#90744: Transport Methods for Critically Ill Patients

Transport of the sick or injured patient from one location to another is not a new concept. For all of recorded history, patients have been moved so that they could receive medical treatment. Soldiers wounded on the battlefield have been transported in moving conveyances ranging from horse-drawn carts to purpose-built aircraft. The first soldiers transported by air were flown in hot air balloons during the Prussian siege of Paris in 1870. Throughout the 20th century, transport methods developed slowly and, at times, haphazardly. However, during the late 1960s and early 1970s, Congress enacted numerous pieces of legislation addressing emergency medical care and transport. These laws were the impetus to develop sophisticated transport systems. Since that time, transporting of patients has developed into a subspecialty of emergency medicine, involving physicians, nurses, paramedics, respiratory therapists, and other prehospital care providers. Transferring a patient in a safe and efficient manner is now considered essential in the provision of medical care.

Four types of hypoxia can occur to impact the oxygenation status of the patient transported by air. The physiology of these four types will be reviewed, followed by a discussion of the manifestations of hypoxia and interventions that can be instituted to minimize or prevent these harmful effects.

As an aircraft ascends, atmospheric pressure decreases and gas expands (Boyle's law). Gas expansion can be directly measured; 100 cubic centimeters (cc) of gas at sea level will expand to 130 cc at an altitude of 6,000 feet, to 200 cc at 18,000 feet, and to 400 cc at 34,000 feet. Gas expansion is a potential problem in all transports that ascend, but is especially harmful to patients transported in unpressurized aircraft flying above 12,000 feet.

Air can be present in many places in the body and in support equipment during patient transport, including the pleural space when a pneumothorax is present, air splints, and endotracheal tube cuffs. Pretransport stabilization measures can be instituted to prevent air expansion complications from hampering patient outcomes.

A pneumothorax that is recognized prior to transport should be treated with either a chest tube or, if chest tubes are impractical due to environmental limitations, a flutter valve attached to a one-way valve (Heimlich valve). Endotracheal tube cuffs should be monitored during transport as the air in the cuff will expand. The cuff may be partially deflated on ascent to prevent tracheal damage. (It is important to remember that gas can significantly expand during ascent and then decrease during descent. If air is removed, such as from an endotracheal tube cuff, it should be reinflated upon descent.)

Air splints should have air removed during ascent and replaced during descent. If this simple maneuver is overlooked, the splints become very tight, compromising the patient's circulatory status.

The gastrointestinal (GI) tract contains a great deal of gas. A nasogastric tube placed prior to transport will decrease gas expansion and reduce the risk of vomiting. A patient with a colostomy or ileostomy can have a rectal or nasogastric tube inserted into the stoma to reduce gas expansion in the lower bowel.

The patient may complain of dental pain from dental caries (tooth decay) that have not been managed appropriately. Little can be done during transport to ease the patient's pain except the administration of pain medication. The patient may also complain of ear pain (this is most common among the pediatric population). Expansion of gas trapped in the middle ear can be treated with vasoconstrictor nasal sprays and by assisting the patient with maneuvers to clear their ears. One useful procedure in the pediatric population is to have the child suck. A small child can suck on a pacifier, and if not contraindicated, an older child can have a small amount of liquid through a straw. The sucking motion helps relieve the pressure. Performing the Valsalva maneuver often assists with clearing the middle ear.

Finally, equipment can have gas inside that will expand. Glass intravenous (IV) bottles have air inside, and as the aircraft ascends, the gas expands and the rate of fluid delivery increases. The bottle should be vented in order to achieve proper functioning. However, a safer technique is to utilize plastic IV bags that do not contain air and also do not present a hazard during unexpected turbulence.

Most of the complications of gas expansion occur during fixed-wing transports as the altitude achieved is much higher. However, gas expansion can occur in helicopter and ground transports that traverse high mountain passes. It is essential to perform the interventions described above whenever the transport involves significant changes in altitudes.

