Air Medical and Interhospital Transport

Air Medical Transport

Based on the experience of the Korean and Vietnam Wars, air medical transport has grown to become an integral part of trauma care in the United States. Currently, over 650 private, hospital-based, public service, and military air medical helicopters transport more than 300,000 patients annually. Two thirds of the transports are interhospital, with the remaining one third transported directly from the scene. An air medical helicopter responding to an emergency takes off every 90 seconds in this country.

I. Equipment

• Most air medical transport today is accomplished with twin-engine helicopters specifically configured for medical missions. Some flight programs fly instrument flight rules (IFR) missions, allowing transport of trauma patients in weather conditions that previously prevented rotorcraft transport. Most aircraft with reconfiguration can transport two patients, in addition to two flight crew members and the pilot. The practical transport range for helicopter transfer is generally 150 miles. For longer distance transports or in poor weather conditions, fixed-wing aircraft are often utilized.
• The flight environment is noisy, making simple procedures such as auscultation of blood pressure and breath sounds difficult or impossible. Therefore, nonaudible-dependent monitoring is used. Most flight crews rely on noninvasive blood pressure monitoring, end-tidal CO₂, and pulse oximetry to monitor patients in flight. Rotorcraft rarely fly at altitudes above 2,000 feet above ground level (AGL). At these altitudes, pressure changes have only a minor impact on the volume of air-filled spaces such as a pneumothorax.
• The flight crew communicate with each other and the patient through headsets or helmets connected to internal communication systems. The crew must be able to communicate with the receiving hospital. Advance notification of patient assessment and changes in patient condition en route allow the receiving trauma center to be better prepared.

II. Triage

• The transport of trauma patients directly from the scene should be supported by online medical control or preapproved protocols based on the factors of time, distance, geography, patient stability, and local resources. Although some literature is conflicting, a recent multicenter study demonstrated that air medical transport was associated with a significant reduction in blunt trauma mortality rates compared with ground transport. Undue delay of transport from the scene to the closest hospital while waiting for a helicopter should be avoided. Rendezvous at the hospital's helipad would be a more appropriate use of time.
• Interhospital transport of trauma patients usually involves moving a patient to a facility with a higher level of care.
• The National Association of EMS Physicians (NAEMSP) and the American College of Emergency Physicians (ACEP) have recommended triage guidelines for on-scene helicopter transport (Table 7-1).
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• Weather, geography, logistics, or other factors determine flight suitability. The final decision to accept the mission should lie solely with the pilot. Crew safety is paramount.

  TABLE 7-1 On-Scene Helicopter Triage
  Trauma center candidate based on triage criteria Trauma score <12 Unstable vital signs (e.g., hypotension or tachypnea) Significant trauma in patients <12 or >55 y Multisystem injury Ground providers' perception based on mechanism of injury Penetrating trauma to abdomen, pelvis, chest, head, or neck

III. Flight Crew

• More than 70% of the medical flight crews consist of a nurse-paramedic team. Approximately 20% of programs use two nurses, and only 3% of programs use a flight physician. Respiratory therapists are also combined with nurses in a small percentage of programs.

IV. Interventions

• Transport crews should be experienced in the care of critically ill patients. Crew members should be highly trained in airway management utilizing rapid sequence intubation, as well as resuscitation, vascular access, and control of hemorrhage. These interventions should be initiated prior to liftoff.
• Intravenous analgesia, sedation, and chemical paralysis, as well as administration of vasoactive substances and blood products, can be done in flight. These interventions must be performed under strict online medical direction or predetermined approved protocols.

V. Helipad Access Team

• A helipad team trained in helicopter safety is usually designated to assist the flight crew in unloading and transporting the patient from the helicopter to the emergency department. Helipads should be in close proximity to the resuscitation area, limiting the need for therapeutic interventions on the helipad.
• When helipads are remote from the resuscitation area (e.g., rooftop with elevator and corridor transport), occasional therapeutic interventions may be required on the helipad. Only a limited number of resuscitative procedures should be performed on the helipad. Focus should be on identifying the need for immediate lifesaving procedures, establishing an airway, decompressing a tension pneumoth-orax, applying direct pressure to an open bleeding wound, or administering resuscitative drugs and countershocks for dysrhythmias. Other interventions (IV catheter placement for volume resuscitation or thoracotomy) are best performed in the emergency department.

