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?

Current level of care

Stability of the patient

Options available to provider and patient

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	Limited diagnostic and interventional capabilities
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:

Organizational physicians design the transport system and evaluate operations.

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

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

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.

13 What type of skills should be considered imperative for transport personnel?

The level of skill required for transport personnel depends on the patient population. For a pediatric/neonatal critical care transport service, the personnel must be skilled in managing all routine and emergent pediatric and neonatal issues. Examples include airway stabilization and management with bag/mask ventilation, intubation, rescue airways, surgical airway placement, and ventilatory support. Ability to understand and use critical adjuncts, such as rapid-sequence intubation; expertise in establishing vascular access, including IV and intraosseous routes; understanding of fluid resuscitation; and ability to use pharmacologic adjuncts for cardiovascular support are imperative. Knowledge of infection control and ability to assess patients adequately and effectively at a referral center are also important.

King BR, Foster RL, Woodward GA, McCans K: Procedures performed by pediatric transport nurses: How “advanced” is the practice? Pediatr Emerg Care 17:410–413, 2001.

King BR, Woodward GA: Procedural training for pediatric and neonatal transport nurses. Part I: Training methods and airway training. Pediatr Emerg Care 17:461–464, 2001.

King BR, Woodward GA: Procedural training for pediatric and neonatal transport nurses. Part II: Procedures, skills assessment and retention. Pediatr Emerg Care 18:438–441, 2002.

14 What factor most increases the risk for transported patients?

Whenever the patient is moved from one location to another (e.g., bed to stretcher, incubator), the opportunity for line or tube displacement increases. Movement can cause appropriately immobilized patients to become malpositioned, perhaps decreasing desired protection, impeding respiratory efforts, or even worsening an existing injury. Multiple modes of transport increase movement needs and potentially increase risk to the patient. If a patient deteriorates during or shortly after movement, consider sequelae of the move as a potential cause.

15 What equipment is important in a critical care ambulance environment?

The answer depends on the patient population. Minimal required equipment should include appropriate pediatric interventional supplies, medication, monitors, radios, and phones. Monitoring capability should include pulse oximetry, respiratory rate, blood pressure, temperature, end-tidal carbon dioxide monitors, and electrocardiography. One should strive for point-of-care laboratory testing, which allows rapid analysis of blood gases, chemistries, hemoglobin, and glucose.

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. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 93–134.

16 How can referral for transport be streamlined?

Development of a specialized communication center with a centralized number is important. The ability to triage incoming calls efficiently to appropriate command physicians or transport personnel is vital. Transfer agreements and up-to-date knowledge of bed availability can markedly decrease time necessary for patient acceptance.

18 What are the responsibilities of the referring physician during the transport process?

The referring physician must assess the patient to the best of his or her ability. He or she must ensure that the chosen transport service allows no decrease in the level of care. Plans for stabilization and intervention should be discussed with the receiving hospital or transport service, and, if at all possible, recommendations should be followed. Disagreements about patient stability or inability to perform a task for other reasons should be discussed with the command physician. If the patient’s condition changes, the transport service should be notified immediately. The family must consent to the particular type of transport (air, ground) and to the receiving hospital. The agreement should be documented in writing. There should be a written order for transport services. The referring physician and care team should be available for discussion in person or by telephone when the transport service arrives.

In addition, the referring physician must ensure that:

IV access has been secured.

All tubes and lines are taped securely to help avoid dislodgment during transport.

A copy of medical records, radiographs, and laboratory results accompany the patient.

A medical summary is completed and included with transfer materials.

Blood products or medications are ordered and available, if their use is considered for the transport.

The referring physician and care team are available for discussion in person or by telephone when the transport service arrives.

Bolte RG: Responsibilities of the referring physician and referring hospital. In McCloskey K, Orr R (eds): Pediatric Transport Medicine. St. Louis, Mosby, 1995, pp 33–40.

