AU/ACSC/2010

AIR COMMAND AND STAFF COLLEGE

AIR UNIVERSITY

THE CLOCK IS TICKING IN PEDITRIC CRITICAL CARE TRANSPORT! MAKING THE

RIGHT TRANSPORT CHOICES FOR OUR PATIENTS

By
Louis E. Bellace, Major USAF NC

A Research Report Submitted to the Faculty

In Partial Fulfillment of Graduation Requirements

Advisor: Dr. Andrew Niesiobedzki

23 Oct 2011
Air Command and Staff College
Distance Learning
Maxwell AFB, AL
1

Disclaimer
The views expressed in this academic research paper are those of the author and do not
reflect the official policy or position of the US Government or the Department of Defense. In
accordance with Air Force Instruction 51-303, it is not copyrighted, but is the property of the
United States Government.

TABLE OF CONTENTS (in Progress place holder)

Dislaimer ..........................................................................................................................................2
Table of Contents .............................................................................................................................3
Acknowledements ............................................................................................................................4
Section 1 Introduction ......................................................................................................................5
Section 2 Background ......................................................................................................................7
Section 3 Current/Past Research ....................................................................................................12
Section 4 Data Analysis .................................................................................................................16
Section 5 Conclusions ......................................................................................................................0
Section 6 Recommendations ............................................................................................................0
Section 7 Abstract ............................................................................................................................0
Section 8 Definition of Terms..........................................................................................................0
Section 9 Bibliography ....................................................................................................................0
Section 10 End Notes .......................................................................................................................0

ACKNOWLEDGMENTS

I would like to thank my wife Cynthia sons CJ, Justin and, my mother-in-law for the last
three years of support and encouragement as I made this journey. It cannot be understated the
level of commitment required to undertake an endeavor such as this and I am forever grateful for
everything. I would also like to acknowledge the support and advice that each and every
professor has offered in support of my goals to reach this point. The Air University staff has been
open and friendly at every turn. Most of all I would like to thank the Lord for allowing me the
opportunity to serve this great nation in the capacity I do and providing me the experience and
leadership opportunities he has revealed.

SECTION 1: Introduction

The transport of critically ill and injured patients from one medical facility to another has
evolved over many years of trial and error to the current system we have today. Military and
civilian medical teams have been on the cutting edge of technology and management helping to
be part of the evolution of critical care transport as an art. The benefit of this evolution is
increased survival rates and shorter hospitalization periods. In Germany for example, there is a
network of helicopters which has evolved over the past twenty years to cover the entire country.
1

Statistics gathered over this period of time show:

1. An average response time to the scene of the incident of just 10 minutes.

2. Intensive care stays in hospital have been shortened by between five and seven days.
3. 9% fewer infections.
4. A significant reduction in the number of deaths during transport to hospital.

The utilization of specialty care transport teams has only been around for a short time
frame. Having the ability to maintain a patients life during transport can be likened to art of
sorts. Many years of training and education equip the teams to handle any situation encountered
on transport. The key is utilizing the proper mode of transport.

The patients encountered during inter-facility transport span the continuum of acuity.
Acuity is defined as a keenness or acuteness. Understanding acuity will help put the decisions
made by Critical Care Transport Teams into a better perspective. Choosing the correct mode of
transport for critical care patients will affect their outcome. A trained and properly equipped
5

Pediatric Critical Care Team is capable of providing lifesaving care in an expedient manner
utilizing the fastest and most efficient transport mode. An example to illustrate this point better
would be a pediatric trauma patient suffering from an acute brain hemorrhage. The patient will
die if surgical intervention by a qualified neurosurgical team is not performed successfully in a
very short period of time. Critical care transport teams can bridge this gap and save lives. Can
the choice of transport mode during Pediatric Critical Care Transport make a difference in the
patients outcome?

Critical Care Transport teams utilize three common recognized modes of transport.
Ambulance transport provides the most common form of critical care transport for many teams.
This mode allows for consistent rapid inter-facility patient movement within a reasonable
operational area. Generally one to 2 hours away from the receiving facility. Rotor wing
transport on the other hand allows for rapid response and provides a greater range of operations
but with fixed assets and patient capacity. Fixed wing transport provides national and global
reach with fixed assets and duration. All three modes of transport possess their individual
capabilities, limitations and inherent dangers. A lot of debate has surfaced in clinical arenas over
the relative mode of transport related to the patients outcome. Many physicians believe rotor
wing transport is costly and of no great value to outcome secondary to the overall safety of the
service. The ability of pediatric critical care teams to transport severely ill and injured patients to
Tertiary and Quaternary care facilities in an expedient manner will have an impact their
survivability and outcome.

