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Patient transportation
Skills and techniques
Update 2011
Erik Jan van Lieshout Department of Intensive Care and Mobile Intensive
Care Unit, Academic Medical Centre, University of
Amsterdam, the Netherlands
Copyright 2011. European Society of Intensive Care Medicine. All rights reserved.
Contents
Contents
Introduction ................................................................................................................................................ 1
1/ Approach to transfer of critically ill risks vs benefits...........................................................................3
Indications for transport in critically ill patients ................................................................................... 4
Ethical considerations .............................................................................................................................5
Risks of transport of critically ill patients .............................................................................................. 6
Guidelines ............................................................................................................................................... 8
2/ Planning the transfer of a critically ill patient ..................................................................................... 10
Deciding to transport the patient .......................................................................................................... 10
Early versus late transfer The need for stabilisation ......................................................................... 12
The transfer team .................................................................................................................................. 14
Transfer equipment ............................................................................................................................... 15
Trolley ................................................................................................................................................ 15
Equipment for monitoring and physiological support ..................................................................... 16
What to monitor................................................................................................................................. 17
Defibrillator/pacemaker .................................................................................................................... 17
Mechanical ventilator ........................................................................................................................ 18
Cylinders with pressurised oxygen and air ....................................................................................... 18
Syringe pumps ................................................................................................................................... 19
Suction equipment ............................................................................................................................ 20
Emergency kit ................................................................................................................................... 20
Additional equipment ....................................................................................................................... 20
3/ Conduct of the transfer ........................................................................................................................ 23
Safety .................................................................................................................................................... 23
Special environments ........................................................................................................................... 23
Choosing the transport vehicle............................................................................................................. 24
Air medical transport ............................................................................................................................25
Indications .........................................................................................................................................25
Choice of aircraft ................................................................................................................................25
Altitude effects ...................................................................................................................................25
Acceleration/deceleration forces ...................................................................................................... 26
Treating the patient during transport ................................................................................................... 27
Problems during transfer ...................................................................................................................... 27
What may happen .............................................................................................................................. 27
Strategies to combat problems ......................................................................................................... 28
Stabilisation of the patient................................................................................................................ 28
4/ Providing pre-hospital care .................................................................................................................. 31
The call out ............................................................................................................................................ 31
Pre-hospital teams and their skills ........................................................................................................ 31
Patient assessment and care on the scene ........................................................................................... 32
Triage .................................................................................................................................................... 34
Other pre-hospital procedures ..............................................................................................................35
Immobilisation after trauma .............................................................................................................35
Prevention of hypothermia ................................................................................................................35
Securing an airway ............................................................................................................................ 36
The receiving unit ................................................................................................................................. 36
The handover ........................................................................................................................................ 38
Conclusion ................................................................................................................................................ 39
Appendix .................................................................................................................................................. 40
Self-assessment Questions ....................................................................................................................... 42
Patient challenges..................................................................................................................................... 46
Learning objectives
LEARNING OBJECTIVES
After studying this module on Patient transportation, you should be able to:
FACULTY DISCLOSURES
DURATION
6 hours
INTRODUCTION
Transportation of the critically ill patient is inevitable in most health systems.
Pre-hospital transportation may be necessary after major injury or as a result of
life-threatening illness for example, myocardial infarction, intracranial
haemorrhage, or metabolic coma.
Singh JM, MacDonald RD. Pro/con debate: do the benefits of regionalized critical
care delivery outweigh the risks of interfacility patient transport? Crit Care
2009; 13(4): 219. Review. PMID 19678918
Belway D, Henderson W, Keenan SP, Levy AR, Dodek PM. Do specialist transport
personnel improve hospital outcome in critically ill patients transferred to
higher centers? A systematic review. J Crit Care 2006; 21(1): 817;
discussion 1718. Review. PMID 16616617
Mealer ML, Shelton A, Berg B, Rothbaum B, Moss M. Increased prevalence of
post-traumatic stress disorder symptoms in critical care nurses. Am J
Respir Crit Care Med 2007; 175: 693697. PMID 17185650
Waldmann C, Soni N, Rhodes A, editors. Oxford Desk Reference: Critical Care.
Oxford: Oxford University Press; 2008. ISBN: 978-0-199-22958-1. pp.
576578
[1]
Introduction
[2]
Task 1. Approach to transfer of critically ill risks vs benefits
Although there are differences between pre-, intra- and inter-hospital transfer
(such as: indication, duration of transport, environment of transport,
availability of help in the event of a complication, lighting, available space for
work, equipment, and others), the main considerations and principles for
preparation are similar. Pre-hospital or primary transfer will be discussed in
more detail in the PACT module on Multiple trauma.
Patient transport is a clinical skill like placing a central venous line and requires
a training process. Only experienced staff should accompany a critically ill
patient. Benefits and risks should be weighed in every critically ill patient before
transport.
[3]
Task 1. Approach to transfer of critically ill risks vs benefits
Depending on the local situation for example, small rural hospital vs. large
specialist centre the frequency of inter-hospital ICU transfers will vary
considerably. But even in large specialist centres inter-hospital transfer may
still be indicated in some circumstances e.g. transfer to undergo organ
transplantation.
Potential benefits should be discussed by senior ICU staff members and any
other relevant experts before a decision to transfer is made.
A. Not every tertiary centre specialises in the same services. For a liver transplant or
coiling of an intracranial aneurysm, inter-hospital transfer may be the only way to
ensure that your ICU patient receives appropriate care. Furthermore, lack of
availability of ICU beds is common in some jurisdictions, sometimes more common in
larger units.
[4]
Task 1. Approach to transfer of critically ill risks vs benefits
Ethical considerations
Lack of ICU resources as a reason for inter-hospital transport may pose an
ethical dilemma for the entire team. A medicolegal consideration could be the
existing doctorpatient relationship established with other patients before the
last patient was admitted. In that case the rule last in first out has sometimes
applied.
However, as ICU physicians, we are not only are responsible for a single patient,
but for the entire cohort of ICU patients and potentially, all patients within the
hospital and health system. Therefore another approach might be to choose a
less critically ill patient in the unit to be transported to another institution
within a network of ICUs. This might constitute better allocation of overall ICU
resources regionally. Such decisions are difficult and should be taken after
senior discussion with the interests of the patient involved as the primary
consideration.
[5]
Task 1. Approach to transfer of critically ill risks vs benefits
[6]
Task 1. Approach to transfer of critically ill risks vs benefits
Papson JP, Russell KL, Taylor DM. Unexpected events during the intrahospital
transport of critically ill patients. Acad Emerg Med 2007; 14(6): 574577.
