Patient A, 18 years of age, sustains cervical spinal trauma when diving into a river. He has no demonstrated motor or sensory function below C3 and has no respiratory drive. He is rescued by a local ambulance crew and transported to the nearest facility, a small rural hospital with limited resources. The emergency room physician appropriately requests air transport of this patient to the Level 1 Trauma Center, located 350 miles away.

While awaiting transfer, Patient A is stabilized by the referring hospital staff. He had been placed on a backboard and in a hard cervical collar at the scene, and the staff ensure that he is well-secured to the board. His ventilations are continually being assisted through an endotracheal tube. Admission laboratory results are obtained, and all are within normal limits. Head-to-toe evaluation identifies no further injuries. Subsequently, a Foley catheter is placed. His medical records are copied, and a copy of his cervical spine radiograph is made.

The transport crew arrives and performs an assessment of the patient. The referring hospital personnel have done an exceptional job in stabilizing Patient A; the only interventions that the team performs are to restart an IV that appears somewhat unstable and to place small towels under his coccyx and shoulder blades to prevent pressure injury development. Although Patient A appeared to be quite healthy prior to this accident and is in no current distress, arterial blood gases are obtained to ensure that no respiratory complications exist. After the results are obtained, he is placed on the transport stretcher and secured for transport.

Just prior to leaving the hospital, a person comes through the door in tears, stating she is Patient A's fiancée. She runs to the stretcher and throws herself over the top of him. At this point, the patient starts to cry, and it appears that the emotional impact of this devastating injury is beginning to be felt. The fiancée wants to accompany the patient but is told that there is no room for her. The transport team allows Patient A and his fiancée a few moments together prior to departure.

During transport, a flight crew member notes that Patient A's body is quite cool. The cabin of the helicopter is air-conditioned, and the fan is blowing on the patient. Assuming that the spinal cord trauma disrupted his temperature regulating mechanisms, the team works to maintain an adequate body temperature.

Upon arrival at the trauma center, Patient A is evaluated in the emergency department. His core body temperature is 93 degrees and measures are undertaken to warm him. After further stabilization measures are performed, he is transferred to a spinal cord center, where he remains for four months, learning to use a portable ventilator and a wheelchair.

Discussion

The patient was well stabilized prior to the arrival of the transport team. The interventions the team performed could have been performed prior to their arrival if better communication had occurred. Advice on stabilization measures is always appreciated by the referring hospital staff and would have saved time at the referring hospital.

The psychologic aspects of Patient A's care were not fully evaluated prior to the arrival of the fiancée. Had the emergency department staff performed more in-depth evaluation of the impact of this injury, they would have learned of the fiancée's existence and could have called her earlier in his care. A tearful scene just prior to departure did not help the patient cope with the devastating injury.

In transport, the patient should have been kept warm. Allowing the patient's body temperature to drop to 93 degrees was an oversight on the part of the transport crew. In all transports, the crew should evaluate the patient for complications of the illness or injury sustained, not just how the patient will tolerate the stressors of transport.

Patient B is 5 years of age and is found at the bottom of her grandmother's pool on a cold winter day. She is pulled from the water by the paramedics, and resuscitation efforts are initiated. She is found to have an agonal rhythm and intermittent spontaneous respirations. Cardiopulmonary resuscitation (CPR) is continued, and she is transported to the local children's hospital, approximately 55 minutes away by ambulance.

Prior to transport, the paramedics intubate the patient with a 5.0 endotracheal tube and start one IV line in her antecubital fossa. She is continually hand ventilated with 100% oxygen at an approximate rate of 30 breaths per minute. Her wet clothing is removed, and she is covered with a rescue blanket.

During transport, Patient B develops a bradycardic rhythm with occasional ventricular ectopy. She is given a weight-appropriate dose of atropine, and her heart rate remains between 90 and 100 beats per minute. Standing orders prescribe the administration of sodium bicarbonate, and she receives this dose 30 minutes before arrival at the children's hospital.