The manner in which a patient is transported from one medical treatment facility to
another plays a very important role in the patients outcome. Pediatric Critical Care transport is

a very specialized clinical resource requiring medical personnel with specialized pediatric
training and equipment to make life alerting decisions to save a life. The choices we make
impact the outcome of the patient. Choosing the mode of transport for a patient ultimately rests
on the shoulders of the sending facilities attending physician according to many states laws.
The critical care team is often a subject matter expert (SME) and can assist the transferring
medical team with options to optimize care and affect the outcome as it relates to stabilization
and transport. Ground transport is facilitated by critical care mobile intensive care units (MICU).
These vehicles are generally equipped with a wide variety of life saving interventional
equipment to facilitate rapid inter-facility transports within a set radius of operation.

Average crew compliments range from two to six providers of mixed clinical
backgrounds including physicians. Helicopter or Rotor wing transport as it is commonly called
allows for rapid inter-facility transports with a limited clinical compliment and limited
equipment capabilities due to size and weight restrictions of the aircraft. Fixed wing transport is
generally offered as a means to transport patients from greater distances out of reach of rotor
wing aircraft. The acuity of these patients does not differ in any way accept the distance from
the receiving facility. A debate exists that many physicians feel that rotor wing transport is
costly and unsafe and makes no difference in the patients outcome.

The National Transportation and Safety Board (NTSB) statistics reveal that there were
47 Helicopter Emergency Medical Service (HEMS) crashes two of which resulted in fatalities in
2009. Ambulance crashes occur approximately 20 times per month, two of which are fatal for
some or all of the occupants. Ground ambulance crashes are not tracked well nationally due to
vagueness in the Department of Transportation standards. The focus of this paper will attempt

be to determine what mode of transport will facilitate the best patient outcomes based on patient
acuity, distance, weather and, safety while highlighting some best practice recommendations. To
prove this point, a retrospective study of pediatric patient transports over a 2 year period together
with literary reviews will attempt to support the hypothesis.

SECTION 2: Background

Transport medicine has evolved over a period of time that spans the Napoleonic Wars to
present day operations in Iraq and Afghanistan. Dominique Jean Larrey, one of Napoleons
battle surgeons, is credited with several initial concepts that remain cornerstones in modern
transport medicine. Larrey developed the concept of triage (from the French verb trier meaning
to sort) to efficiently categorize the injured. Additionally, he recognized the importance of
trained individuals to care for the wounded in the field. This care had to be extended during
rapid transport to a field medical facility with care provided en route. To accomplish this, he
employed the ambulance volante or flying ambulance.2 This large horse-drawn carriage was
used to ferry the wounded to the field hospital. During the Great War, the first true Air
Ambulance flight was made when a Serbian officer was flown from the battlefield to hospital by
a plane of the French Air Service. Records kept by the French at the time indicated that, if
casualties could be evacuated by air within six hours of injury, the mortality rate among the
wounded would fall from 60 percent to less than 10 percent - a staggering reduction!

The first recorded medevac by helicopter occurred during the Second World War in
Burma behind Japanese lines. Four wounded soldiers were airlifted one at time to safety. After
WWII ended the first known civilian used Air ambulance occurred in Saskatchewan, Canada. In
1947 the first known US Air ambulance service was Schaefer Air Service in Las Angeles. The
8

age of paramedicine was still decades away from inception so patients were accompanied by a
physician or nurse when available. The initial use of Rotor wing transport emerged in the 1950s
during the Korean conflict. This real-time test of helicopters on the battlefield would prove
indispensible and pave the way for continued use and increased patient survival. Patients were
airlifted from the battlefield and evacuated to a Mobile Army Surgical Hospital or M.A.S.H.
facility to receive any lifesaving care. Survival rates approaching 74 percent were recorded if
treated within the first hour of injury. During Vietnam the use of helicopters become a necessity
for battlefield as well as Medevac operations. Due to the use of helicopters for evacuation, and
the advanced medical facilities available, 82 percent of Americans seriously wounded were
saved (compared to 71 percent in WWII and 74 percent in Korea)-the highest survival rate of any
modern war. Only 2.6 percent of those who reached hospitals died.3 The acknowledgment that
properly trained and equipped personnel could have an effect on the outcomes is supported by
the statistics presented from history.

