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Helicopter Emergency Medical Services During Coronavirus Disease 2019 in Nepal

Published:April 21, 2021DOI:https://doi.org/10.1016/j.amj.2021.04.005

      Abstract

      Virtually every country in the world has been affected by coronavirus disease 2019 (COVID-19). Nepal is a landlocked country located in Southern Asia. Nepal's population has suffered greatly due to a shortage of critical care facilities, resources, and trained personnel. For appropriate care, patients need access to hospitals mostly in the centrally located capital city of Kathmandu. Unfortunately, Nepal's resources and personnel dedicated to transferring COVID-19 patients are scarce. Road and traffic infrastructure problems and mountainous terrain prevent ground ambulances from performing effectively. This, in addition to Nepal lacking national standards for prehospital care, create great challenges for transferring patients via ground emergency medical services. The concept of helicopter emergency medical services (HEMS) began in 2013 in Nepal. Presently, 3 hospitals, Nepal Mediciti Hospital, Hospital for Advanced Medicine and Surgery (HAMS), and Grande International Hospital, coordinate with private helicopter companies to run proper HEMS. One entity, Simrik Air, has dedicated 2 Airbus H125/AS350 helicopters for the sole purpose of transferring COVID-19 patients. HEMS effectiveness is expanding in Nepal, but much remains to be accomplished.
      Nepal is a landlocked country located in Southern Asia.

      Acharya S. Rights of Nepal as landlocked country in reference to the transit relation with India and China. Available at:https://ssrn.com/abstract=2707947. Accessed February 10, 2021.

      Most of the highly advanced critical care medical centers are located in the capital of Kathmandu. Many of the medical facilities in the peripheral regions are economically disadvantaged and lack advanced care.

      Aryal BP. Critical health care centralized in capital. Available at:https://myrepublica.nagariknetwork.com/news/critical-health-care-centralized-in-capital/. Accessed February 9, 2021.

      This Himalayan nation has suffered a great deal at the hands of the current pandemic. As of March 6, 2021, 274,608 people have been infected with coronavirus disease 2019 (COVID-19) according to the Nepali Ministry of Health and Worldometers.

      Nepal coronavirus. Worldometer. Available at:https://www.worldometers.info/coronavirus/country/nepal/. Accessed March 6, 2021.

      Thus far, 270,766 people have recovered, 3,010 have died, and more than 800 are currently deemed ill.
      There has been a subsequent rise in the need for emergency medical services (EMS). However, Nepal lacks standards for ground ambulance providers. There are no universal education or training requirements for ambulance staff. Patients are suffering from the undeveloped prehospital care system. Ambulance clinicians lack proper training, equipment, and education to deal with critically ill patients.

      Prehospital: first national conference on pre-hospital care for emergencies in Nepal. Available at:https://heoc.mohp.gov.np/pre-hospital/. Accessed January15, 2021.

      Transferring critical COVID-19 patients between facilities by ground is impractical and nearly impossible. This is due to terrain and traffic infrastructure issues such as impassible roads with no traffic signs. Also, traffic rules are either nonexistent or not enforced in many areas. Traveling to distant hospitals by ground EMS could take days. The same distance is covered by helicopter emergency medical services (HEMS) in hours. A limited number of severe COVID-19 patients have been transported via Nepal Ambulance Service

      Nepal Ambulance Service. Available at:https://www.nepalambulanceservice.org/. Accessed February 20, 2021.

      and other hospital-based ambulance services since the beginning of COVID-19 to date.
      HEMS has developed into the preferred option to deliver patients to critical care facilities. According to Bhandari and Yadav,
      • Bhandari D
      • Yadav NK
      Developing an integrated emergency medical services in a low-income country like Nepal: a concept paper.
      HEMS has been confirmed as a great resource in this mountainous country of Nepal.
      HEMS launched in 2013 at Grande International Hospital in Nepal.
      • Karki S
      Helicopter rescue in Nepalese jungle.
      Another hospital in the capital, Nepal Mediciti Hospital, began HEMS in 2017. The Hospital for Advanced Medicine and Surgery added HEMS availability in 2018. Although Nepal does not have a single dedicated helicopter to transport critically ill patients, the HEMS system is coordinated with privately owned helicopter companies. Helicopters allow clinicians to limit the patient's out-of-hospital time, optimally reducing the degree of morbidity and mortality.
      Initially, medics were required to compile all of their medical equipment and rendezvous with the helicopter at the airport. This proved to be a time-consuming process. Currently, a helicopter flies to the hospital to gather the medics and equipment.
      Initially, the helicopter pilots were unaware of how labor-intensive managing and transporting critical patients could be. Many patients required advanced airway management with a mechanical ventilator. Gradually, through education and experience with the flight medics, the pilots came to understand the hurdles of managing COVID-19 patients. The pilots now factor additional time for patient management into their fuel calculations and weather observations. The collaborated work between helicopter pilots and medics is more efficient.
      On October 12, 2020, Simrik Air announced that they dedicated 2 Airbus H125/AS350 helicopters for the sole purpose of transferring COVID-19 patients under the support of a patient isolation unit (PIU).

      Simrik Air: Service. Available at:https://simrikair.com/our-service/medical-evacuation-relief-flights./. Accessed January 20, 2021.