Upon arrival, Patient B's vital signs are: pulse 90 beats per minute; blood pressure 86/52 mm Hg; assisted ventilations at 30 per minute; and temperature of 91 degrees. Immediate interventions include rechecking her ABCs and obtaining a chest x-ray to confirm endotracheal tube placement. A set of arterial blood gases are obtained, and the results are: PO₂ 65; partial pressure of carbon dioxide (PCO₂) 53; pH 7.23. Efforts are initiated to warm her, and after two hours, her body temperature is 96 degrees.

She is admitted to the pediatric intensive care unit (ICU), where she can be closely monitored. During the first 24 hours, an intracranial pressure monitor is inserted and signs of increased intracranial pressure are evident. The diagnosis of severe anoxic brain injury is made, and Patient B remains in a vegetative state.

Discussion

This case presents some of the dilemmas that are present in the prehospital care environment. One may ask why the paramedics chose to drive this child by ambulance rather than request helicopter transfer, the answer being quite simple; the helicopter was out-of-service at the time and the crew had no other options available to them.

In the prehospital environment, preparation for transport includes stabilization of the ABCs. Few diagnostic measures can be undertaken; the crew must rely on its initial assessment findings. Patient B was intubated, was ventilated with 100% oxygen, and had an IV line started, thus managing the ABCs. Her wet clothing was removed, but she was quite hypothermic upon arrival at the children's hospital. It would have helped to wrap the patient's head with a towel in transport and then replace this towel after it was water saturated to conserve body heat, as every body surface is equally susceptible to heat loss.

The patient also was predisposed to the problems previously discussed in the neurologically compromised patient. Her anoxic injury caused an increased intracranial pressure and the noise and vibrations experienced during the ambulance ride may have worsened this condition. Another measure that was not undertaken, but that should have at least been considered, is the placement of a nasogastric tube. The moving vehicle could have predisposed this child to vomiting and the risk of aspiration. If circumstances were different, other interventions may have been undertaken, including placement of a Foley catheter.

Patient C is a man, 62 years of age, who is complaining of chest pain upon his arrival at the local hospital. Evaluation of his complaints, laboratory studies, and chest pain demonstrate a massive anterolateral myocardial infarction. Thirty minutes after arrival in the emergency department, the patient sustains a cardiac arrest secondary to ventricular fibrillation. He is successfully resuscitated utilizing advanced life support measures. After the cardiac arrest, he remains quite unstable, having multiple runs of ventricular tachycardia despite multiple antiarrhythmics. The emergency physician consults with the cardiac care center at the referral hospital, and the patient is accepted into their care. Arrangements for air transport are made and Patient C is stabilized according to the instructions of the consulting cardiologist.

While awaiting the arrival of the air transport team, the referring personnel obtain a set of arterial blood gases for measurement. The patient's PO₂ remains at 72 despite increasing the oxygen percentage delivered. A second IV line is started per instructions. It is decided not to insert a nasogastric tube, as it has been more than six hours since Patient C last ate and he states he has never experienced motion sickness.

Upon arrival of the transport team, the patient is moved to the transport stretcher. While moving the patient, increased ventricular ectopy is noted. The dosage of antiarrhythmic medication is increased and the oxygen face mask is replaced with a non-rebreather mask, which is capable of a higher oxygen concentration delivery. The patient is transferred to the waiting helicopter, and the team takes off.

