Transport Medicine

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Chapter 73 Transport Medicine

George A. Woodward, MD, MBA

1 List the goals of interfacility transport

To meet the unique needs of ill and injured infants and children, to meet the needs of the medical community, to allow for regionalization, to provide high-quality care, and to deliver the patient to the receiving center in stable or improved condition.

Woodward GA, Insoft RM, Pearson-Shaver AL, et al: The state of pediatric interfacility transport: Consensus of the second national pediatric and neonatal interfacility transport medicine leadership conference. Pediatr Emerg Care 18:38–43, 2002.

Woodward GA, King BR, Garrett AL, Baker MD: Prehospital care and transport medicine. In Fleisher G, Ludwig S, Henretig F (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Phildelphia, Lippincott Williams & Wilkins, 2006, pp 93–134.

2 What issues should be considered at the time of transport?

image Current level of care

image Stability of the patient

image Options available to provider and patient

image Type of care that the patient requires and urgency of need for advanced medical care

3 List the advantages and disadvantages of the seven methods of ground transport

See Table 73-1.

Table 73-1 Seven Methods of Ground Transport

Method Advantages Disadvantages
Private vehicle Immediate Potential for nondirect transport
    No medical care available
Taxi Direct transport to hospital No medical care
Volunteer ambulance Direct transport to hospital Minimal medical care
Basic life support (BLS) Direct transport to hospital Limited medical care
Advanced life support (ALS) Direct transport to hospital Variable pediatric experience
  Emergency resuscitative care Limited diagnostic and interventional capabilities
Some interventions available
Critical care ambulance Direct transport to hospital May have limited or no pediatric expertise
  Sophisticated medical care  
Pediatric specialty interfacility transport Direct transport to hospitalPediatric expertise Limited resource; may not be immediately available

4 True or false: When choosing an ambulance service or interfacility transport provider, the receiving hospital is legally responsible for ensuring the adequacy of transport service

False. Under Emergency Medical Treatment and Active Labor Act (EMTALA) regulations, the referring hospital and clinicians are responsible for ensuring that the quality of care during transport does not diminish and that an unstable patient is not placed in a less sophisticated environment. The transporting system is responsible for ensuring that the medical care it delivers meets the defined standard of care.

Woodward GA: Legal issues in pediatric interfacility transport. Clin Pediatr Emerg Med 4:256–264, 2003.

5 What are the advantages and disadvantages of ambulance transport?

The ambulance leaves from a referring facility and travels directly to the receiving facility. It has the ability to stop if problems arise during transport. Team composition changes and additions are easy and safe. Ambulance transport is relatively inexpensive, family member(s) can accompany the patient, backup vehicles are often available, and there are few weather restrictions. Disadvantages include noise, vibration, motion sickness, road conditions, traffic, detours, delays, and accident risk.

6 Describe the advantages and disadvantages of transport by helicopter

Helicopters offer the advantage of rapid transport (often one-third to one-half of ground transport time to the same location). They have the ability to access difficult locations and avoid traffic. A major disadvantage is the need for a local landing zone or helipad, without which the speed advantage is diminished. Size and space limitations may limit patient assessment or intervention. Altitude physiology, including pressure changes and hypoxia, is important, but may not be a major issue for low-altitude helicopter transport. Other flight issues include stress on equipment, humidity, fatigue, gravitational forces, weight restriction, and emergency survival, as well as increased noise and vibration. Helicopter travel may be limited by weather; many systems are regulated by visual flight rules rather than instrument flight rules. (The capability for instrument flight rules enables safe flight in weather with diminished visibility.) Helicopter transport is expensive.

7 What are the advantages and disadvantages of transport with fixed-wing aircraft?

Fixed-wing (jet, airplane) transport offers the advantage of speed and is appropriate for transports over 100–150 miles. An airplane often can fly over or circumvent bad weather. The cabin can be pressurized to diminish problems with altitude physiology and often offers more room than a helicopter for patient assessment and intervention. A disadvantage is that the airport location may not be convenient to the hospital. Required additional ground or helicopter transport increases the time as well as the risk to the patient.

8 Without parental consent, can a minor be transported?

If a parent or legal guardian is not available for consent, the treating physician may decide and document that the benefits of transport exceed the risks of waiting for parents and may provide emergency consent. Consent would be provided for the treatment and transport for that emergent issue only. Consent from the legal guardians should be sought and obtained as soon as possible.

Woodward GA: Legal issues in pediatric interfacility transport. Clin Pediatr Emerg Med 4:256–264, 2003.

9 Is it necessary for children to consent for transport?

The parent/legal guardian is responsible for consent for treatment. Ideally, assent (or agreement) of the process is also obtained from the child but is not mandatory, unless the child is emancipated. Rules for emancipation and age of majority vary by state and should be understood prior to transport.

10 What are the key elements of a pediatric transport system?

Adequate preparation for transport involves designing and developing a transport process before it is needed. Educating all levels of providers, appropriate patient care during transport, and reviewing and addressing systems and quality issues during and after transport are imperative. Other key elements include medical supervision and involvement during transport, experienced on-site personnel, cooperation between referring and receiving hospitals and personnel, and adequate quality assurance and improvement.

American Academy of Pediatrics, Section on Transport Medicine Editor in Chief: George A. Woodward, MD, MBA, FAAP. Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006.

11 In what areas is medical oversight important?

Medical oversight may be the most important element of the transport system. Knowledgeable physicians must be involved at all levels:

image Organizational physicians design the transport system and evaluate operations.

image Referring physicians should be experts in initial care and stabilization. They should know how and when to refer patients to an appropriate transport service.

image Command or supervising physicians must be immediately available to the transport system for questions or issues that arise during transport.

image Receiving physicians must be aware of the patient’s arrival and capable of streamlining the transition to care at the receiving hospital.

12 What degree or level of education should pediatric transport personnel possess?

No singular optimal degree or level has been established. The most important qualifications are experience in pediatric critical care or neonatal care and an appropriate skill level, as determined by routine assessment. Personnel must have specific training and experience in the care of critically ill children. They may include physicians, registered nurses, nurse practitioners, paramedics, and respiratory therapists. All who are involved must be familiar with the transport environment and capable of recognizing and stabilizing any problems that arise in that transport population.

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