19 Can a general rather than a pediatric transport service adequately transport children?

The optimal transport of patients depends on resource availability. If a pediatric critical transport service is available, it potentially offers the highest level of care for pediatric patients. If a pediatric transport service is not available, a general transport service may adequately transport the child. What one gains in availability and efficiency of response, however, may be minimized by an inability to optimally diagnose and intervene for the pediatric patient. General services often do not transport a significant number of critically ill pediatric patients; therefore, their pediatric expertise may be diminished by lack of experience. Referring and receiving physicians should take the opportunity to increase the pediatric expertise of general transport services to ensure adequate care.

20 How can a transport service develop pediatric expertise?

Many options are available. One is to visit and emulate the best practices of other services. The American Academy of Pediatrics publishes “Guidelines for Air and Ground Transports of Neonatal and Pediatric Patients” and also provides a course in pediatric education for prehospital professionals. Introduction to pediatric advanced life support is provided by the American Heart Association. The Committee on Accreditation of Medical Transport Systems offers standards and an accreditation process for transport systems. The Internet offers many opportunities for discussion of pediatric transport, including the pediatric interfacility transport e-mail list at PEDTPT-L@Listserv.brown.edu.

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.

21 What is the appropriate response to inadequate care during transport?

A review of patient care with care providers and involved facilities is important. This review must be done in a constructive fashion with a plan to increase the level of care for the next patient. Do not be view this as an opportunity to dictate standards of care or to take a position on one side of an issue.

23 What major issue should be considered in selecting a transport service?

Determine whether the immediate goal is to transport the patient to an intensive care setting or to bring intensive care capabilities to the patient. The answer may help to determine the type of transport and level of sophistication necessary for the transport personnel and service.

24 How does EMTALA affect the transport of pediatric patients?

EMTALA places clear duties on both referring and receiving hospitals. The referring clinicians must do everything possible to stabilize the patient’s medical condition before transport unless the facility cannot provide an adequate level of care. Patient or parent consent for transport must be obtained. EMTALA requires receiving hospitals to accept a patient for transport if space and appropriate level of care are, or can be, available. The patient’s ability to pay should not be considered by the referring or receiving hospital. When considering critical care transport for an acute medical or surgical need, discussion with the patient or family about transport should not include financial ramifications of the decision.

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

25 What are two major concerns about altitude physiology?

According to Boyle’s law, an increase in altitude brings a decrease in barometric pressure. Decreased barometric pressure (P) results in an increase in volume (V) of gas (Boyle’s law: P₁V₁ = P₂V₂). Boyle’s law has ramifications for air in enclosed spaces, such as ear canals, endotracheal tube and blood pressure cuffs, mast trousers, intestinal gas, pneumothorax, and pneumocranium. There is approximately a 20% increase in gas volume between sea level and 5000 feet and a 100% increase between sea level and 18,000 feet.

Dalton’s law, or the law of partial pressure (P_T = P₁ + P₂ + P₃…), states that the total pressure of a gas is a sum of its components. Although the concentration of oxygen in air is always 21%, air is less dense at higher altitudes; therefore, an increase in altitude results in a decrease in ambient oxygen available to the patient.

Woodward GA, Vernon DD: Aviation physiology in pediatric transport. In Jaimovich DG, Vidyasagar D (eds): Handbook of Pediatric and Neonatal Transport Medicine, 2nd ed. Philadelphia, Hanley & Belfus, 2002, pp 43–54.

26 How serious is the concern about problems related to altitude?

Most patients do not have problems with air physiology at the relatively low altitudes at which helicopters usually fly or with pressurized fixed-wing transport. However, if the patient has a small, unrecognized air collection, decompression sickness, or diving illness, or if the air transport must traverse significant altitude, associated problems may develop. The decrease in ambient oxygen is usually not a factor because of the availability of supplemental oxygen and positive-pressure delivery. For patients at maximal oxygen and pressure support at sea level, however, an increase in altitude may be of significant concern.

Woodward GA, Vernon DD: Aviation physiology in pediatric transport. In Jaimovich DG, Vidyasagar D (eds): Handbook of Pediatric and Neonatal Transport Medicine, 2nd ed. Philadelphia, Hanley & Belfus, 2002, pp 43–54.