A drop in ambient humidity also occurs with an increase in altitude. This loss of humidity is enhanced in a pressurized aircraft; cabin pressurization is achieved by introducing compressed air from the engines, recycling the air, and removing moisture to protect the aircraft and its electronic systems from corrosion. Ambient humidity in a pressurized aircraft after one hour of flying time is less than 5%.

Patients who are dehydrated or diaphoretic are at increased risk for dehydration, causing a further decrease in their circulating volume. A dry environment is also harmful to a patient's respiratory tract, as drying of the mucous membranes and loss of ciliary action can lead to an increased risk of respiratory tract infections.

Providing adequate hydration to the patient during transport can minimize the effects of dehydration. Ensuring adequate circulating volume prior to transport will ensure that the patient is stabilized appropriately. Adding humidification to the oxygen delivery system throughout transport will counter the drying effects of oxygen.

The standard lapse rate for temperature is that for each 1,000-foot gain in altitude there is a 2 degree centigrade drop in temperature, until the temperature reaches negative 55 degrees centigrade. The harmful effects of a decreasing temperature arise when the fuselage of the aircraft becomes cold. This cold is transmitted through the cabin walls causing the interior to cool. The coldest area in the aircraft is against the outside walls, where the patient stretcher is usually secured. An unconscious patient will not be able to report being cold and the effects of hypothermia may be subtle. An additional factor that impacts this concept is that the transport personnel are working and producing heat; their body temperature may actually feel warm and, therefore, they do not recognize that the environment has cooled significantly.

Although this problem is greatest during the colder winter months, the effects of the drop in temperature are experienced year-round. A drop in body temperature causes a decrease in the patient's level of consciousness and can produce shivering. The decrease in the patient's level of consciousness can be attributed to a number of factors, including hypoxia, dehydration leading to a decreased circulating volume, and a decreased temperature. Because the transport personnel have limited resources available to them to determine the cause of patient deterioration, they should assume that the problems of transport are compromising the patient and intervene to correct these problems.

Decreased temperature is not solely an altitude-induced problem. During a transport, a patient is subjected to a number of environmental changes. As an example, a patient may be injured at a scene of an accident and not found for a period of time. During this delay in receiving medical care, the patient becomes hypothermic. He is subsequently found, stabilized, and transported by ground ambulance to the nearest facility. During ground transport, the transport personnel heat the interior of the ambulance and work to maintain the patient's body temperature. Upon arrival at the hospital, the staff works to warm the patient. During evaluation of the patient's injuries, the determination is made to transport the patient to a trauma center, which is located 250 miles away. Arrangements for air transport are made and the patient is stabilized for transport. At this point the patient's temperature may be stabilizing; however, he is then transported from the hospital to an ambulance and transported from the ambulance to the aircraft. During air transport the patient again becomes hypothermic due to the decreased temperatures at altitude. Finally, before arriving at the Trauma Center, he is again transferred out of the plane and into another awaiting ambulance. The patient has been subjected to at least seven different environments, and if these transfers occurred in the middle of winter, it is obvious what this can do to impact the patient's condition.

Paramount to preventing temperature changes in patients is awareness of the ambient temperature. Minimizing the patient's exposure during transfer is of utmost importance. Maintaining an adequate supply of linens to warm the patient is helpful. Burn patients are at great risk from environmental changes and may benefit from the use of a rescue (Mylar) blanket. Pediatric and elderly patients are prone to hypothermia, and using a hat will help reduce up to 10% of radiated heat loss [4].

An additional complication that occurs with a decrease in temperature is that air molecules contract when cold. This is the opposite of the effects that occur with an increase in altitude as previously discussed. In a cold environment, air splints may deflate, thereby losing their effectiveness. This is most often encountered when a patient is in air splints and is removed from a warm hospital to the cold air outside. Each time the environmental conditions change, the effects on gas expansion or contraction should be compensated for.