PMID 17535981
Seymour CW, Kahn JM, Schwab CW, Fuchs BD. Adverse events during rotary-
wing transport of mechanically ventilated patients: a retrospective cohort
study. Crit Care 2008; 12(3): R71. PMID 18498659
Study the transport documentation for the last five patients transported
within your hospital or between hospitals. Were there critical incidents during
transport? How serious were they (minor or potentially life-threatening)? Could these
critical incidents have been anticipated, and possibly avoided, with better planning? Be
aware of under-reporting of critical events. Even though automated documentation of
vital data and machine settings can be captured using a patient data management
system (PDMS), such systems are only starting to be used outside the ICU.
Check your own equipment for ICU transport. Imagine clinical With sufficient
situations in a radiology room which you might not be able to preparation and good
handle, forcing your to return to the ICU. Consider updating or equipment, transport of
severely ill patients, even
expanding the material on your transport unit.
in prone position, is
possible without an
adverse event
A. Adequately stabilise the critically ill patient. Use checklists and guidelines. It is safer
to intubate and mechanically ventilate a patient in respiratory distress in the ICU
before transport than to wait for clinical deterioration and be forced to perform
intubation in an elevator, ambulance or aircraft. The same holds true for starting
vasoactive agentsand, therefore, gaining central venous access.
[7]
Task 1. Approach to transfer of critically ill risks vs benefits
Warren J, Fromm RE Jr, Orr RA, Rotello LC, Horst HM; American College of
Critical Care Medicine. Guidelines for the inter- and intrahospital
transport of critically ill patients. Crit Care Med 2004; 32(1): 256262.
PMID 14707589
Electronic version of the Warren J et al. reference, see http://www.sccm.org
[Click LearnICU/Administration/Administrative Guidelines]
[8]
Task 1. Approach to transfer of critically ill risks vs benefits
[9]
Task 2. Planning the transfer of a critically ill patient
Even if a critical care patient is in severe cardiogenic shock due to ongoing myocardial
infarction, the expected benefit of primary percutaneous coronary intervention could
outweigh the high risks of inter-hospital transport. The balance between time-
consuming pre-transport stabilisation and delaying the intervention is crucial.
Every transport poses an additional risk to the critically ill patient. If there is
any doubt, the risk-benefit analysis must be reviewed with the senior member of
the transport team, who carries final responsibility during transfer.
A so called time out of the transport team before departure has successfully
been used as a security check. Items on a checklist would include the following:
[10]
Task 2. Planning the transfer of a critically ill patient
Even though many of these tasks are the clear responsibility of a defined team
member (road condition for the driver, medical condition to the physician) it is
of mutual interest that the entire team is aware of the risks and alternative
possibilities of the transfer.
Creating a specific transport checklist for your own department seems fairly
easy but using a checklist for checklists might help to address design and
implementation issues which are sometimes unfamiliair for nurses and
physicians.
http://gawande.com/the-checklist-manifesto
http://www.projectcheck.org/checklist-for-checklists.html
Assign specific roles for specific members of the transport team, e.g. who is
responsible for artificial respiration including ventilator settings and positioning
of the endotracheal tube. Other necessary tasks such as administration of
medication should be assigned to someone else.
[11]
Task 2. Planning the transfer of a critically ill patient
A. 1. Is the receiving clinic informed and ready to admit the patient; who is the
responsible receiving physician?
2. What is the clinical status of the patient? (the ABC of ACLS/ATLS may serve as a
guide to assess the clinical status). Is there a need for securing the airways or artificial
ventilation? What are the settings on the ventilator, e.g. PEEP and FIO2, the number
and medication of syringe pumps.
3. Where exactly is the patient expected i.e. ICU vs. CT or MRI suite vs. emergency
department? Is the team and necessary equipment ready to continue intensive care in
that room? remember weight limits of the CT trolley, number of syringe pumps etc.
4. What are the alternative modes of transfer? e.g. road ambulance vs helicopter. What
are the needs and limits e.g. weight limit of the stretcher, legal requirements for
fixation of the patient in a helicopter. Special heavy duty transport stretchers may be
needed (possibly from the fire brigade). Such meticulous planning will take time but
may help reduce the actual transport time.
[12]
Task 2. Planning the transfer of a critically ill patient
The time needed to stabilise a critically ill patient varies Early communication
considerably and, occasionally, is not possible. In cases of acute will give you enough time
to organise additional
myocardial infarction or cerebral stroke, an ICU patient should
personnel. If the
be transported as soon as possible to a cardiac catheterisation ambulance staff do not
lab or a stroke unit. In other situations however several hours possess the necessary
may be taken to optimise the patient and make proper experience to handle the
preparations for ICU transport e.g. before transfer for renal patient, call a specialist
replacement therapy. and/or a specialised
nurse to accompany the
transfer e.g. a
neonatologist, or a
paediatric intensivist if
your patient is a child
Grines CL, Westerhausen DR Jr, Grines LL, Hanlon JT, Logemann TL, Niemela
M, et al.; Air PAMI Study Group. A randomized trial of transfer for
primary angioplasty versus on-site thrombolysis in patients with high-risk
myocardial infarction: the Air Primary Angioplasty in Myocardial
Infarction study. J Am Coll Cardiol 2002; 39(11): 1713-1719. PMID
12039480
Silbergleit R, Scott PA, Lowell MJ, Silbergleit R. Cost-effectiveness of helicopter
transport of stroke patients for thrombolysis. Acad Emerg Med 2003;
10(9): 966972. PMID 12957981
Cantor WJ, Burnstein J, Choi R, Heffernan M, Dzavik V, Lazzam C, et al. Transfer
for urgent percutaneous coronary intervention early after thrombolysis for
ST-elevation myocardial infarction: the TRANSFER-AMI pilot feasibility
study. Can J Cardiol 2006; 22(13): 1121-1126. PMID 17102829
Recognise which urgent treatments required by some critically ill patients are
unavailable in your hospital, thus necessitating a transfer. Create a list of indications
for immediate transfer.
Trauma patients, for instance, need to be referred to a trauma centre. For more
about triage and the management and transportation of severe trauma patients
look at the following flash conference:
ESICM Flash Conference: Mathieu Raux. Critical Care Refresher Course
Trauma. Transportation of severe trauma. Barcelona 2010
[13]
Task 2. Planning the transfer of a critically ill patient
[14]
Task 2. Planning the transfer of a critically ill patient
Transfer equipment
Trolley
Newer transport equipment may be suitable even for MRI suites so that
changing equipment is not necessary.
[15]
Task 2. Planning the transfer of a critically ill patient
All ICU equipment considered essential for monitoring and treating the
critically ill patient should be used during transfer. Modern ICU equipment, e.g.
high specification ventilators, is often suitable for use during transfer, with
internal batteries for stand-alone use and options for data storage. It should be
robust and firmly attached to the patient trolley to limit the risk of
disconnection, dislodgement/damage or causing injury to patient/staff.