During the Iraq war however there was a decrease in survivability of soldiers reaching
definitive care. A much needed but missing component was not in place, Critical Care Transport
Teams. Military leadership banked on the success of the Vietnam War and never anticipated the
acute care transport environment our soldiers would need to make it home and survive. The
acuity and care required to maintain the lives of wounded soldiers after their initial contact with
field medical teams was out of the scope of the Aeromedical transport teams the USAF had in
place. The Air Force fielded Critical Care Air Transport Teams in 1996 and filled the much
needed roles of primary care providers for patients with specialty care needs. Since their
inception survival rates have approached 97% and continue to maintain that rate even in todays

warzones. Much of what is done in the civilian environment is taken directly from the military
and refined to meet the needs of specific patient populations encountered.

The civilian critical care transport environment upholds many of the same standards as
the military and faces its own challenges. The teams are small well trained and equipped to
handle pre-hospital and inter-facility patients of varying ages. They bring skills and speed that
enables them to perform advanced clinical procedures to increase a patients chance of survival
in the first Golden hour of insult. Borrowing many of the skills and techniques from their
military counterparts has created a knowledge bridge between the battlefield and the street that is
changing year to year.
Critical Care medicine began in the 1950s. It was noted earlier by Florence Nightingale
that there were advantages to grouping postsurgical patients together in a dedicated area. By the
1960s every hospital had at least one ICU bed. By 1997, more than 5,000 ICUs were
operational in the United States.4 Along with this growth came the advent of certification by
both nurses and physicians alike. The purpose was to establish standards of competency and
management to increase patient survival rates. In 1986, the American Board of Medical
Specialties recognized the specialty of critical care medicine by approving a certificate of special
competence for physicians certified by one of four primary boards (anesthesiology, internal
medicine, pediatrics, and surgery).5
The health care industry changed in the 1980s. It decreased federal funding and made
changes to Medicare causing many smaller facilities to close. Large institutions started to
specialize in the type and levels of care they provided. This allowed them to control cost and
maintain viability while keeping competition low. This shift in care models created the need for
10

transfer patients to specialized centers that were designed and trained to manage patient specific
needs. Initially transfer was done by ground ambulance crews with an ICU trained nurse. The
nurses were not always prepared for the autonomous role they undertook and it also kept the
local volunteer based ambulance out of service for extended periods. The demand for highly
trained critical care teams existed and the platform of choice was the helicopter. The helicopter
offered them speed and decreased the time the patient spent out of hospital between facilities.
Weather was the most limiting factor and continues to be one of the main considerations
throughout the industry along with payload. However, these teams were not always trained or
equipped to manage and treat the pediatric and neonatal patient populations. Clinical decision
makers had to find a way to transfer very sick patients but with trained pediatric and neonatal
practitioners providing the majority of the care.

These teams would utilize the same transport modalities described above but the team
composition would have to be more specialized to meet the patients specific care requirements.
These requirements included equipment such as incubators designed for the transport
environment and pediatric specific ventilation and cardiac monitoring equipment along with
medication infusion pumps. During this period there were no certification requirements or
standards of care related to the management of this patient subset in a transport environment.
Teams were staffed by nurses and physicians that worked within the hospital units. They would
staff the ambulance per call basis based on the specific patient needs and utilize equipment that
was not suited for the transport environment. This move toward specialization and later
certification was championed and standardized by many nursing organizations. The
establishment of transport certification set the standard of care expected for patient care within
the respective transport environment.
11

The certifications that exist currently are Certified Emergency Nurse (CEN), Certified
Transport Registered Nurse (CTRN), Certified Flight Registered Nurse (CFRN), Critical Care
Registered Nurse (CCRN), and Pediatric Critical Care Nurse (PCRN). All of these specialty
certifications establish their own set of standards that are nationally recognized and accepted
throughout all states.