Cold environments also impact IV solutions and medications, most notably those containing mannitol. Solutions stored in the aircraft are quite cool and should be warmed prior to administration. Mannitol may crystallize when cooled, rendering it useless. These solutions should be stored in the warmest spot in the cabin (usually the cockpit) and, if necessary, rewarmed. Warming of IV fluids can be done by utilizing a heat pack that is wrapped around the IV bag and part of the tubing. While this method will not assist in rewarming a hypothermic patient, it will prevent the administration of cold fluids. Mannitol is usually not stored in the aircraft in cold locales; it is considered to be one of the items that is loaded into the aircraft immediately prior to departure.

Time/temperature indicator (TTI) labels that can monitor mean kinetic temperatures, allowing for assessment of potential or real pharmacologic degradation, are used in clinical evaluations. With this type of measurement method, flight crews would be assured that the medications stored onboard the transport vehicle are safe and effective for patient care.

Acceleration and deceleration forces occur in all methods of transport; the severity and angle of these forces varies by vehicle type. Acceleration forces occur on takeoff, climb-out, or when a ground ambulance speeds up. These forces can produce what is known as positive G forces. These forces can be significant enough to cause fluid shifts in severely compromised patients. Blood pools in the dependent areas, most commonly the legs. The effects of positive G forces can produce what is known as "grey-out." This is a phenomenon that occurs when there is an inadequate circulating blood volume to the head, essentially causing the individual to faint momentarily. As soon as normal circulation is established the patient's level of consciousness returns to its previous state.

Deceleration forces occur upon slowing down, stopping, or during a rapid descent. As most patients are positioned in the transport vehicle with their head forward, these forces produce negative G forces, or "red-out," which is a rush of blood to the head. The term red-out was coined when this phenomenon was noted to produce a momentary reddening of the sclera in the eye as intraocular blood volume increased. Negative G forces are most harmful to the patient with increased intracranial pressure. This rush of blood to the cranial cavity causes a sudden, abrupt rise in intracranial pressure and subsequent deterioration in the patient's level of consciousness.

The effects of acceleration and deceleration forces vary with the speed, angle, and duration of the forces. Military pilots are subjected to these forces on a frequent basis and have developed a tolerance to them. These forces are most pronounced in a fixed-wing transport on either takeoff or landing. In certain situations; the pilots have some control over these factors, such as obtaining a slow rate of descent and having a longer landing roll. These issues are discussed with the pilots prior to departure and the pilots will work with the air traffic controllers to try to achieve the maximum benefit for the patients, while working within the constraints of the environment and vehicle performance.

Positioning the patient is crucial to limiting the effects of these forces. In most aircraft the stretcher should be secured with the head forward, requiring that the patient be placed in this position. If the patient can tolerate a head-elevated position, this will limit the abrupt rise in intracranial pressure that occurs during deceleration. Elevating the feet of the patient during takeoff can prevent fluid accumulation in the patient's feet during acceleration.

Lateral forces are a possibility, though rare, during helicopter transport. Usually, these lateral forces are of little consequence; many times the patient and crew are unaware of this type of movement. Lateral forces can also be experienced in ground transport while turning a corner. However, the driver of the vehicle should maneuver in such a manner that these forces do not harm the patient and crew.

According to the American Association of Neurological Surgeons, spinal immobilization in patients with penetrating trauma is not recommended because of increased mortality from delayed resuscitation.

(https://www.cns.org/guidelines/browse-guidelines-detail/2-prehospital-cervical-spinal-immobilization-after Last Accessed: July 22, 2022)

Level of Evidence: III (Strategy for patient management for which the clinical utility is uncertain.)

Often patient transfers involve long distances and, therefore, long transport times. The patient who is immobilized on a stretcher throughout a transport (either by land or by air) is subjected to a number of factors, including pressure sore development and venous stasis. Space limitations and the inability to change the patient's position exacerbate this problem. Patients at increased risk for complications include trauma patients, the elderly, and any patient with previously compromised circulatory status.