[16]
Task 2. Planning the transfer of a critically ill patient
What to monitor
Three-lead (or more) ECG with heart rhythm and assessment of the
ST segment
Invasive pressures (or if too time-consuming or not available, non-
invasive blood pressure may be acceptable)
Haemoglobin oxygen saturation
End-tidal capnography
Temperature.
Deakin CD, Sado DM, Coats TJ, Davies G. Prehospital end-tidal carbon dioxide
concentration and outcome in major trauma. J Trauma 2004; 57(1): 65
68. PMID 15284550
Davis DP, Dunford JV, Poste JC, Ochs M, Holbrook T, Fortlage D, et al. The
impact of hypoxia and hyperventilation on outcome after paramedic rapid
sequence intubation of severely head-injured patients. J Trauma 2004;
57(1): 18; discussion 810. PMID 15284540
Defibrillator/pacemaker
[17]
Task 2. Planning the transfer of a critically ill patient
Mechanical ventilator
Q. How could you find out before transport whether your portable
mechanical ventilator is suitable for use during transport of patients
with severe respiratory insufficiency?
A. In many portable ventilators the airway pressure is dependent on the pressure of the
oxygen cylinders. When this pressure is insufficient to deliver the necessary Pmax
and/or PEEP, hypoventilation or desaturation may occur in patients with severe
respiratory insufficiency. Before transfer of the patient on the MICU trolley, a short
period on the portable ventilator (1015 mins) should prove its suitability (trial period).
Benchmark reports are currently available for transport ventilators. These may be of
assistance when deciding which machine to purchase.
The hoses and plugs for oxygen and pressurised air on transport trolleys are
more prone to wear and tear than equivalent stationary fittings in the ICU.
Therefore annual maintenance and premature replacement of vulnerable parts
should be integrated in the safety management system of your intra- and inter-
hospital transport system.
[18]
Task 2. Planning the transfer of a critically ill patient
A: The barometer of the cylinder displays the pressure e.g. 200 bars (200 times the
normal ambient pressure). For a five-litre cylinder, the amount of oxygen available will
be 5 litres x 200 = 1000 litres. If the patient is ventilated with 15 litres/min and FIO2 of
50% you need 7.5 litres O2/min. The time for the cylinder to empty is 1000/7.5 = 133
min. With many portable ventilators you will also need additional pressurised air.
Syringe pumps
As more drugs are available with a very short duration of action and better
titratibility, syringe pumps are increasingly being used for administration of
sedatives, analgesics or vasopressor support.
The above may be the root cause of an adverse event during changing of pumps.
Be aware of the differences in concentration and have someone check the
correct dosage together with you. If in doubt, draw new syringes with the
concentration you are used to, rather than taking over some awkward
concentration at the referring hospital. Remember you will need to
communicate the correct dosage at the receiving unit.
[19]
Task 2. Planning the transfer of a critically ill patient
Suction equipment
Emergency kit
Additional equipment that does not require a lot of space, such as intubation
material, is often stored in an emergency kit. A separate emergency medication
kit should be easily accessible and stocked before each trip with patient-specific
and refrigerator-kept drugs as needed.
Bring a limited, standard set of disposables instead of storing all possible items
in a bulky emergency suitcase. If stabilisation prior to transfer is adequate, the
material is seldom used. The case could be sealed allowing for for quick
inspection prior to departure combined with weekly checks on expiration dates,
battery capacity etc. Clear labelling increases awareness of where specific
material is stored, and avoids time-consuming searches for material in an
emergency.
Put together an emergency kit including equipment and drugs for your
ambulance with the minimum medications you consider indispensable for transport of
a critically ill patient. How many ampoules of which drugs would you include?
A final check of the emergency case is mandatory before you leave a relatively
safe environment such as the emergency department or ICU. Be sure to check batteries,
cylinders and expiration dates!
Additional equipment
[20]
Task 2. Planning the transfer of a critically ill patient
A.
How useful to patient care during the transport is the device?
What are the risks for the patient if the device is displaced unintentionally (e.g.
blood loss)?
What is the battery capacity and what are the risks to the patient if the device
shuts down?
Is it safer to uncouple the device during transport because the risks outweigh
the benefits?
Do weight, size, possibility of firm attachment to ambulance or legal restrictions
preclude the use of a device, especially in aeromedical transport?
[21]
Task 2. Planning the transfer of a critically ill patient
Find out the technical limitations of equipment used during transport outside
the ICU. What are the weight limits or patient size limits for stretchers being
transported by ambulance or helicopter, and for CT or MRI patient trolleys? What are
the maximum limits of the transport ventilator (peak inspiratory pressure, PEEP,
minute ventilation)? Check the electrical current in your transport vehicle: is a 220 Volt
AC current available, and how many sockets are installed? What is the maximum
ampere limit of the electrical fuse and battery capacity of your equipment? Do you have
replacement batteries? Find out what kind of equipment you may use during transfer,
and which medical monitoring devices may interfere with the electronic equipment of
your ambulance/air ambulance. Which specialised interventions can be performed in
your ambulance (defibrillation in a helicopter, intra-aortic balloon counterpulsation in
an ambulance, extra-corporeal cardiac assist device)?
[22]
Task 3. Conduct of the transfer
Safety
The transfer trolley and equipment should be checked before and after each
transfer, with checklists to be signed for quality audit. Regular checks by
members of other departments do not preclude an additional check by the
intra-hospital transport team before the patient leaves the ICU to ensure that
all equipment is functioning properly.
The use of a dedicated checklist just before departure (analogous to a time out
in the operating room) supports a systematic safety check of equipment and
drugs.
Set appropriate alarm limits and ensure the alarm volume is loud enough to be
heard.
Special environments
Special arrangements must be made when in close proximity to MRI scanners
which produce magnetic fields several times greater than that of the earth. All
ferromagnetic material is attracted by such magnetic fields, which are active
even when no scans are being performed. Transfers for MRI scans require
specially designed, non-ferromagnetic equipment, which is usually available
in/near the MRI suite. A less satisfactory alternative, using standard equipment
secured outside the range of the magnetic field with long hoses and monitoring
leads to the patient, may be used in some scanners
pacemakers or infusion pumps, may not function properly during and after MRI and a
need for their presence precludes MRI scanning. Standard medical devices such as
ventilators or infusion pumps are not compatible with MRI and special
arrangements/equipment must be used.
A relative contraindication to MRI is claustrophobia due to the narrow space inside the
scanner and sedation or even general anaesthesia may be required for susceptible
patients.