During the initial moments of the transport, Patient C is very alert and interested in his surroundings, asking many questions about the helicopter. Within fifteen minutes, the patient becomes quiet and appears to be dozing. However, at the same time, the crew notice another increase in ventricular ectopy. While another IV drip is being mixed, the patient sustains a cardiac arrest in the helicopter. CPR is initiated, and attempts at intubation are made. Finally, after the fourth attempt, an endotracheal tube is successfully placed, and the patient is ventilated with 100% oxygen. The crew suspects that the cause of the arrest is a hypoxic myocardium secondary to the hypoxia associated with altitude. After 15 minutes of CPR and resuscitation efforts, Patient C again regains a cardiac rhythm and is stabilized. His condition remains critical; he remains comatose after cardiac arrest in the helicopter and is admitted to the cardiac care center in a severe cardiogenic shock. He has an intra-aortic balloon inserted and is supported on the pump for two weeks. After that time, without improvement in his condition, his family chooses to discontinue the balloon pump, and the patient dies shortly thereafter.

Discussion

Patient C's critical condition was not fully recognized by the individuals caring for him. He was alert and awake and this may have caused the healthcare providers to be complacent in their evaluation of him. He had no previous cardiac history and he was not considered to be a high risk individual. The ectopy that he sustained in the emergency department is common after a large myocardial infarction and should have alerted the physicians and nurses to his tenuous condition.

The stabilization measures undertaken by the staff were appropriate and thorough. With a PO₂ of 72 and a cardiac arrest, Patient C was a candidate for endotracheal intubation. The flight crew should have been aware of the risks inherent in transporting this patient, and he should have been intubated prior to departure. Multiple intubation attempts in the helicopter are not uncommon; it is a difficult environment, with poor lighting and poor patient access.

This patient's outcome may or may not have been affected by the omissions of the referring personnel and the flight team members. However, they should have better assessed the severity of the patient's condition and intervened as necessary.

Patient D is a man, 23 years of age, who was burned when a propane heater exploded while he was sleeping in his camper. He was able to escape from the camper prior to the entire truck exploding into flames. However, he sustained more than 60% partial- and full-thickness burns, mostly of the lower torso, back, and legs. He is treated at the scene by a volunteer ambulance crew that is only trained in basic life support measures. They apply an oxygen face mask, cover the patient with blankets, and transport him to the nearest facility 90 minutes away. The facility is a rural hospital, staffed by nurse practitioners and physician assistants, with a physician on-call 45 minutes away.

Upon arrival at this facility, placement of an IV line is attempted. After 45 minutes of unsuccessful attempts, the physician arrives and places a brachial cutdown. Lactated Ringer's solution is started, and initially the fluid was run wide open. Evaluation of Patient D's injuries includes calculating body surface area involvement, which is determined to be approximately 60%. He weighs 70 kilograms, and according to the fluid resuscitation formulas, his fluid requirements for the first 24 hours are 16,800 cc. Based on this calculation, the calculated fluid infusion rate is 1,050 cc/hour for the first eight hours. However, it is important to remember that this formula is based upon starting the IV fluids at the time of injury. By the time the line is placed, more than 2.5 hours have passed. This means that the patient is more than 2 liters behind (if utilizing the Parkland formula). Depending on the patient's condition, fluids can be increased so that the calculated amount is given in the first eight hours, or fluids can be administered according to the calculated formula and the patient monitored for response to these fluids. Patient D is an active, healthy young male without pre-existing medical diseases, and the decision is made to increase the fluid infusion rate to catch him up to these calculated needs. He tolerates this without problems, maintaining a normal blood pressure and an adequate urine output.

In assessing this patient, it is noted that he has singed hair on his head and mustache. No burns are noted on his head, and his airway appears clear. The oxygen delivery system is switched to a non-rebreather mask, capable of delivering approximately 95% to 100% oxygen. The decision to intubate is delayed at this time. Other interventions include cleaning and dressing his wounds and placement of a Foley catheter. He is administered 100 mg of intramuscular meperidine for pain. Arrangements for air transport to the burn center are initiated.

Upon arrival of the helicopter, the transport crew performs an assessment of Patient D. His airway remains clear without evidence of swelling, and the team chooses not to intubate him. The Lactated Ringer's solution had continued wide open, and he has received 5 liters of fluid up to this point. The team slows the infusion to a rate of 900 cc/hour with the knowledge that the patient's urine output had been greater than 50 cc/hour during the last hour.