The patient at greatest risk is the patient with a spinal cord injury requiring transport on a backboard. It is important to remember that the time of immobilization is not only the length of the transport; ground transport times, unexpected delays, and transfer times should also be considered. As an example, a patient is injured in a motor vehicle accident at a remote site and is secured to a backboard to protect the cervical spine. The patient is then transported to the local hospital for stabilization and evaluation. The decision is made that the patient requires the expertise only available at a trauma center and arrangements for transport are initiated. During the evaluation of the patient, the x-rays are inconclusive and the patient is to remain on the backboard until a definitive diagnosis can be reached. Subsequently, the patient is taken by ground ambulance to the local airfield, flown to the airfield near the trauma center, and is again transferred by ground ambulance to the trauma center. The length of time from the scene of the accident to the trauma center may exceed 5 to 6 hours, although flight time was less than 1.5 hours.

Signs of poor perfusion are often difficult to assess during transport. Lighting is less than optimal; therefore, assessment of extremity color and capillary refill are hampered. The patient may complain of tingling or numbness in a compromised area; however, the patient with a decreased level of consciousness would be unable to report these sensory changes. Doppler monitor ultrasound can be utilized to assess for the presence of pulses in distal extremities. The absence of pulses requires further investigation of the cause and interventions to improve circulation.

The patient who is secured to a backboard runs the risk of pressure sore development in a number of locations. The most common pressure areas include the coccyx and sacral areas. Additionally, the scapulae are prone to compromised circulation. A patient in a hard cervical collar for spinal cord immobilization should be monitored for pressure sore development at the angles of the jaw and at the occiput of the skull.

Before departure, all splints, casts, and pressure areas should be padded. The patient on a backboard can have a small towel or pad placed under their back and coccyx area without risking a change in spinal cord alignment. During transport, proper positioning should be accomplished and, if possible, range of motion within the constraints of the vehicle can be performed. Constant vigilance of the extremities and areas of high risk before, during, and after the transport is required to prevent pressure sore development.

Changes in inner ear equilibrium caused by unusual movements are the primary cause of motion sickness. However, other causes can include: hypoxia, excessive visual stimuli, stress, fear, unpleasant odors, heat, and poor diet. Gastric gas expansion that occurs on aircraft ascent can further potentiate the problem.

Nausea and vomiting are the two most common symptoms of motion sickness; other signs include chills and headache. In the transport environment, all persons are at risk of motion sickness, including the transport personnel. Those individuals who have a predisposition to motion sickness may prophylactically premedicate with transdermal patches. The problem that arises with the use of these patches is that, to be effective, they should be applied a half hour or more prior to departure; however, since these transports are generally not planned, this preventive measure may not be feasible.

To prevent or limit the effects of motion sickness, transport personnel should apply oxygen and ensure that the individual is in the supine position. Staring at a fixed object will help reduce the inner ear imbalance that precipitates the problem. Cooling the interior of the vehicle also will help reduce the symptoms. In severe cases, insertion of a nasogastric tube to suction will reduce gastric contents and vomiting.

Interestingly, transport personnel rarely, if ever, experience the symptoms of motion sickness while caring for a patient in transport. Most cases of crew motion sickness occur while on the way to pick up a patient. It appears that the concentration and work involved in caring for the patient helps overcome these complications.

All transport vehicles are noisy. Engine noises create a constant loud hum; sirens in a ground ambulance are very loud and of a harsh intensity. Constant noise can create a stressful environment as well as increased irritability in all persons in the transport vehicle. Patients who are exposed to this constant input experience changes in their vital signs, including tachycardia and hypertension.

Reduction of environmental noise can be accomplished in a number of ways. Flight crews in helicopters utilize headsets to reduce noise input, as well as to allow for communication with other crew members. Headsets can also be used for the patient; however, it should be remembered that when noise reduction techniques are utilized on the patient they cannot hear normal conversation. This may prevent the patient from appropriately answering questions, as well as increase their anxiety when they assume that the crew is talking about them and they cannot figure out what is being said.

Cotton balls are the simplest form of noise reduction. However, they are easily forgotten when the patient arrives at the receiving hospital and communication may be difficult for this very simple reason. Another method employed to help the staff with the noise is the use of Doppler monitor devices to assist in obtaining vital signs or to assess for air movement through the trachea. A stethoscope may be rendered useless in obtaining vital signs in a very noisy environment, but it can assist in communicating with the patient. By placing the ear pieces into the patient's ears and speaking at the diaphragm, the patient may be able to better communicate with the crew.