An example of what can happen when a metal object is placed in the MRI
environment: In this case, a cleaner entered the MRI scanner room with a
polishing machine, after removing all metal objects from his pocket. Fortunately
no patient was being scanned at the time as the patient trolley of the MRI was
completely destroyed.
Reproduced with the permission of the Academic Medical Centre,
University of Amsterdam, Department of Radiology 2004
Diaz MA, Hendey GW, Bivins HG. When is the helicopter faster? A comparison of
helicopter and ground ambulance transport times. J Trauma 2005; 58:
148153. PMID 15674165
McVey J, Petrie DA, Tallon JM. Air versus ground transport of the major trauma
patient: a natural experiment. Prehosp Emerg Care 2010; 14(1): 4550.
PMID 19947867
[24]
Task 3. Conduct of the transfer
The use of air medical transport in Europe, the United States and Australia
differs dramatically and is influenced by distances between hospitals, the
history and development of medical services, cooperation with the military,
geography, and insurance policies.
Choice of aircraft
The choice between rotary wing aircraft (helicopters) or fixed wing aircraft
should be made following a risk and cost vs benefit analysis using criteria like
travel distance, landing infrastructure, weather conditions, and clinical
emergency. Medical staff, untrained in air medical transport, should not
accompany such a transport, which is best handled by someone with expertise.
United States Naval Flight Surgeons Manual, 3rd edition. [Online] Available
from http://www.vnh.org/ [Accessed 15th December 2010]
For more information regarding the choice of aircraft read the following
reference:
Waldmann C, Soni N, Rhodes A, editors. Oxford Desk Reference: Critical Care.
Oxford: Oxford University Press; 2008. ISBN: 978-0-199-22958-1. pp.
580581.
Altitude effects
[25]
Task 3. Conduct of the transfer
Acceleration/deceleration forces
A. Air medical transport, with the increased height above sea level and decreased
ambient pressure, may cause closed air spaces to increase their size, according to
Boyles law e.g. an undrained pneumothorax, ileus/megacolon or intracranial air after
open head injury. Patients with decompression sickness following diving mishaps may
also deteriorate due to the use of air transport.
A. Depending on weather, road conditions and distance, helicopters may arrive faster
on the scene, and transport back to the hospital may also be faster. However, the
available space is much smaller in a helicopter, it may carry less equipment, and in case
of an adverse event with the patient, unlike a ground ambulance, the helicopter cannot
just stop by the road to allow the transport team a calm moment to perform an
intervention.
The answer to this question will be very dependent on the factors above and the
jurisdiction and environment in which the question arises. In Australia, for
example, it has been suggested that distances greater than 200km were faster
served by air transport. A recent retrospective study of trauma patients
observed that 5.61 more lives were saved per 100 patients in the group
transported by air vs road transport.
[26]
Task 3. Conduct of the transfer
McVey J, Petrie DA, Tallon JM. Air versus ground transport of the major trauma
patient: a natural experiment. Prehosp Emerg Care 2010; 14(1):45-50.
PMID 19947867
For more information about the transport of patients with severe trauma, see
ESICM Flash Conference: Mathieu Raux. Critical Care Refresher Course
Trauma. Transportation of severe trauma. Barcelona 2010
Pick a patient in your ICU and compile lists of medications and additional
supplies you would take with you for intra-hospital and inter-hospital transport.
Evaluate the differences.
Before leaving the safe environment of an ICU, plan for possible deterioration of
the critically ill patient by organising appropriate additional therapy (i.e.
medication, transfusions) to be taken along. Even a simple medical intervention
such as placement of an intravenous line may not be possible in the close
confines of a helicopter or an ambulance.
[28]
Task 3. Conduct of the transfer
ECG 1
A: This patient was taken to the cardiology suite without prior stabilisation where the
transport physician was greeted with barely disguised scepticism by the cardiologists.
However, when the patient was intubated for cardioversion he developed third degree
AV block, (see ECG strip 2) and went into severe cardiogenic shock, necessitating
immediate introduction of a pacemaker. An attempt at stabilisation before starting the
transfer would have lead to the cardiogenic shock in the small hospital without the
necessary resources for stabilisation.
ECG 2
[29]
Task 3. Conduct of the transfer
Chest X-ray
THINK: how much time will be saved if an ambulance drives at maximum possible
speed for a 40 km transfer between hospitals, e.g. for transfer of a patient with
myocardial infarction and to what extent will the time saved influence the patients
outcome? In comparison, how could you improve the process of care to save a
comparable amount of time? Thus what are the possible risks and benefits of driving
with emergency siren and flashing lights?
Greene J. Rising helicopter crash deaths spur debate over proper use of air
transport. Ann Emerg Med 2009; 53: 15A-17A. PMID 19244622
Johnson TD, Lindholm D, Dowd D. Child and provider restraints in ambulances:
knowledge, opinions, and behaviors of emergency medical services
providers. Acad Emerg Med 2006; 13: 886892. PMID 16825667
[30]
Task 4. Providing pre-hospital care
Q. Imagine you are the dispatcher receiving the call for help. What
should you ask the person calling from the accident site? Six items of
information are suggested here.
A. The more information you have, the better you can react. Important information
includes:
1/ Who is calling and how this person can be reached in case additional questions arise
2/ What happened, i.e. type of incident
3/ The number of victims and their type of illness or injuries
4/ Kinds of victims (e.g. children, pregnant women)
5/ Where the accident happened and how to get there
6/ Whether additional rescuers are needed in addition to medical help, e.g. to extricate
persons trapped in a car, to extinguish a fire, to secure the site e.g. risk of ongoing
shooting.
Additional helpful information includes weather and road conditions and obstacles to
air rescue.
The safety of the rescuers is important and must be considered first. Even
moderate injury to a member of the pre-hospital team has two immediate
effects; firstly it reduces the help available at the scene and secondly it produces
an additional patient who requires assessment and treatment.
[31]
Task 4. Providing pre-hospital care
Studnek JR, Ferketich A, Crawford JM. On the job illness and injury resulting in
lost work time among a national cohort of emergency medical services
professionals. Am J Ind Med 2007; 50: 921931. PMID 17918231
Good communication is the key to the success of a transfer team. Unless there is
a severe shortage of personnel, the team leader should not get involved in direct
patient care; his/her role is to give precise instructions to specific individuals.
As in aeronautics, closed loop communication can be used to ensure successful
transmission of tasks: i.e. the person who receives instruction repeats it to make
sure that the instruction is understood.
Whenever possible, a member of the pre-hospital care team should attend to the
needs of relatives and bystanders, who may be severely traumatised by the
events.