The patient's dressings are reinforced with dry dressings, and the extremities are elevated to decrease edema formation. Throughout their assessment, the patient continually complains of pain. He is given 10 mg of morphine sulfate IV, with some relief of pain. The meperidine that he received intramuscularly was most likely sitting at the site of injection as his circulation was poor and was, therefore, not helping to relieve his pain.

The patient is transferred to the transport stretcher, and efforts are made to keep him as comfortable as possible. Due to the location of his burns, it is impossible to keep him from lying on his wounds; the team works to make subtle position changes as often as possible. The helicopter trip to pick up the patient is turbulent. The team wants to reduce the risk of motion sickness and vomiting on the return trip, so prior to departure, they place a nasogastric tube.

In transport, Patient D continues to complain of pain and is given frequent small doses of IV morphine sulfate. Upon arrival at the burn center, it is noted that he had received more than 50 mg of IV morphine sulfate, without compromise to his ventilatory status. In fact, the patient continues to complain of pain, although he does note some relief of its severity.

The patient remains stable during the transport. Upon arrival, his vital signs are stable, urine output remains more than 50 cc/hour, and his core body temperature is 96 degrees. He is admitted to the burn center, and the next morning has grafting over 35% of his wounds. After a lengthy stay at the facility, he is released with appointments for rehabilitation.

Patient E is a man, 33 years of age, working in a logging camp during the summer months. He is a well-conditioned, active male with a love of the outdoors. While at work one day, a log falls from the logging truck, crushing him beneath the weight. An emergency medical technician (EMT) who works at the logging camp rushes to the scene and directs the care of the patient while the log is being lifted off him.

Patient E sustains significant trauma to his chest, abdomen, and lower extremities. He is awake, talking, and in a tremendous amount of pain. The EMT is only trained in basic life support measures; he applies an oxygen mask to Patient E and directs an associate to call for helicopter transport to the local trauma center. While awaiting the arrival of the helicopter, the EMT places the patient in air splints to stabilize his suspected fractures.

When the helicopter crew arrives, the team immediately chooses to intubate the patient. Although he is maintaining his airway at present, he continues to lose blood and his condition is becoming more serious. Two large bore IV lines are started, one on each upper extremity. Lactated Ringer's solution is infused wide open until the patient has received two liters of fluid. The air splints on his lower extremities limit the ability of the team to examine the injuries to Patient E's lower extremities. By the EMT's report, Patient E has sustained multiple bruises to the lower abdomen, a displaced pelvis, and an obvious fracture to the left femur. The crew is able to palpate distal pulses on the right and left feet, the left pulse being slightly weaker than the right. As the transport is relatively short (25 minutes), the patient is loaded into the helicopter.

During transport, the patient's neurologic status appears to decompensate. The patient is no longer awake and responding to the transport crew. At this point the crew increases the oxygen percentage to 100% and obtains another set of vital signs. The patient's systolic blood pressure drops by 20 points, and fluids are again run at a wide open rate. A check of his peripheral pulses shows a diminished pulse of the right foot, with no change noted in the pulse on the left foot.

The patient is attached to a pulse oximeter for the transport and at this point it is noted that his oxygen saturation has dropped from 94% to 80%. Placement of the endotracheal tube is checked and the oxygen system is evaluated for proper functioning. When all components are evaluated and found to be functioning properly, it is assumed that the patient has developed a complication secondary to the chest trauma. The most obvious complication would be the development of a pneumothorax, and a flutter valve is placed. Immediately after placement, the patient's oxygen saturation increases to 88% and subsequently rises to 90%.

Upon arrival at the trauma center, the trauma team evaluates the patient and performs a head-to-toe assessment. A chest x-ray is obtained and confirms the development of a pneumothorax, as suspected by the transport team. During the assessment of the patient, it is noted that he has a cold, pulseless right foot. The mechanisms of injury and patient history are again evaluated in an effort to determine the cause of this complication. The femur fracture noted by the EMT at the logging camp is on the left side; it is suspected that an undiagnosed fracture has also occurred on the right side.