SECTION 3: Current/Past Research

The case for specialized transport affecting patient outcomes was recently written about
in an article by Andrew Loehr and Patricia Messner, PhD. Many members of adult EMS
transport teams lack the experience and training to identify the subtle changes that indicate a
deteriorating condition in a pediatric patient. They typically havent had experience caring for
this vulnerable population, and arent necessarily trained in pediatric advanced life support or
pediatric and neonatal airway management.6 They further go onto comment that pediatric and
neonatal specialty teams work closely with pediatric intensivists and neonatologists while in
transit.

Loehr and Messmer both agree that team makeup plays an important role in patient
outcome stating adult EMS transport teams tends to consist of a paramedic and emergency
medical technician, a specialty transport team might include two RNs and either a paramedic or
a respiratory therapist. The latter can be a significant asset because of the ailments encountered.
The equipment needed to care for the pediatric and neonatal population is very different and
often include inhaled gas therapy and nitric oxide that other teams are not capable of providing.
They both advocate for a shift in practice and better utilization of pediatric and neonatal teams.

12

Orr et al conducted a study in 2009 that illustrated the importance and need for
specialized transport teams. The study concluded that specialized transport teams experienced
fewer adverse events and lower mortality rates. Utilizing two cohorts non-specialized vs.
specialized teams they found a 23 % vs. 9 % mortality rate.7 In perspective a general transport
team is seven times more likely to have a child die on them than with a specialized team.

The belief that survivability is directly linked to mode was studied and reported by
Cunningham et al in 1997. They utilized a retrospective study of trauma patients over a 6 year
period in North Carolina. The study looked at the mortality rates of patients brought to eight
state designated level 1 trauma centers to establish any correlation between modes of transport,
specifically ground versus helicopter. The study compared outcomes of 1,346 patients arriving
via helicopter and 17,144 patients arriving via ambulance. They were able to filter and stratify
much of the data to establish credibility and reported that 67% of helicopter patients and 82% of
ambulance patients survived.8 The researchers point out that severity of injury affected outcome.
Table 1 depicts the scene trauma scores relative to outcome in both groups. A trauma score (TS)
of 1 to 16 is assigned to each patient with 16 being the best possible score any patient would
receive based on type of injury, vital signs and level of consciousness. Table 2 depicts the
patients injury severity scores (ISS) as compared to the trauma score groupings and established
probable survivability of the patients in each trauma score grouping. The significance here is
that the severity of injury based on the trauma score and ISS did not affect the outcome
regardless of the mode. Table 3 is showing the actual mortality relative to the mode of transport
among the 5 stratified groups. The groups were defined by their ISS and TS scores showing
Group 5 having the best chance of survival with lower scores and Group 1 being the most
severely injured. Figure 1 is a graphic representation of Table 3s data. The conclusions draw
13

from this study suggest that most EMS systems are predicated on the belief that early definitive
care improves outcome.9 The results of this study demonstrate two key findings: the majority of
trauma patients transported by both helicopter and ground ambulance have low injury severity
indices, and outcomes are not uniformly better in patients transported by helicopter. Despite the
large number of patients and hospitals included and the lengthy period covered by the study, the
positive effect of helicopter transport on survival was suggested only in a minority of patients,
i.e., those with TS between 5 and 12 and ISS between 21 and 30. 10

Table 1

Table 1. Scene Trauma Score distribution and survival in patients transported by helicopter and ambulance

14

Table 2

Table 2. TS and ISS distribution, and survival in patients transported by helicopter and ambulance

Table 3

Table 3. Mortality rate by probability of survival group

15

Figure 1

Figure 1. Probability of survival (PS) group and actual outcome in patients transported by ground and helicopter

In another similar but more specific study evaluating the effective use of Rotorwing
transport for pediatric trauma patients, Larson et al evaluated the outcomes of patients form
injury scene (IS) to a trauma center to those transported by air after hospital stabilization (HS).
The study compared outcomes and length of stay. The patients were stratified by and ISS of
minor less than 15 and major greater than 15. The total number of patients included in the study
were 842 HS and 379 IS patients. Overall death rates reported were 5.5% in the HS group and
8.7% in the IS group. Also mean intensive care unit (ICU) length of stay did not differ

16

significantly. The HS group spent an average of 118.3 hours in the ICU while the IS group spent
an average of 149.1 hours.