A. Providing the mother is reasonably calm and cooperative and there is sufficient
room in the ambulance, it is advisable to take her along. Separation of the child from
the family will cause additional stress for the child and the mother. A family member
may be the best analgesic and sedative for the boy. Further, the mother can provide
important information on the childs health status, and she will understand that all
efforts have been undertaken to save her childs hand.
comfort care e.g. good analgesia may be considered. This is the stay and play
approach.
If the patient is unstable, the second step is to decide if the problem can be
solved with simple means on the scene, e.g. extrication of a foreign object from
the pharynx or relief of a tension pneumothorax with a drain. If there is no fast
solution, as in the case of penetrating chest injuries, it is imperative not to waste
time, and the patient should be referred to an appropriate emergency centre,
e.g. a trauma centre. This is known as the scoop and run approach.
In many emergencies, a play and run approach may be appropriate: fast relief
of the most urgent problems e.g. insertion of a chest drain without orotracheal
intubation and fast transport to a trauma centre with minimal delay.
A. 1/ In burn injuries immediate cooling of the burned body area is more important
than transport. However, beware of whole body hypothermia!
2/ Immediate and extensive flushing of the eye with plain water is the single most
important therapeutic intervention; examination by an ophthalmologist can follow
later.
3/ In crush injuries with extensive destruction of muscle tissue, generous and early
administration of crystalloids is needed to prevent acute renal failure.
Weighing the relative importance of transport time vs type of injury may be very
difficult and requires considerable experience/expertise. If extended transport
time is expected, treatment of life-threatening injuries must begin on the scene
and be continued during transport.
See the following references and the PACT module on Multiple trauma.
Salomone JP, Ustin JS, McSwain NE Jr, Feliciano DV. Opinions of trauma
practitioners regarding prehospital interventions for critically injured
patients. J Trauma 2005; 58(3): 509515. PMID 15761344
Excellent interactive sessions are available under
http://www.trauma.org/resus/moulage/moulage.html
demonstrating the superiority of the stay and play or the scoop and run
approach.
Some North American studies found that severely injured patients have a better
chance of survival if they are transported as quickly as possible by private means
(bystanders or police) without any medical treatment on the scene at all.
However, the needs of an inner city penetrating trauma victim versus those of a
patient suffering myocardial infarction on a hike are different. For myocardial
ischaemia patients, the stay and play involving basic and advanced life support
as indicated has been shown to be effective. A compromise for immediate
measures at the scene that has been suggested is: do, but do it fast and only if
needed.
Seamon MJ, Fisher CA, Gaughan J, Lloyd M, Bradley KM, Santora TA, et al.
Prehospital procedures before emergency department thoracotomy:
scoop and run saves lives. J Trauma 2007; 63: 113120. PMID 17622878
Stiell IG, Nesbitt LP, Pickett W, Munkley D, Spaite DW, Banek J, et al; OPALS
Study Group. The OPALS Major Trauma Study: impact of advanced life-
support on survival and morbidity. CMAJ 2008; 178(9): 11411152. PMID
18427089
Review the pre-hospital care report for the last five patients admitted to your
ICU. Check if a decision was made concerning cardiorespiratory stability and note the
procedures performed at the scene and the time spent out of the hospital. Evaluate the
strategy adopted in light of later events in hospital and the final diagnoses.
The acceptable goals for vital parameters e.g. blood pressure during transport
are decided on an individual basis for each patient.
Triage
In cases of multiple casualties, it is imperative to triage patients according to the
ABCDE of the advanced trauma life support algorithm. Triage is a structured
process used to recognise those victims in acute danger and those most likely to
benefit from acute care. If the resources available are sufficient, triage will result
in those who have the most serious conditions being treated first. If resources
are limited and the facility is overwhelmed, triage may target those who need
only simple or short interventions for treatment and those with severe injuries
may only receive comfort care. The principles of triage apply not only to trauma
victims but also to those with a medical emergency, e.g. myocardial infarction or
[34]
Task 4. Providing pre-hospital care
Imagine a bus accident with ten seriously injured patients. They will be
admitted to your hospital within the next 15120 minutes. On which criteria would you
admit a patient to your ICU or send him on to the next institution. Would you transfer
any of your presently admitted patients to another institution or to a normal ward in
order to make room for one of the new patients?
For the ethical aspects related to triage see the PACT module on Ethics Task 4
(admission and discharge policies).
Prevention of hypothermia
THINK: Crystalloids are the main fluid for intravenous infusion. How can delivery
of crystalloids influence the lethal triad and what could be done to prevent possible
side effects?
Wang HE, Callaway CW, Peitzman AB, Tisherman SA. Admission hypothermia
and outcome after major trauma. Crit Care Med 2005; 33(6): 12961301.
PMID 15942347
Shaz BH, Dente CJ, Harris RS, MacLeod JB, Hillyer CD. Transfusion
management of trauma patients. Anesth Analg 2009; 108(6):17601768.
PMID 19448199
See also PACT on Multiple trauma
Securing an airway
Airway management may be difficult during transfer and there is little evidence
on the effectiveness of pre-hospital intubation on outcome.
See the PACT module on Airway management.
A.
Difficulty keeping the airway open, e.g. obesity and increased sleepiness
following morphine. Airway protection deserves special consideration in case of
increased nausea or vomiting.
Difficulty ventilating, e.g. heavy snoring, worsened sleep apnoea with obesity
and morphine.
Difficulty oxygenating, e.g. pulmonary oedema in left ventricular failure.
A. Intubation may render the situation more difficult: the patient will need sedation
with risk of increased cardiovascular instability. In the case of accidental extubation,
the situation may really get out of hand, as airway control is even more difficult outside
the safe confines of the ICU.
emergency admissions may have better outcomes than those referred to smaller
hospitals. However, stabilisation of vital parameters at a smaller institution with
secondary transfer to a (larger) receiving hospital may be appropriate when the
total transfer distance or time is great.
Be particularly suspicious if a patient does not present with the signs and
symptoms you would consider appropriate to the injury e.g. insufficient rise in
heart rate in a patient with substantial bleeding or minimal pain with obviously
severe injuries. There may be serious underlying or accompanying conditions or
injuries. When in doubt, suspect the more serious differential diagnosis of
illness or injury and transfer the victim to a large centre rather than a small
hospital.
A. This patient with a closed head injury and amnesia together with repeated vomiting
has an increased likelihood of intracranial injury requiring neurosurgical intervention.
You may have to insist that she to be taken to the trauma centre to rule out any serious
injury. The paper by Stiell et al. gives an excellent basis for deciding which patients
need a neurological work up after an apparently minor injury.
Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, et al. The
Canadian CT Head Rule for patients with minor head injury. Lancet 2001;
357(9266): 13911396. PMID 11356436
Contacting the receiving unit early and providing extensive information helps
them prepare for patient admission and activate appropriate services, e.g. the
trauma team or stroke unit. In addition, the CT suite may be reserved for a
patient in urgent need of diagnostic work up.
Question the local EMS dispatcher about the protocol currently used for the
referral of trauma patients to hospitals in your area. Note if Trauma Centres are
formally designated. Assess if a physician is involved in the choice of hospital and how
the receiving unit is informed.
[37]
Task 4. Providing pre-hospital care
The handover
The handover of the patient at the receiving unit deserves special attention. It is
a point at which information may be transferred accurately, inaccurately or lost.
Even though written information including laboratory results and radiological
images is imperative for correct documentation and later reference, an oral
report is faster and allows for emphasis of specific findings. In addition, an oral
report allows the receiving crew to question contradictory findings and to clarify
information. Ideally a handover follows a checklist such as the ABCDE for
primary survey and AMPLE (allergies, medications, past history, last meal and
events) for history. Even though these mnemonics were first developed for the
trauma setting, they also allow a structured handover in the medical setting.
Such a structured transfer of information is not only imperative after pre- or
inter-hospital transport, it also applies to intra-hospital transport, e.g. was the
trip to the radiology suite uneventful and what were the findings of the scans
etc?
[38]
Conclusion
CONCLUSION
Transport of critically ill or injured patients whether within or between
hospitals requires planning and analysis of the risks and benefits. Numerous
decisions must be made by the professionals involved in patient care at every
stage in the process, whether at an accident site, in a vehicle en route to the
hospital, or during transfer to another department for diagnostic work up.
Through the cooperative efforts of multiple team members with varied
backgrounds and skills, we improve the chance that critically-ll patients will not
only arrive safely at the hospital, but will also be discharged in a state that
allows them to enjoy the trip back home.
Although the content of the following flash conference lecture does not
correspond in all detail with this module, it provides a good overview of the
module and is a suggested revision mechanism.
[39]
Appendix
APPENDIX
Example 1. Form for documentation of patient data. Reproduced with the permission of
Swiss Air Rescue
[40]
Appendix
[41]
Self-assessment
SELF-ASSESSMENT QUESTIONS
EDIC-style Type K
[42]
Self-assessment
EDIC-style Type A
A. ID of the patient
B. Target hospital and unit
C. Check of medications
D. Who will pay for the transport
E. Estimated transport time
[43]
Self-assessment
A. 40 minutes
B. 60 minutes
C. 80 minutes
D. 100 minutes
E. 120 minutes
A. Veno-venous ECMO
B. Intra-aortic ballon pump
C. Suction on a thoracic drain because of bronchopleural leak
D. High flow CVVHD
E. Inhalation of NO
14. The main reason to choose air transport instead of ground transport
is:
[44]
Self-assessment
Self-assessment answers
Type K
A. T A. F A. F A. T A. F A. F A. T
B. T B. F B. F B. F B. T B. F B. T
C. F C. T C. T C. T C. F C. T C. F
D. F D. F D. F D. F D. T D. T D. F
Type A
8. Answer E is correct
9. Answer C is correct
10. Answer D is correct
11. Answer A is correct
12. Answer D is correct
13. Answer D is correct
14. Answer C is correct
[45]
Patient Challenges
PATIENT CHALLENGES
While on call in the 14 bed intensive care unit of a 300 bed regional
hospital, you receive a call from the central office of the local ambulance
service telling you that an ambulance will arrive in approximately 20 minutes with a
near-drowned, possible multiple trauma victim.
An elderly lady fell into the water while her husband tried to manoeuvre his motor
yacht into a small berth. As far as the ambulances central office is aware, the
ambulance team had to intubate the patient; however, they still seem to be having
problems with oxygenation and ventilation. No other details concerning the patients
are known.
Q. You still have 20 minutes left to prepare for the arrival of the patient. You may
want to recall the handling of previous polytraumatised patients and what you
learned. What organisational aspects of the current situation need to be considered?
A. Were there critical incidents? Were there mishaps you wish not to repeat? What
was done well? How can you get additional information? Are there any safety issues
that need to be addressed? What if other critically ill patients arrive and there is a
need for triage, i.e. prioritising different patients? What resources are likely to be
required e.g. free operating room, availability of an ICU bed, clinical specialists who
may need to be called from inside or outside the hospital for help?
Studnek JR, Ferketich A, Crawford JM. On the job illness and injury resulting in
lost work time among a national cohort of emergency medical services
professionals. Am J Ind Med 2007; 50: 921931. PMID 17918231
Q. In the emergency room (ER), you meet the anaesthesiologist and trauma surgeon,
who, in this institution, is the team leader. Specific tasks need to be undertaken by
specific people. How can you use the time until the patient arrives in the ER to ensure
that the team is fully ready to deal with the patient?
A. The anaesthesia residents position is at the head of the patient to take care of the
airway and to operate the ventilator or anaesthesia machine (if required), the CRNA
(certified registered nurse anaesthetist) or equivalent will take care of lines and
[46]
Patient Challenges
infusions while the surgeon and team will take care of the traumatic injuries
according to ATLS standards. However, all of the trauma team may be required
depending on the most pressing requirement and your task as the intensivist in the
ER in this scenario is to assess the patients medical status, participate/help with
immediate priorities and plan for continued care in ICU.
Medical treatment started in the ER will often need to be continued in ICU. Therefore
it is useful to be involved in decision-making including the timing of interventions
deemed necessary e.g. CT scans or angiography as some may be more efficient if
performed early i.e. before transfer to ICU. You may be dealing with the
consequences of decisions days or weeks later.
Eisen LA, Savel RH. What went right: lessons for the intensivist from the
crew of US Airways Flight 1549. Chest 2009; 136: 910917. PMID
19736195
Repeated transfer of information from one team to another increases the risk
of information being lost or distorted and disturbs the continuum of care. Thus, early
collaboration with other team members and handing over information to the follow-
up team is a crucial step in care. Exact written documentation may be critical and
may be legally important.
Handover of information
Q. When the ambulance team arrives, the young emergency physician is quite
stressed and describes extensively the scene on the port. He emphasises how difficult
ventilation was with poor oxygen saturation at an FIO2 of 1.0 and 10 cm H2O PEEP.
What would you like to know first? How should you react?
Pre-hospital care
[47]
Patient Challenges
Q. You ask the emergency physician to proceed with a structured handover following
the ABC of the ATLS manual. How might s/he proceed?
A: The patient was intubated at the scene. Two attempts were required as the patient
had vomited and there were large quantities of sputum and saliva. Oxygenation was
poor with spontaneous breathing although transcutaneous oxygen saturation
readings were unreliable due to poor perfusion of the fingertips. After endotracheal
intubation, gastric contents were aspirated from the tube, even though the view of the
vocal cords was good and the tube was considered to be positioned correctly.
