constant their atmospheric barometric pressures decrease because of the kinetic properties of gases. According to Dalton's law, the total pressure of a gaseous mixture is equal to the sum of the partial pressures of each gas present in the mixture. Interpretation of aviation physiology will also require the medical team to appreciate Boyle's law. Boyles's law predicts the gas expansion of gas-filled body cavities with the increase in altitude from its baseline sea level This will lead to the expansion of medical devices like endotracheal tubes and IV fluid bags. These gases in these spaces can expand up to 35 percent during the flight and the team has to be aware of this.

Clinical Management of Urosepsis Patients during Transport

When it comes to the management of urosepsis, the natural evolution of the ailment should always be taken into consideration when determining the parameters to be monitored. For starters, the patient's oxygen saturation should be continuously measured at all times. This is due to the fact that the patient is at risk of hypoxia. It is possible to trace the origin of hypoxia to a dysregulated immune system, which results in a cascade of events that disrupts the equilibrium between the fibrinolytic and coagulation cascades in the patient. There is an override of coagulation, which results in the production of thrombi and, as a result, hypoxia due to decreased oxygenation. The blood pressure of a patient suffering from urosepsis is a critical measure that needs to be maintained continuously throughout the flight. This is due to the fact that when sepsis is typically paired with severe hypotension, it is a sign of a more serious condition. Blood pressure monitoring should be performed at regular intervals as a result of this fact.

During the handover process, the most critical point to emphasize is the significance of communication. In order for the patient to be transferred to a different health facility, the team members must be introduced and identified properly at the receiving facility. Depending on the situation, the transfer could take place verbally or in writing. During the handover process, the following tasks must be done. Patient status must be communicated clearly, and the patient must get regular clinical updates. This will include any interventions that have been carried out to date, as well as the outcomes of those treatments, in addition to any future initiatives. The patient's microbiological samples should also be turned over for culture and sensitivity testing when the patient is being turned over, according to the guidelines. Since patient management is of the utmost importance in order to ensure that effective management efforts are made on the patient's behalf, purposeful measures should be put in place. The reception team should be equipped with the essential skills and equipment to manage this patient, among other things.It is also imoortant to note that 

For the patient to be transported to a certain facility, the aeromedical team must understand that this confirmation must be obtained. Another element to consider is the possibility of the requirement for auxiliary transportation services such as road transportation. A further medical escort may be required. As a result, adaptability and flexibility will be required. There is a requirement for suitable equipment, medications, and monitoring that will be necessary for the road transfer 

It is critical to note that after every patient has been managed, facilities should be established to ensure that the patient is followed up with and has his or her records audited. This is due to the fact that patient follow-up and audit are essential tools for ensuring the quality of care provided to patients. This is especially true for patients who have had poor outcomes or in whom there has been an error in the patient's management. In order to ensure that the facility provides top-tier quality service, the aeromedical retrieval unit can make use of tools such as check lists, manuals, and guidelines to ensure that the quality of service delivered to patients is of the highest possible standard.

Conclusion

With that said, it is clear that aeromedical retrieval is an essential tool that needs to be utilized in transfer of patients that are critically ill i.e. for our scenario one with urosepsis. To ensure that all goes smooth, their needs to be pre-flight, in flight and post flight considerations that needs to me adhered to for proper management of the patient. Also being cognizant of aviation physiology effect on disease outcome will ensure that necessary adjustments are made to cater for our patient with urosepsis

References 

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  2. Johnson D, Luscombe M. Aeromedical transfer of the critically ill patient. Journal of the Intensive Care Society. 2011 Oct;12(4):307-12.
  3. Araiza A, Duran M, Surani S, Varon J. Aeromedical Transport of Critically Ill Patients: A Literature Review. Cureus. 2021 May 7;13(5).
  4. Shesser R. Medical aspects of commercial air travel. The American journal of emergency medicine. 1989 Mar 1;7(2):216-26.
  5. Chandan G, Cascella M. Gas Laws, and Clinical Application.
  6. Teichman PG, Donchin Y, Kot RJ. International aeromedical evacuation. New England Journal of Medicine. 2007 Jan 18;356(3):262-70.
  7. Tzani P, Pisi G, Aiello M, Olivieri D, Chetta A. Flying with respiratory disease. Respiration. 2010;80(2):161-70.
  8. Evans CE. Hypoxia and HIF activation as a possible link between sepsis and thrombosis. Thrombosis Journal. 2019 Dec;17(1):1-4.
  9. Bonkat G, Cai T, Veeratterapillay R, Bruyere F, Bartoletti R, Pilatz A, Köves B, Geerlings SE, Pradere B, Pickard R, Wagenlehner FM. Management of Urosepsis in 2018. European urology focus. 2019 Jan 1;5(1):5-9.
  10. Hotchkiss RS, Moldawer LL, Opal SM, Reinhart K, Turnbull IR, Vincent JL. Sepsis and septic shock. Nature reviews Disease primers. 2016 Jun 30;2(1):1-21.
  11. Ramadas R, Hendel S, MacKillop A. Civilian aeromedical retrievals (the Australian experience). Bja Education. 2016 Jun 1;16(6):186-90.
  12. Low A, Hulme J, editors. ABC of transfer and retrieval medicine. John Wiley & Sons; 2014 Dec 31.
  13. Loyd JW, Larsen T, Swanson D. Aeromedical transport. InStatPearls [Internet] 2021 Aug 11. StatPearls Publishing.
  14. Hon HH, Wojda TR, Barry N, MacBean U, Anagnostakos JP, Evans DC, Thomas PG, Stawicki SP. Injury and fatality risks in aeromedical transport: focus on prevention. Journal of surgical research. 2016 Aug 1;204(2):297-303.
  15. Gomes MA, Alberti LR, Ferreira FL, Gomes VM. Historical aspects of aeromedical transport and aerospace medicine-review. Rev. Med. Minas Gerais. 2013;23(1):116-23.
  16. Bourn S, Wijesingha S, Nordmann G. Transfer of the critically ill adult patient. Bja Education. 2018 Mar;18(3):63.
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