Table 3

Hospital Referral
(95% CI)

Scene Flight
(95% CI)

p Value

All patients
Mean ICU length of stay (h)
47.0 (37.756.3)
Mean hospital length of stay (days) 7.4 (6.58.3)

54.1 (41.366.8) 0.3801

7.7 (6.39.2)
0.4284

Minor trauma (ISS _ 15)

Mean ICU length of stay (h)
15.2 (12.517.9)
Mean hospital length of stay (days) 4.6 (4.05.2)

14.9 (8.621.2)
5.2 (3.96.5)

0.2765
0.4902

Major trauma (ISS _ 15)

Mean ICU length of stay (h)
118.3 (90.2146.4) 149.1 (113.9184.2) 0.0272
Mean hospital length of stay (days) 14.1 (11.616.6)
14.7 (11.118.4)
0.3527

Table 3 ICU and Hospital Length of Stay Comparison by Kaplan-Meier Method

Table 2

All Patients
Total Patients
Deaths
Minor Trauma (Iss < 15)
Total Patients
Deaths
Major Trauma (ISS> 15)
Total Patients
Deaths

Hospital Referral
(%)

Scene Flight
(%)

842
46 (5.5)

379
33 (8.7)

0.033

564
3 (0.5)

259
1 (0.4)

1.000

278
43 (15.5)

120
32 (26.7)

0.009

Table 2 Mortality Comparison

17

P Value

The research study concluded through retrospective analysis of pediatric trauma victims,
that they could not verify any benefit for pediatric patients transported directly from the injury
scene to a pediatric trauma center. In fact, our study suggests that hospital stabilization before
transfer by air ambulance improves survival and shortens ICU stays for patients with major
trauma when compared with patients flown directly from the scene.11

SECTION 4: Data Analysis

The Childrens Hospital Emergency Transport Team is a dedicated hospital based
transport team comprised of pediatric critical care nurses and paramedics. The medical team is
trained to manage patients with a wide range of medical diagnosis and trauma from prematurity
through adulthood. All of the team members hold certifications in specialty care nursing as well
as pre-hospital Department of Health credentials as Pre-Hospital Registered Nurses. The
paramedic team members are nationally certified and some hold advanced certifications in
transport medicine.

The team averages approximately 3,000 transports per year. Out of those

transports approximately 250 are facilitated via rotorwing. The data used to conduct this study
was gathered over a 1 year period and is broken down to manage the many variables influencing
the research. Fiscal Year 2011 data showed that the team participated in 3,005 total transports.
1,726 of them were coded as a level 4 transports. Another 249 were coded as a level 5 transports
and of the total calls, 196 were rotorwing transports. This breaks down to monthly averages of
250 transports. 234 transports occurred via ground and another 16.3 were via rotorwing.

18

The average time spent on ground transport is approximately 2.2 hours. This time is
calculated from patient contact to arrival at the hospital. Rotorwing transports average between
1 and 2 hours from patient contact to return. There are variables affecting the average time
including distance, patient acuity and, the availability of a landing zone in proximity to the
referring institution.

The scoring system used by the transport team is a numerical acuity system that rates the
call based on severity and intensity of treatment required to manage the patients medical
condition. Level 4 calls are defined as two or more body systems requiring multiple
interventions. An example to clarify would be a patient with seizures or head trauma. Level 5
calls are defined as acute life threatening emergencies and are the most labor intensive. An
example would be a multisystem trauma patient or cardiac arrest. The focus of the data
presented will be on the level 4 and 5 type calls. These calls are the upper limits of acuity and
warrant the most intensive care possible to manage the patient.

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ABSTRACT (under construction)

The purpose of this research project is to prove that choosing the correct mode of
transport for critical care patients will affect their outcomes. A trained and properly equipped
Pediatric Critical Care Team can provide lifesaving care in a timely manner utilizing the fastest
and most efficient transport mode. Critical care transport teams have the ability to bridge this gap
and save lives. Critical Care Transport teams utilize three common modes of transport.
Ambulance transport provides the most common form of critical care transport for many teams.
This mode allows for consistent rapid inter-facility patient movement within a reasonable
operational area. Rotor wing transport on the other hand allows for rapid response and provides a
greater range of operations but with fixed assets. Fixed wing transport provides national and
global reach with fixed assets and duration. All three modes of transport have their individual
capabilities, limitations and inherent dangers. A lot of debate has surfaced in clinical arenas over
the relative mode of transport related to the patients outcome. Many physicians believe
helicopter transport is costly and of no great value to outcome secondary to overall safety. The
ability of pediatric critical care teams to transport severely ill and injured patients to tertiary and
quaternary care facilities in an expedient manner will have an impact their outcome. a
retrospective study of pediatric patient transports over a two year period together with literary
reviews will support the hypothesis.