B: Breathing is being controlled by manual inflations and in the ER and the patient
is being transferred to an ED room transport ventilator. Abundant frothy oedematous
fluid appears in the endotracheal tube with every expiration; the transcutaneous
oxygen saturation reads 80 %.
Before you proceed with C and D problems, you return your attention to the A
problem until it is resolved. Even though a tracheal tube is in place, this does not
necessarily mean that the airway is secured. Both you and the trauma surgeon
auscultate the patients chest. Symmetrical breath sounds can be heard over both
lung fields and the capnography trace shows regular expiration although with a
strong obstructive pattern. Finally you and the Anaesthesiologist confirm the correct
position of the tube between the vocal cords by direct laryngoscopy.
Q. The patient has obvious pulmonary oedema. What is your working hypothesis
regarding its aetiology?
[48]
Patient Challenges
One of the team disconnects the tracheal tube in order to aspirate the oedematous
fluid. S/he also reduces the PEEP setting on the ventilator to 5, as compromise of the
haemodynamic situation due to high external PEEP is suspected.
A. When aspirating the pulmonary oedema, surfactant will be removed from the
lungs together with the oedema, worsening lung collapse, ventilation and
oxygenation. Furthermore, the loss of external end-expiratory pressure may lead to
further alveolar collapse.
Reducing PEEP on the transport ventilator, which is now attached, appears to have
exacerbated pulmonary oedema and the oxygenation. However, attempts at
reinstituting higher PEEP on this ventilator are poorly attained and have limited
benefit.
Q. Could there be a problem with the transport ventilator and would an ICU
ventilator, together with a battery pack and oxygen/air bottles, be better?
A. Many simple transport ventilators may not be able to provide an adequate amount
of PEEP (up to 20 cmH2O or more). Therefore you request a (sophisticated)
ventilator from the ICU, which may provide a much higher driving pressure and more
PEEP.
[49]
Patient Challenges
Equipment
Q. The team leader wishes to continue with the ABC. What is the next step?
A. C, the circulation.
The cardiac rhythm is reported to have been atrial fibrillation (AF) from the time that
monitoring started. You note a ventricular response of approximately 140/min and a
systolic blood pressure of 90 mmHg. However, at this point we have no information
about the previous medical history of the woman and whether she had pre-existing,
chronic AF.
The patient had been intubated using midazolam, ketamine and rocuronium, thus
neurologic function is hard to assess at this point. However, pupil size seems to be
symmetric.
Monitoring
Q. What else would you like to know from the emergency physician?
A. More needs to be known about the accident as well as more information about the
previous medical history of the victim.
The emergency physician explains that apparently, the boat operator (husband)
confused reverse with forward gear when he tried to berth his motor boat.
Consequently the 80-year-old woman fell from the boat onto the pier and from there
into the water. She was pulled out several minutes later.
Later a more complete history revealed that the woman had no allergies, did not take
any medication regularly and did not have any significant past history. She had had
breakfast a few hours prior to the accident and when the emergency physician
arrived, she was in severe respiratory distress and had a GCS of 12 (E 3, V 3, M 6).
[50]
Patient Challenges
Other than the difficulty with oxygenation and the Atrial Fibrillation, the transport
itself was uneventful.
Special environment
Q. What are the differences in medical transport between a road ambulance and a
rescue helicopter?
Q. According to Boyles law, the product of pressure and volume are constant for a
given volume of gas under constant temperature. Thus, with increasing altitude, i.e.
decreasing ambient pressure, there may be patient consequences at altitude. Please
summarise the immediately important factors.
A. Any confined gas (pneumothorax, endotracheal cuff, intracranial gas, etc) will
increase in volume. In the cranium or thorax, this may cause compression of related
structures. In the case of the tracheal tube cuff, the cuff pressure may increase above
30 mbar with consequent mucosal damage.
A chest radiograph is taken which shows the tracheal tube in correct position, several
rib fractures and bilateral diffuse infiltrates. However, no immediately treatable cause
of respiratory insufficiency such as a pneumothorax was seen. The haemodynamic
situation has deteriorated even further. Following insertion of a radial arterial
cannula, the systolic blood pressure now reads only 85 mm Hg.
[51]
Patient Challenges
A. More information may be obtained from a CT scan and the surgeon suggests that
the patient should now go to radiology.
The patient is now ventilated with a sophisticated ICU ventilator, an FIO2 of 1.0, I:E
of 1:1 and a PEEP setting of 14 mmHg. Peak inspiratory pressure is 34 mmHg and
there are no signs of intrinsic PEEP. The haemodynamic situation has not improved,
however, and then the patient needs to be stabilised before transport.
A. Now that you are reasonably confident that the patient does not have chronic AF
and that this episode is acute in nature, and also that it causing hypotension in a
patient that is already sedated on a ventilator, you opt for synchronised
cardioversion.
Following synchronised cardioversion, the ECG shows sinus rhythm of 110/min and
systolic blood pressure has increased to 115 mmHg. The patient may now be stable
enough to travel to the CT suite.
A. Duration of the transfer? Role assignment of the team. Space for all the equipment.
Connections to tubes and lines. Is the CT suite ready for the procedure and are the
corridors clear?
[52]
Patient Challenges
Preparation is of the essence for a successful transport. Have a Plan B in case there is
a mishap during transfer. Consider limiting the size of the transport team each with
specific roles assigned to take care of the patient.
While you are still in the ER, the medical emergency team (MET) contacts you to
request an ICU bed for a patient with myocardial infarction who had to be
resuscitated on the ward. Furthermore an ER colleague wants to transfer a young
woman to ICU after attempted suicide with an overdose of benzodiazepines. Together
with two planned admissions from the operating room, this could mean no available
ICU bed for your patient.
A. First of all, consider if the planned admissions are immediately necessary and
consider practical, holding solutions until the larger picture is clearer and the senior
staff in ICU have had the opportunity to review and prioritise.
Other practical options within the institution are being explored. For example, the ER
colleague is being asked to manage the patient in the ER for the moment or to
consider referral to other options that may be available in the hospital e.g. asking the
OR manager to have the young woman managed in the post anaesthesia care unit
with or without flumazenil reversal. The MET team is making a cardiology referral as
the patient may need to be transferred directly to the cardiology catheter laboratory.
Furthermore the overall situation in ICU is being reviewed as it may be possible to
request intermediate care for the most stable of the patients referred or already in
ICU thereby buying some time to see the trends and allowing the best overall
decisions to be made in the circumstances.
Triage
Q. Is it worth admitting a critically injured elderly lady to the ICU or may care be
futile?