VI. Safety

• The leading causes of accidents are weather, collision with an object or terrain, and loss of control of the aircraft. Pressure on pilots to fly and failure to observe minimum weather standards are contributing components to accidents. The pilot's decision to complete a mission should be based on aviation factors alone and not influenced by patient criteria.
• In general, a 500-foot ceiling and 1-mile visibility are required for daytime visual flight rules (VFR) flight. This may be geography-specific, depending on the presence of mountains and pockets of fog. Day-local is defined as <25 nautical miles from departure point to destination point, with generally the same terrain elevation.
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  Figure 7-1. Air view (A) and ground view (B) of safe approaches.

  TABLE 7-2 Safety Around the Helicopter

  The same safety standards should be practiced whether the helicopter's engines are running or shut down. Do not approach the helicopter unless signaled to do so by a flight team member. Remain clear of the helicopter at all times unless accompanied by a flight team member. When approaching the helicopter, always approach from the front of the aircraft and move away in the same direction. When approaching the helicopter on a slope, never approach from the uphill side. Always approach from the downhill side because the main rotor to the ground clearance is much greater. Always be aware of the blade clearance. Never walk around the tail rotor area. No unauthorized personnel are allowed within 100 ft of the aircraft. No intravenous devices or other objects should be carried above the head, and long objects should be carried parallel to the ground.

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• Comprehensive safety orientation programs for local ground EMS personnel that include instruction covering helicopter communication, set-up of landing zones, patient preparation, and conduct around the aircraft are an essential part of any EMS air medical program (Fig. 7-1).
• Table 7-2 outlines safety conduct around the helicopter.

Interhospital Transport

I. Introduction

Emergent interhospital transport usually occurs after initial stabilization of the trauma patient and determination by the referring facility that the patient's needs for definite care are beyond the scope of local capabilities. This practice is in response to evidence supporting the view that trauma outcome is enhanced if critically injured patients are cared for in facilities dedicated to the needs of the acutely injured. A trauma center should have referral centers that facilitate transfers, outreach teams to provide referring facilities with continuing education, and public education programs about trauma systems and injury prevention. A. Transfer of the trauma patient occurs with the expectation that care will continue en route to the receiving facility and that changes in patient status will be identified and treated. These goals frequently require specialized personnel and equipment. Coordination between referring and receiving institutions and medical direction during transport are fundamental to guarantee continuity of care.

II. Before Transport

Interhospital transport can be performed by a transport team from the referring facility, the receiving facility, or by a third party. It is the responsibility of the referring physician to decide the best mode of transportation (air vs. ground) and to ensure that the transporting personnel have the necessary expertise and equipment to deal with the patient's condition and possible complications. For example, some non-hospital-based personnel may not be trained in the use of certain hospital equipment (intravenous pumps, ventilators, or other devices); this should be recognized and addressed before transport.

• The transporting crew can be any combination of paramedics, nurses, or physicians, depending on the patient condition and local policies. If the referring physician is to provide medical direction during transport, transfer orders should be discussed before departure.
• Complete documentation of all patient care records must be sent. This includes results of all therapeutic and diagnostic interventions, copies of all imaging studies performed, and patient consent for transfer. Teleradiology allows a trauma center to review a patient's studies before arrival. This also allows the center to help referring facilities manage patients who do not require transfer to a trauma center.
• It is essential that the transport team establish direct communication with both referring and accepting physicians. Communication with the referring physician must detail the following information:
  • Identification of the patient and medical history
  • Mechanism of injury and circumstances about the incident
  • Prehospital management before arrival to the emergency department
  • Interventions performed during initial stabilization and patient's response
  • Pertinent physical examination findings
  • Ongoing therapy
  • Potential complications that may occur during transport
• The transport team should then perform its own directed evaluation, equivalent to a primary survey, without delaying transport. This evaluation should include, but not be limited to, the following:
  • Airway
    • Recheck the airway or assess adequate position of the endotracheal tube with appropriate methods that can include direct visualization, end-tidal CO₂, auscultation, esophageal detector device, or chest x-ray.
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  • Respiratory
    • Document respiratory status before initiation of transport.
    • Check for appropriate functioning of ventilatory equipment.
    • Check or place nasogastric tube to prevent aspiration in obtunded or intubated patients.
    • Check position of any tube or device (e.g., thoracostomy). Chest tubes ideally should have pleuravacs attached and placed on suction for transport.
  • Cardiovascular
    • Document heart rate, pulse, pulse oximetry, and blood pressure before initiation of transport.
    • Control external bleeding and reevaluate bandages applied for bleeding control.
    • Secure two large-bore IV catheters.
    • Secure adequate supply of blood products for transfer.
    • Connect invasive lines (e.g., arterial lines, central venous pressure [CVP] lines, and pulmonary artery catheters) to the transport monitor to allow continued hemodynamic monitoring during the transport.
    • Connect patient to electrocardiograph monitor.
  • Central nervous system
    • Document neurologic examination and Glasgow Coma Scale (GCS) score before initiation of transport or administration of paralytic or sedative agents.
    • Secure head, cervical, thoracic, and lumbar spine with immobilization devices, as needed.