20

Definition of Terms

Pediatric Critical Care Team- A team of medical professionals comprised of various

backgrounds trained to manage and stabilize pediatric patients. Team composition will vary but
usually is a mix of a Registered Nurse, Paramedic, Respiratory Therapist, Pediatrician and
Emergency Medical Technician.
Rotor Wing- Describes any helicopter designed for patient care.
Fixed Wing- Describes any airplane designed for patient care.
Tertiary Care Facility- Specialized consultative care, usually on referral from primary or
secondary medical care personnel, by specialists working in a center that has personnel and
facilities for special investigation and treatment
Quaternary Care Facility- refers to advanced levels of medicine which are highly specialized
and not widely used. Experimental medicine, service-oriented surgeries and other less common
approaches to treatment and diagnostics
Specialty Care Transport Unit (SCTU) - A vehicle designed and equipped to transport
critically ill and injured patients usually staffed by physicians and nurses trained to manage
patients during interfacility transport.
Mobile Army Surgical Hospital (MASH) - refers to a United States Army medical unit serving
as a fully functional hospital in a combat area of operations. The units were first established in
August 1945, and were deployed during the Korean War and later conflicts. The U.S. Army
deactivated the last MASH unit on February 16, 2006.
Mobile Intensive Care Unit (MICU) A vehicle designed and equipped to transport critically
ill patients from either the pre-hospital or interfacility sectors usually staffed by a paramedic
team.
National Transportation and Safety Board (NTSB) The governmental agency that oversees
all transport related manners by conducting objective, precise accident investigations and safety
studies
Helicopter Emergency Medical Service (HEMS) Term used by industry to describe the use
of helicopters to transport patients.
Emergency Medical Services (EMS) - Any department of health recognized organization that
provides pre-hospital or inter-facility transport.
21

Trauma Score (TS) - a system of combining cardiopulmonary assessment with the Glasgow
Coma Score in estimating the degree of injury and the prognosis in a trauma patient. The
cardiopulmonary factors included are respiratory rate and systolic blood pressure.
Injury Severity Score (ISS) The Injury Severity Score (ISS) is an anatomical scoring system
that provides an overall score for patients with multiple injuries. Each injury is assigned
an Abbreviated Injury Scale (AIS) score and is allocated to one of six body regions (Head, Face,
Chest, Abdomen, Extremities (including Pelvis), External). Only the highest AIS score in each
body region is used. The 3 most severely injured body regions have their score squared and
added together to produce the ISS score.

22

BIBLIOGRAPHY
Britto, Joseph. Morbidity and severity of illness during interhospital transfer: impact of a
specialized paediatric retrieval team. BMJ Journal. September 30, 1995

Bledsoe, Bryan E. , DO, FACEP, EMT-P, Benner, Randall W., Med, MICP,NREMT-P, Critical
Care Paramedic. 2006, pp. 3-14
Cunningham, Paul MD; Rutledge, Robert MD; Baker, Christopher C. MD; Clancy, Thomas V.
MD. The Journal of Trauma. A Comparison of the Association of Helicopter and Ground
Ambulance Transport with the Outcome of Injury in Trauma Patients Transported from the
Scene. December 1997 - Volume 43 - Issue 6 - pp 940-946
Kanter, Robert K. MD, Boeing, Nancy M. RN, MS, Hannan ,William P., MD, Kanter Deborah
L., RN. Excess Morbidity Associated With Interhospital Transport. PEDIATRICS Vol. 90 No. 6
December 1992, pp. 893-898
Kupas, Douglas F., M.D., Dula, David J., M.D., FACEP, Pino, Bruno J. Patient Outcome Using
Medical Protocol to Limit "Lights and Siren" Transport. Prehospital and Disaster Medicine,
October-December 1994, Vol. 9, No.4
Larson, Jeremy T. MD. Ann M. Dietrich, MD. Shahab F. Abdessalam, MD. Howard A.
Werman, MD. Effective Use of the Air Ambulance for Pediatric Trauma. The Journal Of
Trauma. Volume 56 Number 1. January 22, 2003
Loehr, Andrew B, MSN,RN, CPNP, Messemer, Patricia R. PhD, RN-BC,FAAN. The Case for
Specialized Transport Teams. American Journal of Nursing. September 2011-Volume 111Number 9 pg. 11
Mercy Flight Western New York, History of Air Ambulance and Medevac. Sampled 6 September
2011. http://www.mercyflight.org/content/pages/medevac
McPherson, Mona L., MD, MPH, Graf , Jeanine M., MD. Speed Isn't Everything in Pediatric
Medical Transport. PEDIATRICS Vol. 124 No. 1 July 2009, pp. 381-383
(doi:10.1542/peds.2008-3596)
STRAUSS, RICHARD H. MD. Aeromedical transport services accepting pediatric patients and
their abidance by published guidelines. Pediatric Emergency Care. December 1992