A. At this point it is far too early to decide. We do not have enough information to
assess this point.
Ethical considerations
[53]
Patient Challenges
Q. How do prioritise the care of these injuries and the critical illness of the patient?
A. You discuss the injuries in a team together with the radiologist, the trauma
surgeon and the anaesthesiologist.
At this point, the patient does not need any major intervention and it is decided to
transfer the patient directly to the ICU. The skin lesions can be taken care of in the
ICU and you avoid an unnecessary transfer to the OR for the sutures of the wounds.
On the way back, when you are near to the ICU, the haemodynamic situation
deteriorates again as the sinus rhythm reverts to atrial fibrillation with a ventricular
rate of approximately 130/min and a systolic blood pressure of 90. In addition, one of
the infusion lines gets caught while moving the trolley and is pulled out. Fortunately,
no vasoactive drugs are running on that line.
A. Given the short distance to travel to ICU, you decide in this case to continue the
transport and perform cardioversion, either electrically or pharmacologically, in the
ICU.
Dont get so wrapped up in manual tasks that you lose the overview over the
vital threats e.g. dont fumble with the infusion while forgetting to oxygenate the
patient.
Q. What needs to be considered during the transfer from the transport trolley to the
ICU bed? Which therapeutic modalities are most likely to give trouble in the transfer?
Equipment
[54]
Patient Challenges
A. Many learned societies and specialty training bodies have issued guidelines for
transfer of patients. As a general rule, the standards applied to planned patient
transport of the critically ill should be similar to those to any patient under
anaesthesia, including required equipment, monitoring, setting of alarms, training
and education of staff, etc.
In the ICU, a pulmonary artery catheter is inserted and shows a cardiac output of 1.6
l/min and a SvO2 of 42 %. After a bolus of amiodarone the atrial fibrillation is
successfully converted to sinus rhythm. Low dose dobutamine leads to an
improvement in cardiac stroke volume and cardiac output. Ventilatory support has
been slightly reduced - the FIO2 is 0.75 with 12 cm H2O PEEP. Sedation has been
gradually reduced and one hour later the patient starts to awaken and open her eyes
to command. The husband has now arrived and feels both anxious and somewhat
guilty about what has happened to his wife.
Shortly afterwards the bedside nurse noticed asymmetry of the patients pupils and
calls you and the neurosurgeon who requests immediate return to the CT suite for a
further scan. In addition, the husband, who has heard this conversation, wants
everything to be done for his wife.
A. Before embarking on another transfer, you examine the patient for updated
clinical information.
She still opens her eyes and squeezes both hands and raises both lower limbs equally
to command and there is no facial asymmetry. You also notice an implanted lens in
her left eye. Her husband confirms that she has had cataract surgery on her left eye.
You therefore convince the neurosurgeon that little additional information is likely to
be gained from a further scan and weighing this against the potential hazard of
another scan, it is better to cancel the scan.
Always weigh the risks of a transfer against the possible benefits of additional
information.
The patient from the cardiology catheter lab arrives and takes the last bed in the
ICU.
Q. Have you space for any other patient? How do you proceed?
A. Even though the first duty is to care for the individual patients presently within
ones care, you review all the patients in the ICUt to establish who might be suitable
for discharge in the event of need e.g. an emergency.
[55]
Patient Challenges
It is also important to prepare for possible future requests for emergency admissions
and to know the status of all patients in ICU and know which are suitable for
discharge, if any. Unfortunately, all your remaining patients are on ventilator
support, and none appear suitable for transfer to a regular ward before the following
day at least.
You make the necessary provisional arrangements with your colleague from one of
these facilities, although for now the patient remains in your unit. There is also a drug
addict patient who is stable but is a slow wean following long-term ventilation due to
aspiration pneumonia. As it is early in the afternoon, you explore the possibility of
transferring him back to the ICU in a smaller regional hospital, nearer his home.
Triage
You consider the appropriate medical capabilities, e.g. is there a dedicated intensivist
to care for the patient? Do you know that the ICU has experience in dealing with
patients who are difficult to wean from ventilation? There is evidence that centres
who deal with certain diagnostic groups frequently, e.g. victims of major trauma,
achieve better than expected outcomes. Other parameters may include distance to his
home (for relatives travelling to visit) or, in certain jurisdictions, his insurance status.
MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al.
A national evaluation of the effect of trauma-center care on mortality. N
Engl J Med 2006; 354: 366378. PMID 16436768
[56]
Patient Challenges
In an inner city setting, it may be more appropriate to keep a road ambulance ready
for emergencies and have a helicopter make the transfer of a relatively stable patient.
A helicopter often cannot land in a city and collaboration between different
professionals is important. As the HEMS base is located some 50 km away and there
are a few emergencies, you decide to call a road ambulance.
A. The ICU nurse who is presently taking care of him should accompany him on the
transfer, if possible. This provides continuity of care and more accurate transfer of
information. There needs to be the ability to treat any complications during transport
e.g. accidental extubation or cardiorespiratory deterioration. In most health systems
this will require the additional presence of a doctor with skills in re-
intubation/critical care support.
A. The transfer team must establish that the institution is prepared to accept the
patient. The patient, if awake, and the patients next of kin should be consulted and,
ideally, they should be agreeable to the transfer (this may not be required but such a
situation does raise ethical issues). The admitting physician (if there is one) and the
receiving physician in the receiving hospital need to be consulted and appraised of
the patient and organisational issues.
The transfer itself should not pose an additional risk to the patient as the same
standard of care will be provided as within an ICU. A sufficient supply of oxygen/air,
to cover for unforeseen events e.g. delays due to a traffic jam, appropriate
medications, monitoring and equipment. Even though many modern transport
ventilators are capable of pressure support or assisted ventilation, thought should be
given to the safest mode for transfer. The best option might be deep sedation and
muscle relaxation, in case the patient starts to fight the ventilator or becomes
agitated, delirious or claustrophobic.
In retrospect, direct transport of the elderly woman to a trauma centre was indicated
and the final outcome was positive. This patient experienced pre-hospital, intra-
hospital and inter-hospital transport. All three types of transport have their own risks
and must be planned accordingly. Pre-hospital care and primary transfer seems
exciting and often attracts younger members of staff. However, since optimum
management of the primary problems and the possible complications during transfer
may significantly influence outcome, the most experienced physicians with
substantial knowledge of transport of the critically ill are best closely involved with
this challenging area.
The challenges presented during patient transfer may be complex and time-critical. It
is important that all the escorting staff be skilled, able to function independently and
also exhibit good team-working.
Consider whether the terms scoop and run and stay and play could ever be applied
to transfers within the hospital. Why or why not?
[58]