As the air splints are being slowly deflated, it is noted that color is returning to the patient's right foot and pulses again become palpable. When the splints are finally removed, a large ring of keys is found in the front pocket of the patient's jeans. It is suspected that the warm air in the emergency department increased gas expansion within the air splints, causing increased pressure on this key ring. The pressure increase was enough to put pressure on the patient's femoral artery, cutting off circulation to his right leg. If the splints had been left inflated for any longer, the patient ran the risk of losing his right leg.

The injuries this patient sustained included fractured ribs of the right chest (causing the pneumothorax), a fractured pelvis, a ruptured spleen, a small liver laceration, fractured left femur, and a closed fracture of the right tibia and fibula. He is taken to the operating room for repair of the splenic and hepatic injuries and orthopedic stabilization and subsequently transferred to the trauma ICU. During his ICU stay, he develops respiratory distress syndrome but is eventually removed from the ventilator and extubated after six days. His other injuries are stabilized and the patient does well.

Discussion

This patient required astute assessment by the transport crew to safely transport him to the trauma center. The conditions at the logging camp did not allow for a complete assessment of the patient and interventions had to be based on the mechanism of injury and the history taken by the EMT at the scene. During transport, the patient's blood pressure dropped, a sign of significant blood loss. As no blood products were available, the team could only support his volume with crystalloid solution. Due to the short length of the trip, this was adequate for this patient.

The other significant complication that could have been devastating to this patient's long-term functioning was the loss of pulse in his right foot. If the pressure on his femoral artery lasted longer, he may have lost his leg to amputation. Equipment should be checked continually for proper functioning to prevent these untoward complications from developing during transport.

Patient F is a boy, 5 years of age, who was found unconscious by his mother after an undetermined amount of time. At his side were an empty bottle of children's acetaminophen tablets and an empty bottle of children's vitamins. EMS responds and transports the patient to the local hospital. He is intubated and placed on a ventilator with 100% oxygen; an IV line is started and blood is drawn for toxicology screen. His mother estimates that there were about 20 acetaminophen tablets and 25 vitamins ingested. The emergency department staff evaluates the bottles, and concern arises because the vitamins contained iron, increasing the risk of iron overdose.

While further efforts are underway to stabilize Patient F, arrangements are made to transport him to the referral medical center, which subspecializes in pediatrics. While awaiting the transport team, gastric lavage is performed, and when completed, the patient receives acetylcysteine down the lavage tube. Throughout the interventions, he remains comatose with occasional weak gasping breaths.

When the transport team arrives, they ask for a chest x-ray and a set of arterial blood gas (ABG) measurements. The chest x-ray shows no evidence of aspiration; the ABG results on 100% oxygen are pH 7.21; PO₂ of 85; and PCO₂ of 54. Based on these results, the team continues the oxygen at 100% but increases the rate of ventilations to 40 (from 30) breaths per minute. The lavage tube is left in place and a Foley catheter is inserted. Patient F's vital signs remain stable, although his blood pressure is on the low side of normal at 88/62 mm Hg.

Prior to departing, the team allows the mother and father to spend time with the patient. The mother asks repeatedly if she can accompany the team. However, due to the confines of the helicopter, this is not possible. The team provides her with as much information as possible about the receiving hospital, including telephone numbers, maps, and plans for admission. As the team leaves, the mother becomes distraught and has to be held back by her husband and other members of the emergency department.

In transport, Patient F's systolic blood pressure drops to 76/42 mm Hg. The team suspects that he is beginning to suffer an acute GI bleed secondary to the iron overdose. However, because this cannot be confirmed, they intervene within the capabilities of the transport, which involves increasing fluid administration. No blood products are available to the team at this time. After three fluid challenges, the patient's blood pressure drops to a palpable level of 50 mm Hg. The fluids are run wide open, and albumin is administered.