Vietnam as Statistics. Sampled Sept 6,2011.

http://home.earthlink.net/~aircommando1/Vietnam.htm
23

Wallen, Elizabeth MD; Venkataraman, Shekhar T. MD; Grosso, Mary Jo RN MSN; Kiene, Kelly
RN; Orr, Richard A. MD. Intrahospital transport of critically ill pediatric patients. Critical Care
Medicine September 1995 - Volume 23 - Issue 9 - pp 1588-1595
Welling, DR, Burris, DG, Rich, NM (2006) Delayed recognition: Larrey and Les Invalides. J Am
Coll Surg 202,373-376
Wikipedia. Mobile Army Surgical Hospital. Sampled 7 September 2011,
http://en.wikipedia.org/wiki/Mobile_Army_Surgical_Hospital

24

End Notes

Mercy Flight Western New York, History of Air Ambulance and Medevac. Sampled 6
September 2011. http://www.mercyflight.org/content/pages/medevac
2

Mercy Flight Western New York, History of Air Ambulance and Medevac. Sampled 6
September 2011. http://www.mercyflight.org/content/pages/medevac
3

Mercy Flight Western New York, History of Air Ambulance and Medevac. Sampled 6
September 2011. http://www.mercyflight.org/content/pages/medevac
4

Bledsoe, Bryan E. , DO, FACEP, EMT-P, Benner, Randall W., Med, MICP,NREMT-P,
Critical Care Paramedic. 2006, pp. 3-14
5

Bledsoe, Bryan E. , DO, FACEP, EMT-P, Benner, Randall W., Med, MICP,NREMT-P,
Critical Care Paramedic. 2006, pp. 3-14
6

Loehr, Andrew B, MSN,RN, CPNP, Messemer, Patricia R. PhD, RN-BC,FAAN. The Case for
Specialized Transport Teams. American Journal of Nursing. September 2011-Volume 111Number 9 pg. 11
7

McPherson, Mona L., MD, MPH, Graf , Jeanine M., MD. Speed Isn't Everything in Pediatric
Medical Transport. PEDIATRICS Vol. 124 No. 1 July 2009, pp. 381-383
(doi:10.1542/peds.2008-3596)
8

Cunningham, Paul MD; Rutledge, Robert MD; Baker, Christopher C. MD; Clancy, Thomas V.
MD. The Journal of Trauma. A Comparison of the Association of Helicopter and Ground
Ambulance Transport with the Outcome of Injury in Trauma Patients Transported from the
Scene. December 1997 - Volume 43 - Issue 6 - pp 940-946
9

Cunningham, Paul MD; Rutledge, Robert MD; Baker, Christopher C. MD; Clancy, Thomas V.
MD. The Journal of Trauma. A Comparison of the Association of Helicopter and Ground
Ambulance Transport with the Outcome of Injury in Trauma Patients Transported from the
Scene. December 1997 - Volume 43 - Issue 6 - pp 940-946

25

10

Cunningham, Paul MD; Rutledge, Robert MD; Baker, Christopher C. MD; Clancy, Thomas V.
MD. The Journal of Trauma. A Comparison of the Association of Helicopter and Ground
Ambulance Transport with the Outcome of Injury in Trauma Patients Transported from the
Scene. December 1997 - Volume 43 - Issue 6 - pp 940-946
11

Larson, Jeremy T. MD. Ann M. Dietrich, MD. Shahab F. Abdessalam, MD. Howard A.
Werman, MD. Effective Use of the Air Ambulance for Pediatric Trauma. The Journal Of
Trauma. Volume 56 Number 1. January 22, 2003

26