27 What is on-line medical command?

With on-line medical command, an off-site physician or other advanced provider offers medical advice to the on-site team in real time during the transport. Off-line medical support involves the development of protocols or guidelines, without interaction at the immediate time of transport.

28 What is the value of exposing the pediatric resident to interfacility transport?

The transport environment provides an opportunity for senior pediatric residents to apply skills developed during the first part of a residency program. Although the patient population and disease processes are similar to those in the hospital, the environment in which care is given is markedly different. Significant preparation is required for optimal participation in the transport process, including development of skills for communicating with transport team personnel and receiving and referring physicians and intimate knowledge of transport vehicles (ambulance or aircraft) and equipment (medications, monitors, interventional equipment). One also must be able to anticipate and respond to issues that do not occur within the hospital, including delays in transport, traffic, mechanical factors, and differences in skill levels and personalities at referring and receiving hospitals.

29 What training and capabilities are required of a resident physician participant involved in transport?

Any resident involved in the transport of critically ill children should have the experience of critical care rotations, including pediatric intensive care, emergency and neonatal care, and general pediatric experience. Capabilities for airway, breathing, and circulatory intervention and ability to access more sophisticated knowledge and expertise are imperative. Transport-specific training is also essential for all who care for patients during the process.

Aoki BY, McCloskey K: Evaluation, Stabilization, and Transport of the Critically Ill Child. St. Louis, Mosby, 1992.

30 What makes transport medicine a high-quality educational experience?

Pediatric transport medicine allows one to experience the delivery of pediatric care in facilities other than the home institution. Evaluating and participating in care at the referring hospital, as well as communicating directly with referring physicians, other clinicians, and parents of critically ill children, are often enlightening and rewarding growth experiences.

KEY POINTS: CRITICAL CARE TRANSPORT

1 Critical care transport is an integral component of the care continuum for ill and injured pediatric and neonatal patients.

2 It requires specific equipment and training and expertise with pediatric critical care skills.

3 It demands understanding of transport personnel and modes of transport for all who participate in transport, whether as a referring, receiving or on-site care provider.

4 It offers significant educational opportunities for medical trainees.

31 Should parents accompany a pediatric transport?

Whenever possible, allow parents to be part of the transport process. Their presence can be invaluable for information and for patient comfort. It is also important to maintain the family support unit as much as possible during these transfers. If, however, parental involvement puts the patient at risk (weight or space limitations of the vehicle; a parent who abusive, is inebriated or belligerent; or a parent who may distract medical attention from the patient during the transport), reconsider their accompaniment.

Woodward GA, Fleegler EW: Should parents accompany pediatric interfacility ground ambulance transports? The parents’ perspective. Pediatr Emerg Care 16:383–390, 2000.

Woodward GA, Fleegler EW: Should parents accompany pediatric interfacility ground ambulance transports? Results of a national survey of pediatric transport team managers. Pediatr Emerg Care 17:22–27, 2001.

32 Identify potential personnel participants for pediatric transport

The transport personnel can include physicians, nurses, nurse practitioners, respiratory therapists, and emergency medical services personnel (emergency medical technician–paramedic [EMT–P] or emergency medical technician [EMT])

33 True or false: Seat belts and restraint devices should be used during transport

True. Safety of the transport patient and personnel are paramount. Unless the patient status dictates that personnel be temporarily mobile, personnel must be restrained at all times when in a moving transport vehicle. In addition, any objects that might move during a rapid acceleration or deceleration must be secured to help ensure a safe environment. Objects that are in an area where one’s head might strike them during an accident must be moved.

King BR, Woodward GA: Pediatric critical care transport—the safety of the journey: A five-year review of vehicular collisions involving pediatric and neonatal transport teams. PreHosp Emerg Care 6:449–454, 2002.

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

34 List strategies for follow-up to a stressful transport or patient care experience

Critical incident stress management helps personnel to understand and cope with stressful events. These preparations and interventions include understanding stressful issues in the transport environment and education regarding coping skills prior to involvement, as well as defusing (discussing) and debriefing (formal incident review) processes after an incident has occurred.

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.

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