III. During Transport

The transport team must know before transport which physician is to be responsible for online medical direction. Responsibility for medical direction will vary, based on local practices and the policies of the transport service. The receiving physician, however, must always be made aware of changes in the patient's condition en route.

• Once the patient has been stabilized, the transport should be completed without delay. It is expected that care during transport be at the same level as received at the referring institution, within the obvious limitations of the out-of-hospital environment. Unstable patients should be accompanied by a provider capable of appropriate medical interventions; this may require a physician.
• The transporting unit must have the capability to continue cardiorespiratory support and blood volume replacement. Constant hemodynamic monitoring is essential. Communication via radio, cellular telephone, or satellite phone should occur to obtain medical direction and to provide updates to the receiving facility.
• When standing orders or protocols (the essential component of off-line medical direction) are given to the transport team, the referring physician must be sure that the orders match the team's capabilities and that the appropriate medications and equipment are present.

IV. After Transport

On arrival at the receiving facility, the transport team must give a complete report to the receiving trauma team. This should include a brief summary of the initial history and treatments, followed by an update of any changes en route and any interventions. In addition, all documentation from the referring institution must be delivered to the receiving team leader. If the patient was transferred for diagnostic procedures and is to be transferred back to the original institution, the same transfer regulations apply now to the receiving hospital. If diagnostic procedures reveal new evidence of present or potential instability, the patient cannot be transferred back without appropriate stabilization.

V. Legal Considerations

The transfer of patients from one institution to another is regulated by federal statute. The legislation that created the patient stabilization and transfer requirements for hospitals and physicians is the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, also known as the

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“antidumping law.” This is the current legal standard. One of the main objectives of this resolution is to guarantee equal access to emergency treatment to all citizens regardless of their ability to pay.

• COBRA attributes responsibility for the patient's transfer to the referring hospital and physician.
  • Violations can result in termination of Medicare privileges for the physician and hospital.
  • A hospital can be fined between $25,000 and $50,000 per violation.
  • A physician can be fined $50,000 per violation.
  • A patient can sue the hospital for personal injury in civil court.
• The Emergency Medical Treatment and Labor Act (EMTALA) established by COBRA legislation governs how patients can be transferred from one hospital to another. Hospitals cannot transfer patients unless the transfer is “appropriate,” the patient consents to transfer after being informed of the risks of transfer, and the referring physician certifies that the medical benefits expected from the transfer outweigh the risks. Appropriate transfers must meet the following criteria:
  • The transferring hospital must provide care and stabilization within its ability.
  • Copies of medical records and imaging studies must accompany the patient.
  • The receiving facility must have available space and qualified personnel and agree to accept the transfer.
  • The interhospital transport must be made by qualified personnel with the necessary equipment.

Axioms

• The outcome of air medical transport for trauma patients is dependent on appropriate triage and the skill of the flight crew.
• Safety of crew and patient is paramount.
• Never approach a helicopter without the assistance of the flight crew.
• Transfers should be made for medical necessity and not financial reasons.
• The medical benefits anticipated from the provision of specialized trauma care at the receiving facility should outweigh the risks of transfer.