Minn. air ambulance uses TXA as standard protocol

Adopted by Mayo One and Mayo Clinic Hospital — Saint Marys Campus emergency department in 2012


By Jeff Hansel
Post-Bulletin

ROCHESTER, Minn. — The Mayo One medical helicopters have enough blood products, equipment and tests to provide hospital-comparable service, although fewer health experts can fit in the limited space.

If there's a treatment option that helps in the hospital setting and could help on the helicopter, "we want that on board" if it's possible,said clinical nurse specialist Kathy Berns, who oversees equipment, medications and education and is one of the flight reviewers.

The Mayo One helicopters have essentially become airborne blood banks.

"We've always been a little bit on the cutting edge," Berns said.

The Mayo One fleet flies more than 1,000 flights a year The helicopters fly within a 150-mile radius of bases at Mayo Clinic Hospital — Saint Marys Campus; the Chippewa Valley Regional Airport in Eau Claire, Wis.; and Mankato Regional Airport.

Mayo's medical helicopters have been carrying blood for more than 25 years, said trauma surgeon Scott Zietlow, Mayo One medical director. But the types of blood products they carry continues to expand to meet patient needs and improve patient outcomes.

Mayo became the first civilian air-medical service to carry thawed plasma, which helps blood clot, starting in 2009, Zietlow said.

"It is not easy to do," he said, "but it is something we believe is vitally important." Most pre-hospital rescue services can offer only saline solution to patients.

All the while, "they're losing blood and clotting factors," Zietlow said. About 30 percent of patients lose the ability for their blood to clot "because of the extent of the trauma," he said.

The sooner treatment begins to counter that, "the higher the likelihood of survival."

War lessons help

Lessons from the wars in Iraq and Afghanistan have helped prove that tourniquets can be life-saving. So, too, can a type of combat gauze that expands to help add pressure and decrease blood loss.

There's a drug called TXA (tranexamic acid) that Mayo One adopted, along with the Mayo Clinic Hospital — Saint Marys Campus emergency department, in 2012 as standard protocol.

It helps "reduce the risk of fatal bleeding events in trauma patients," says a clinic description of a study that proved the drug could be used for military-trauma patients. It was then adopted by some trauma providers in the civilian environment.

Berns imagines one day having an onboard X-ray, one of the few missing components.

Currently, "there's not a machine small enough," she said.

A tissue oxygenation monitor can alert health providers when a patient's tissues aren't getting adequate oxygen, even before vital signs plummet.

When the monitor shows a problem, medical flight crews realize "gosh, they need blood now, even though their vitals look OK."

Mayo One crews tested an oxygenation-monitor for the medical helicopters used by Mayo Medical Transport.

"We said to the company, 'We like it, but it just takes up too much space' — so they made a smaller one," Berns said.

Changes tested on the ground

Each change with the Mayo medical-helicopter service gets tested on the ground and on flights for many months before the possibility of formal adoption. If it works well, it gets added to the medical-helicopter system to help improve patient outcomes.

Another potential change, Zietlow said earlier this year, that he hopes Mayo One will will make is to carry platelets onboard by the end of 2014. Platelets, which clump together to help clot blood, are only useful for five days after donation, according to Mayo.

Carrying a supply onboard Mayo One requires an orchestrated system to make sure the valuable resource gets used in a timely manner. Platelets need to be agitated steadily and kept at specific temperatures to maintain proper storage.

"We're going to get that figured out yet this year," Zietlow said. One need for the Mayo One hanger was a way to keep blood-product supplies cool.

A Minneapolis company called "Minnesota Thermal Science" developed a cooler that was being used in Iraq and Afghanistan. In temperatures of 100-plus degrees, the cooler kept blood products properly cooled. Mayo keeps the cooler refrigerated on the hanger deck, with blood products inside, and can then carry it along on flights.

It's not a single new option that's key, Zietlow said.

Rather, it's "a bunch of small things that all add up to make the difference."

Flight data reviewed

Berns and other flight reviewers look at each flight's data to consider whether anything could have been done better. They also review whether a helicopter flight was the appropriate level of response for each patient's need.

"If they can come by ground ambulance, that's how they need to go," Berns said.

Only about 2 percent of Mayo One patients get dismissed from the emergency department the same day. Berns compared that with a service in the Northeast that reaches 40 percent ER dismissal, suggesting many of those patients' medical conditions were good enough that they could have been transported instead by ground ambulance — a much cheaper alternative.

More than 80 percent of patients taken to Saint Marys by medical helicopter require time in the intensive-care unit.

"That's a profoundly high number, and would be an indicator that you're transporting the right kinds of patients," Zietlow said.

Flying includes risk

"So we don't want to be sending out a helicopter if it isn't necessary," Berns said.

Sometimes medical flight crews must compassionately but assertively advise loved ones that a person's injuries are not survivable. It does not make sense to transport in that case because it will only cost loved ones extra money.

Flight crews carry burden

Flight crews carry with them memories of tremendous loss — the emotional cries of friends and family members on-scene, and the sights of severe trauma.

But they also carry with them many remembrances of lives saved, words of thankful appreciation from trauma survivors who happen to be conscious while transported and the knowledge that patients who in past years would have died now have the chance to continue their lives.

"I'm almost kind of teary, because several cases come to mind," Berns said in an interview earlier this year.

She remembers one patient in need of heart catheterization when the situation was touch-and-go.

The cath lab was already prepped when the helicopter arrived.

The flight crew visited the person a couple of hours after the procedure and the patient said, "thank you. You just gave me another Christmas with my family," Berns said.

Trauma patients, overall, tend toward younger ages, but Mayo One responds to people from premature birth to age "100 or more," Zietlow said.

Whole blood in future?

What does the future hold for Mayo One and medical-helicopter patient transportation?

Trauma surgeon Dr. Donald Jenkins said Mayo is looking at the possibility of using whole blood instead of focusing solely on blood components like red blood cells, plasma and platelets.

"Every soldier in Vietnam who got a transfusion got whole blood," Jenkins said. "Every one of them."

Now, he said, science has shown that "trauma patients need whole blood" and that it's safe to offer it.

The next time you hear Mayo One or another of Mayo's medical helicopters fly over Southeast Minnesota, you'll know that there have been many changes to the flying laboratory, and many more are on the way.

"We're not satisfied," Jenkins said. "We're going to make it better."

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