The noises heard in ambulances, helicopters, and airplanes may be familiar to the transport crew; however, these same noises may produce fear in the patient. It is essential that the crew communicates with the patient, explaining all noises and lights. A preflight briefing will help alleviate some of these fears.

Motion produces vibration. All transport vehicles are affected by vibration. However, this is most noticeable in a helicopter, especially during takeoff and landing. The biggest risk of vibration is the loosening of safety straps so that during a time of turbulence, equipment can come loose and pose a hazard to the safety of all. FAA regulations require that all equipment be secured for takeoff and landing in helicopters and airplanes; however, it is wise to keep all equipment secured at all times in the event of unexpected turbulence.

The patient should be secured onto the stretcher at all times. The safety straps used to secure the patient may be quite uncomfortable for them; during transport, these straps can be loosened slightly but should never be removed completely. The greatest risk comes to patients as they are being moved into and out of the transport vehicle.

Another problem with vibration is its effect upon equipment settings. Over time, constant vibration can cause a loosening of screws, so that equipment does not function properly. Mechanical ventilators are most prone to this complication; settings should be checked frequently during transport.

A rare and unexpected complication that can occur in a pressurized aircraft is the rapid loss of pressurization. This is an emergency situation in which the pilots of the aircraft will immediately put the aircraft into a steep descent to reduce the effects of atmospheric changes. When an aircraft loses its pressurization, the cabin pressure altitude immediately goes from its comfortable flying altitude (between 3,000–6,000 feet) to equilibrate with the altitude outside the aircraft (this can be up to 25,000–40,000 feet). The sudden decrease in cabin pressure produces all of the effects of altitude increase, including hypoxia, gas expansion, decreased temperature, and dehydration, with hypoxia causing the largest risk.

The immediate effects of a loss of pressurization depend upon the altitude of the aircraft at the time of the emergency; the higher the airplane, the greater the complications. The patient and crew could experience a number of problems including a ruptured eardrum, a drop in body temperature, and possibly wind burn, if the cause is due to a loss of a piece of the fuselage.

Decompression sickness is manifested by joint pain (the "bends"), paresthesias, central nervous system changes (e.g., headache, visual disturbances), and the "chokes" (a choking sensation). These symptoms are caused by the release of nitrogen bubbles into the blood stream.

Initially, when a loss of pressurization occurs, the crew is trained to put on their oxygen masks and protect themselves first. The pilots will don their oxygen masks and put the plane into an immediate descent. The crew should ensure that all equipment is secured and does not pose a hazard during this descent. The patient should have oxygen administered, or increased if he or she had previously been receiving oxygen. Symptoms of decompression sickness can be treated with oxygen therapy, or in severe cases, a decompression chamber with hyperbaric oxygen therapy.

Although rapid cabin decompressions rarely occur, transport personnel can now obtain training in handling of this type of emergency. The FAA and the U.S. Air Force have a joint training agreement to offer hypobaric chamber training to civilians at several U.S. Air Force Bases throughout the United States. This type of training allows the participants to experience the effects of decompression and the hypoxia associated with this untoward event, with the intent of being sufficiently trained in symptom recognition to protect themselves and their patients.

These ten stressors of transport are problems for all patients, some to a greater extent than others. Awareness of their probability and interventions to prevent their occurrence will limit the detrimental effects to the patient. Appropriate stabilization prior to transport will ensure that these effects will be minimized. Further stabilization measures will be discussed at length later in this course.

Local, state, and federal regulations all impact transport of patients, both in the air and on the ground. Healthcare providers who are facilitating a transport should be aware of how these regulations affect their choice of transport vehicle, as well as their legal responsibilities before, during, and at the end of the transport.

Ground ambulance regulations are developed at the state level by the Emergency Medical Services (EMS) office. These regulations can vary by state, but should meet the minimum standards as outlined in federal regulations. Most often these state regulations far exceed the minimum standards; however, they do vary significantly from state to state. Regulations are set for basic life support ambulances that are capable of providing advanced critical care measures. The equipment and training of the transport crew will vary depending on the services provided. Patient needs will dictate which type of transport vehicle is required for each transport.

