Definition
- Process of transferring critically ill patients using a team which travels to the patient location from a central location or the destination hospital. The principles of medical retrieval are to:
- Supply a level of medical expertise akin to that of the destination hospital.
- Assess the clinical problem in the place of referral.
- Stabilise the patient’s condition prior to transportation.
- Transport the patient with physiological support & appropriate monitoring.
- Deal with foreseeable en route deteriorations as the working environment allows.
- Monitor and review the quality of the retrieval process.
General considerations
Select patient
- No abs CI to air medical transfer as long as appropriate precautions taken.
- Benefit of transport must outweigh increased risks of transport.
- Must require care available at destination not available at source facility.
- Necessary care must be able to be provided during transport.
Relative CI to air retrieval:
- Bronchopleural fistula
- Bowel surgery<10d
- Active GI bleeding
- Vascular anastomosis<14d
Select mode of transportation
- Road vehicle
- Standard ambulance
- High level care ambulance (Paramedic staff) ± Nursing/medical staff
- Specialist retrieval team + vehicle
- Air medical
- Helicopter
- Indications for 1º helicopter retrieval: trauma score<12, GCS<10, BPsys<90mmHg, 10>RR>35, 60>HR>120, AVPU below V.
- Halves road transit time for distances 50-200km.
- Good for poorly accessible areas – mountainous/over large water expanses
- Faster mobilisation than fixed-wing
- Needs smaller landing area & can land closer to or at hospitals
- Cabin cons: noise level/communication, size limitation, cramped, temperature control, vibration, unpressurized
- Safety: approach wrt rotors.
- Fixed-wing
- Distances >200km or road transport times >3h
- Unpressurised if <900km light aircraft at alt to 3000m
- Pressurised (usually to 2000m) if >900km turboprop/jet at alt to 8000m+
- Pros compared to helicopter: faster airspeed, more cabin space, less noise/vibration, better temp control
- Cons: longer mobilisation time, long landing strip, requires road transport from landing area to hospital
- Helicopter
Select Medical Team
- Doctor – ED, intensivist, or anaesthetist
- Nursing
- Paramedic/s
- Ambulance officer/s
Patient Preparation
Secure
- Airway, ventilation, oxygenation
- All catheters, tubes, drains
- IV access (tape/splints as req) + extra access (min 2 large bore)
Sedation/Analgesia
- Sufficient stock for increased req during transport
- Prophylactic antiemetic (risk of vomiting from medication, condition, or motion)
- Prophylactic anticonvulsant (if fitting risk)
IV Fluids
- Ensure blood volume deficit corrected before transport
- Ensure sufficient stock for transit
- At altitude plastic bags distend & IV s often slow/stop so may need freq flushing
Injuries/conditions
- C-spine stabilisation: special braces – avoid sandbags as mobile
- Consider prophylactic ICC if any pneumothorax or >2 rib # as PTX expands at altitude
- Use Heimlich valves rather than underwater drains for ICC
- Haemorrhage controlled
- Splint # preferably without air splints
- Bivalve plasters prior to ascent
Environment
- Temp likely to fall during transport (esp aircraft)
- Core T monitoring
- Incubators for neonates
Communication
- Ensure patient, relatives, sending/receiving hospital teams all kept informed
- Mobile phone / in-aircraft radio
Documentation
- Notes, investigation results, XRs
- In-transit notes/obs
- Consider consent for transport due to increased risks
Equipment
- Need defib, oxygen & suction.
- Kit should be light, portable, and attachable to fixtures of vehicle/aircraft.
- Alarms should be visible and audible.
- Electronics: Battery containing and compatible with electrical system of vehicle/aircraft.
- Monitors: ECG/cardiac, oximeter, ETCO2, NIBP (auto) or intra-arterial BP, thermometer
- ETT: remove some air from cuff on ascent & re-instil on descent, humidification needed.
- Ventilator: robust, know gas consumption (Oxylog: min vol + 800ml/min), sufficient O2
- Drugs & fluids: Infusion or syringe (ideally) pumps, pre-packed syringes, full resus packs
Anticipated In-Transport Problems
Ideally preparation avoids need to deal with problems in transit.
Loading/unloading
- Line-tube dislodgement, thermal insult, re-bleeding.
Altitude effects
- In normal patients little effect of piO2 as SaHb>90% at alt<2500m.
- However may have effect if piO2, [Hb]<75g/L, paO2, O2 req, fixed cardiac output
- In severe respiratory disorders (e.g. ARDS) may not be able to maintain oxygenation at 100% FiO2 at altitude so fly at lower alt or increased pressurisation (ideally sea level).
- Gas expansion: Volume doubles at 5000m. If not room for expansion then P in cavity.
- Expansion relevant in:
- Patient (generally may CI air retrieval unless can fly at low cabin altitude)
- Fractured skull with aerocoele
- Penetrating eye injury
- Mediastinal emphysema, pneumothorax
- Recent gut sutures, bowel obstruction
- Decompression illness/air embolism
- Equip:
- IV bags
- ETT cuff
- Colostomy bag
- MAST suits
- Staff: sinuses, middle ear
- Solutions:
- Heimlich valve for ICC, vent cavities e.g. NGT, give 100% O2, deflate ETT cuff while at alt.
- Patient (generally may CI air retrieval unless can fly at low cabin altitude)
- Temperature:
- Keep patient warm but ensure coverings don’t obscure patient/hamper access
- Noise, vibration & G forces:
- Detrimental to recent vascular anastomoses or re-expanded PTX, unstable patients, comfort/pain level, haemostasis, IV insertion, auscultation, communication.
- Positioning & Space:
- Ideally (but often impossible) in HI/ICP: head forwards on take-off, opp on landing. Space limitations for access, procedures.
- Vital signs:
- Difficult to monitor due to noise/vibration, may need visual signs/alarms instead of audible ones. Monitor accuracy at altitude or with vibration.
- Crash/Emergency landing:
- Trained crew
- Other:
- Motion sickness, sinus/middle ear pressure, phobias (height, flying, enclosed spaces)