During the last few minutes of the flight, the pilot is in contact with the receiving hospital and is able to pass along a message that the patient is in acute need of blood products. Within minutes, the helicopter lands and Patient F is admitted to the emergency department, where the waiting blood is infused. After four units of blood, his blood pressure increases to 78/54 mm Hg.

As the patient is being stabilized in the emergency department, an additional set of ABGs are obtained, and the results are pH 7.15; PO₂ of 76; and PCO₂ of 46. Sodium bicarbonate is administered on a per kilogram basis. Shortly thereafter, Patient F sustains a tonic-clonic seizure. The seizure lasts approximately five minutes after receiving doses of both diazepam and phenobarbital. He is stabilized and transferred to the pediatric ICU.

After four days, his neurologic status improves and he is arousable. He is eventually discharged; however, he continues with neurologic deficits. With intensive rehabilitation, his long-term outcome is hopeful.

Discussion

During the transport of Patient F, his condition worsened, but not because of the stressors of transport. He tolerated the transport complications well, his oxygenation status had been optimized prior to his departure, and he was well-prepared for the transport. However, one of the life-threatening sequelae of iron overdose is GI bleed, and it was suspected that this was the cause of his hypotension in the transport. As this is a well-known complication of iron ingestion, it may have been worthwhile to obtain two or three units of typed, cross-matched blood prior to departure to accompany the patient in transit. However, this was not considered, and the team was able to support Patient F with fluids during the transport. Fortunately, the transport was not a lengthy one; a longer transport may have seen this patient arrest due to significant blood loss.

Patient G is a man, 70 years of age, who requires transport to a hospital with ventilator capabilities. He is treated at the local 32-bed hospital in his home community for recurrent pneumonia. On his third return trip to the emergency department, he sustains a respiratory arrest and is resuscitated. However, this hospital does not have an ICU, nor are the staff trained in caring for a patient on a ventilator. Therefore, arrangements for transport are made.

The nurses caring for Patient G have previously prepared many patients for transport. They make sure that Patient G has a nasogastric tube and a Foley catheter inserted, and they keep him well-covered with blankets from the warmer. An IV line placed during the resuscitation appears to be functioning without difficulty, and fluids are infused at a to-keep-open (TKO) rate. Patient G continues to be ventilated by the respiratory therapist with 100% oxygen. Finally, the patient's chart, x-rays, and laboratory results are compiled to give to the transporting team.

The transporting team arrives to find Patient G obtunded but responsive to painful stimuli. Arterial blood gas measurements are obtained and reveal a pH of 7.5, PO₂ of 88, and PCO₂ of 24. Based upon these results, the respiratory therapist is instructed to slow the rate of ventilations to 20 per minute. The patient's history is reviewed and includes diabetes mellitus, controlled with 20 units of neutral protamine Hagedorn (NPH) insulin every day, an anterior wall myocardial infarction sustained four years ago, and a history of hypertension, controlled with antihypertensives (although his wife reports that the patient is noncompliant with these medications as he feels "draggy" all the time). At the present time, the patient's blood pressure is reported to be 110/62 mm Hg.

The patient's chest x-ray is reviewed and reveals a large consolidation in the left lower lobe. No other abnormalities are reported. Oral antibiotics had been ordered five days previously, and a single intravenous dose is administered before the arrival of the transport team.

The transport team compliments the referring hospital staff on their stabilization measures and prepares to depart with the patient. The patient's wife is allowed in to see her husband and she begins to cry at his bedside. One of the referring hospital staff remains with her throughout her visit and continually provides psychosocial support. The transport team promises to notify her of his safe arrival and estimates the length of transport to be approximately one hour.