      The PIU consists of polyvinyl chloride plastic covering with high-efficiency particulate air filters. It can also be modified to create a negative pressure up to −18 Pascal. There are several ports where oxygen tubing and equipment can be delivered to the patient. The PIU serves as an essential piece of equipment on all COVID-19 transports.
      When a referring physician requests a patient be transferred to a higher level of care, they call the receiving facility's prehospital care department (PHC). The PHC relays the information to the flight medic and the physician on duty and checks for an available helicopter. The PHC assists dispatche of the helicopter and simultaneously gathers information about the patient. The helicopter flies from the airport to the hospital. The air travel time from Kathmandu is approximately 2-3 minutes to reach 1 of these 3 hospitals. In the meantime, the medical team responds to the helipad. It takes approximately 10 minutes to reconfigure the helicopter into a mobile intensive care unit. In a H125/AS350 helicopter, the patient is accommodated by removing the copilot seat and raising the back seat. The mandatory equipment taken for each case includes a transport ventilator, cardiac monitor, medication pump, polymer bag mattress,O2 cylinders and medication bag. The flight team consists of an emergency physician and either a paramedic or a nurse. There are no national standards for the flight crew, although all of the nurses and medics are senior personnel. The flight medics receive a prehospital care course in-house. The flight nurses work in the emergency room and most have obtained a bachelor's degree.
      The helicopter cabin setup has limitations. The patient's position during transport is supine on a polymer bag mattress.A semi-Fowler's position is preferred because it allows the diaphragm to drop, increasing lung capacity. Many COVID-19 patients require interventions in flight such as supplemental breathing treatments. The limited space in the cockpit as well as personal protective equipment constraints make this more difficult. The cockpit, equipped with the PIU, positions the crew in close proximity to the patient. This could potentially expose the pilot and crew during aerosol-generating procedures. Currently, the medical crew and pilot wear eye protection, gloves, disposable shoe covers, long sleeve fluid-repellent gowns, and N95 masks. At the time of this writing, Simrik Air had transported more than 85 patients with COVID-19. There were approximately 6 patients requiring mechanical ventilation. The others were transferred with the support of supplemental oxygen via a Venturi mask, high mask, simple mask, or nasal cannula. Each patient was treated and transported without incident. Preparation is a key to success in achieving optimal patient outcomes.
      Thus far, the shortest COVID-19 flight was 96 nautical miles from the capital round trip. The longest HEMS transport of a COVID-19 patient covered 570 nautical miles two way. The average distance traveled on COVID-19 transports is 333 nautical miles round trip. The average flight time to transfer patients is 2.5 hours two way. Transferring patients this distance via ground ambulance would average more than 20 hours per round trip. Thus far10,500 feet is the highest altitude that a helicopter has been dispatched for transport of a COVID-19 patient in Nepal.In this elevation pilots and medical crews also use Oxygen.
      Transferring patients who require the support of bilevel positive airway pressure or continuous positive airway pressure has been difficult because of the subsequent need for an extensive amount of supplemental oxygen. Experience has shown that using the PIU with these patients and attempting to carry sufficient amounts of oxygen can be burdensome. These patients also become difficult to manage inside the PIU if their condition deteriorates. Once the patient is inside the PIU, he or she frequently becomes uneasy. The stressors of flight, including the vibration and noise produced by the helicopter, as well as changes in elevation and temperature can all produce more anxiety for patients.
      Four additional helicopter companies have adapted an on-board PIU to assist with the COVID cases: Altitude Air, Manang Air, Kailash Air, and Shree Air. In Nepal, only the military uses night vision goggles for helicopter flights. Due to government regulations, privately owned helicopters are not allowed to fly at night or use night vision goggles.
      Shree Air is also in the process of gaining approval to transport COVID-19 patients via fixed wing aircraft. This will be beneficial for patients because it is less expensive and faster than helicopter transport over long distances. This would also expand medical transport availability after sunset. Additionally, medics would have more space to manage COVID patients, and more than 1 patient could be transferred at a time.
      Because of inadequate insurance policies in Nepal, HEMS creates financial burdens to patients and their families. The additional medical costs the patient receives are high with the inclusion of tertiary critical care charges. Patients are faced with a deadly disease to fight and are jeopardized by finances as well.
      Occasionally, hospital intensive care unit beds are at capacity. This can lead to a patient having a delay in receiving vital care. Sometimes patient transports may be delayed due to weather. The helicopter travel time, reconfiguration of the cabin, and distance covered reduce the number of patients who can be transported. The turnaround time is further impacted by properly donning and doffing personal protective equipment as well as disinfecting the crew, equipment, and helicopter cabin. The highest number of COVID-19 patients transported via helicopter in a single day is 3.
      As in many areas, there are more patients than health care providers, facilities, or equipment. Resources have been exhausted. There remains a great need for additional equipment and for advanced care facilities outside of Kathmandu. There is a demand for more health care providers in hospitals, ambulances, and helicopters. Nepal will benefit greatly as the prehospital care system and HEMS develop throughout the country.

      References

      1. Acharya S. Rights of Nepal as landlocked country in reference to the transit relation with India and China. Available at:https://ssrn.com/abstract=2707947. Accessed February 10, 2021.

      2. Aryal BP. Critical health care centralized in capital. Available at:https://myrepublica.nagariknetwork.com/news/critical-health-care-centralized-in-capital/. Accessed February 9, 2021.

      3. Nepal coronavirus. Worldometer. Available at:https://www.worldometers.info/coronavirus/country/nepal/. Accessed March 6, 2021.

      4. Prehospital: first national conference on pre-hospital care for emergencies in Nepal. Available at:https://heoc.mohp.gov.np/pre-hospital/. Accessed January15, 2021.

      5. Nepal Ambulance Service. Available at:https://www.nepalambulanceservice.org/. Accessed February 20, 2021.

        • Bhandari D
        • Yadav NK
        Developing an integrated emergency medical services in a low-income country like Nepal: a concept paper.
        Int J Emerg Med. 2020; 13: 1-5
        • Karki S
        Helicopter rescue in Nepalese jungle.
        JEMS. 2017; 10: 16
      6. Simrik Air: Service. Available at:https://simrikair.com/our-service/medical-evacuation-relief-flights./. Accessed January 20, 2021.