After take-off in the airplane, the patient develops ventricular ectopy as noted on the cardiac monitor. The team assumes that this is caused by increasing hypoxia, enhanced by the previous myocardial infarction. As the patient is on the ventilator on 100% oxygen, the hypoxia can only be managed by changing the patient's position to maximize gas exchange. He is turned onto his right side to improve his ventilation and perfusion ratio. However, the ectopy continues and the patient is started on an amiodarone drip.

During the ectopy, the patient's blood pressure drops to a systolic pressure of 88 mm Hg. The team increases the IV fluid rate, and immediately the IV becomes nonfunctional. As the patient only has one IV line, this means that the amiodarone (Cordarone) is also discontinued. While numerous attempts are being made at IV line placement, the frequency of the ectopy increases. IV line placement is unsuccessful up to this point, secondary to the patient's contracted fluid status and the multiple attempts that had previously been made during his arrest at the referring hospital.

While the second crew member attempts to start an IV line, the patient sustains a cardiopulmonary arrest. The team begins resuscitation efforts per advanced cardiac life support protocols, including administering medications via the endotracheal tube. The patient continues in ventricular fibrillation for the remainder of the flight and the transport team chooses to discontinue resuscitation efforts after 45 minutes. The difficulty in making this decision to discontinue treatment is that the team has no diagnostic capabilities available to them to determine the cause of the arrest. While it is assumed that this was caused by hypoxia secondary to the pneumonia and enhanced by the previous myocardial infarction, the team cannot be sure. However, after 45 minutes, all efforts available to them have been undertaken and the team has no further interventions at their disposal. Shortly after this, the airplane lands at the airport and the medical examiner is notified of the patient's death.

The final task required of the transport team is notification of the patient's wife of his death in transport. She is assured that all efforts were performed to prevent his death and that he did not suffer during these efforts. She thanks the team for their efforts to save her husband's life and hangs up the telephone.

Discussion

This case presented the difficulties in transporting a patient with a multitude of health problems in an environment with limited resources. The patient's outcome was tenuous before the transport, and was further compromised in the transport environment. However, his condition at the time of the transport was such that he could not have remained at the referring hospital due to their limited resources. Therefore, the transport needed to take place, the risks being an inherent part of the transport.

The transport team did not take the time to start another IV line; had they done so, the patient may have survived the transport, as the arrest may have been avoided. Any patient who has previously arrested and requires transport should have at least two IV lines in place. The patient's IV line had appeared to be functioning; however, it was at a TKO rate, which is not a true test of a line's patency.

The decision to not place a second IV line may have been based on the fact that the referral hospital had been working hard at stabilizing the patient and the transport team did not want to offend them. While this line of thinking is polite, the error of their judgment is obvious. Placing a second line could have been performed without offending the staff by simply explaining the need for a second line, should the first one malfunction. The referral hospital staff seemed interested in helping to stabilize the patient and would most likely have viewed this explanation as a learning experience. Hopefully, the transport team will never make this mistake again. And while the transport team's interventions may be questioned, the death of this patient cannot be blamed on their error in judgment.

Patient H is 38 years of age and has developed preterm labor at 31 weeks' gestation. Tocolytic therapy has been unsuccessful at discontinuing her labor, and she is to be transported by air to a high-risk obstetrical center with the capabilities for delivery of a high-risk neonate. Patient H's history includes a previous cesarean delivery two years ago for uterine atony. She has a two-year-old girl and a husband who is very involved in the child's care.

In preparing the patient for transport, the referring hospital personnel start Patient H on oxygen by face mask. Magnesium sulfate is infusing at a rate of 3 g/minute in an effort to control or stop her labor; a new drip is made so that there will be a sufficient amount of medication to last the length of the transport. Additionally, Patient H is receiving lactated Ringer's solution at a rate of 75 cc/hour. Her husband remains with her throughout the preparation, offering her emotional support.

When the transport team arrives, they review Patient H's history with her and with the referring hospital staff. Patient H is well-informed of the reason for the transport and wants to get to a facility that can provide intensive neonatal support, if needed. Prior to departing the hospital, the transport team places Patient H on a non-rebreather mask to increase her oxygen concentration delivery. She is placed on the stretcher in the left lateral decubitus position and fetal heart tones are monitored prior to departure from the hospital. Fetal heart tones remain at 120 to 130 beats per minute.

During transport Patient H's vital signs remain stable, a Doppler monitor is utilized to monitor the fetus, and after 20 minutes, the patient appears to fall asleep. Thirty minutes into the flight, the transport crew notices that Patient H's respiratory rate has dropped to a rate of 6 breaths per minute. They immediately start assisting her ventilations with a bag-valve-mask device. Her vital signs are obtained; her systolic blood pressure has dropped 20 points. Fetal heart tones are initially not heard; after repositioning the patient, they are measured at 100 beats per minute. At this point, it is apparent that both the mother and fetus are in acute distress and a decision regarding interventions has to be made.

The team continues to hand ventilate the patient with 100% oxygen; after seven to eight minutes, the fetal heart tones increase to a rate of 118 beats per minute. The patient's respiratory rate remains at 6 breaths per minute, and the team continues to ventilate her at a rate of 25 per minute with 100% oxygen.

The team is now 20 minutes from the receiving hospital and the transport continues to its original destination. The patient requires continuous ventilatory support during the remainder of the transport. Fetal heart tones continue to fluctuate between 110 and 120 beats per minute.

Immediately upon arrival at the receiving hospital, Patient H is intubated and placed on a ventilator. She is arousable at this point, and showing signs of acute apprehension. Further studies reveal that her magnesium level is toxic, which caused her ventilatory failure. The magnesium drip is discontinued and she remains on the ventilator until her magnesium level is within normal limits, at which time she is successfully weaned from the ventilator.

When the magnesium drip is discontinued, her contractions increase in frequency and intensity. Other therapies are unsuccessful at controlling her contractions, and her membranes rupture. Within two hours of arriving at the receiving hospital, Patient H delivers a 1,000-gram baby boy. The infant is immediately resuscitated by the neonatal team and transferred to the neonatal intensive care unit (NICU). The baby boy does well and is released when weighing slightly more than 4 pounds.

Discussion

The referring hospital had well stabilized Patient H for the transport, with the exception of obtaining a magnesium level. The transport team neglected to look for this result in the patient's chart, and this set up the course of events leading to the patient's ventilatory failure. Additionally, the healthcare providers should have been monitoring the patient's deep tendon reflexes, as weakened reflexes indicate impending magnesium toxicity. Although this would have been difficult to perform in transport, the team should have attempted to obtain this assessment parameter.

Fortunately, the outcome of this transport was excellent. The patient was successfully ventilated when the need arose, and the fetus responded to this ventilatory support. Had the transport been longer, the team may have elected to attempt an intubation in the aircraft. Successfully mask ventilating a patient for a long period of time is difficult within the confines of the transport vehicle and tiring for the transport crew; however, intubation is also a challenge in this environment.

The transport team appeared not to consider that the patient may have been magnesium toxic. Had this been considered, they could have discontinued the drip and switched to another tocolytic agent. The most serious consequence of this action would have been an earlier delivery of the fetus, possibly during the transport itself. While other tocolytic agents may have been unsuccessful in terminating the preterm labor, the need to discontinue or slow the rate of the magnesium infusion was indisputable.

The successful outcome demonstrates the appropriateness of this transport. Without accessing such a facility prior to delivery, the infant would have been subjected to the stressors of transport as a neonate requiring NICU care and may not have tolerated the transport as well as he did while remaining in utero.

These case studies have demonstrated a number of developments that can occur in the transport environment. While some of the complications may have been avoided with more intensive stabilization, the outcomes of the patients presented most likely would not have changed. Appropriately stabilizing the patient should be considered one of the most important steps in transporting the sick or injured patient.