Air ambulance operations are regulated by the FAA and should meet the requirements of a portion of the aviation regulation known as Part 135. These regulations stipulate the qualifications of the pilot-in-command and other flight crew members, maintenance requirements, and aviation management. Part 135 contains some of the most stringent of all the FAA regulations. Additionally, air transport crew members should be cognizant of the Federal Aviation Regulations (FARs) concerning in-flight safety and emergency procedures.

States may also regulate air ambulance operations within their state. To obtain licensure as an air ambulance, the transport program should meet certain minimum requirements. Although not required in all states, the legislative trend is to regulate the air ambulance operators to minimize the presence of those operating capricious services who believe they can make some extra money by transporting patients.

Accreditation is also available through the Commission on Accreditation of Medical Transport Systems (CAMTS). This is a voluntary review of an air transport program to ensure their compliance with patient care and safety standards. These standards are revised every two to three years. As of May 2022, there were 162 accredited medical air transport services in the United States [16].

Federal regulations also stipulate the requirements for the need to transport patients. These requirements were first introduced in 1985 as part of the Consolidated Omnibus Reconciliation Act (COBRA) and were subsequently amended in 1995 as a portion of the Medicare law, Emergency Medical Treatment and Labor Act (EMTALA). These laws state that all patients should have equal access to care and require the hospital to ensure that proper care is provided. If the hospital is incapable of providing care, arrangements should be made to transport the patient to a hospital with appropriate facilities. To ensure that the transport is performed in a safe and expeditious manner, the following conditions should be met [5]:

It is the responsibility of all persons caring for patients to see that these regulations are followed.

According to the Eastern Association for the Surgery of Trauma, emergency tracheal intubation is indicated in trauma patients with airway obstruction, hypoventilation, persistent hypoxemia (arterial oxygen saturation ≤90%) despite supplemental oxygen, severe cognitive impairment (Glasgow Coma Scale score ≤8), severe hemorrhagic shock, or cardiac arrest.

(https://www.east.org/education/practice-management-guidelines/endotracheal-intubation-following-trauma Last Accessed: July 22, 2022)

Strength of Recommendation: 1 (The recommendation is convincingly justifiable based on the available scientific information alone.)

Airway patency during transport is of primary importance. Potential airway compromise should be anticipated before transport so that proper interventions can be undertaken to ensure that the airway is protected. Performing airway maneuvers in a transport vehicle are, at a minimum, challenging and often are unsuccessful.

Endotracheal intubation should be considered in any patient who has the potential to lose their airway due to aspiration, swelling, or edema. This may include patients with facial or neck burns, epiglottitis, facial fractures, or patients with an altered level of consciousness. Patients requiring mechanical ventilation and ventilatory support should be intubated in a controlled environment prior to departure. Examples of these patients include spinal cord injured patients, patients with chest wall injuries, or patients with other neurologic dysfunction.

Supplemental oxygen should be contemplated and is usually considered to be standard therapy during transport. All patients transported by air are at risk for hypoxia, as previously discussed, and should be considered as candidates for oxygen therapy. Figure 1 shows the predicted in-flight PO₂ for a patient, based upon his arterial blood gas results and the altitude at which the patient is to be transported (i.e., cabin altitude in a pressurized aircraft). You will note that a significant drop in the patient's oxygenation status occurs. As a general rule, it is estimated that inspired PO₂ declines approximately 5 mm/Hg per 1,000 feet ascended [6]. Unfortunately, no consensus formula exists to accurately predict PO₂ decline or how much the oxygen percentage should be increased to combat this drop in oxygenation [7,8]. Transport team members should rely on their astute assessment of the patient's color, capillary refill, and oxygen saturation results to determine how the patient is tolerating the transport.

PREDICTION OF IN-FLIGHT PO₂

Figure 1

Source: Compiled by Author

Chest tube placement may be accomplished prior to transport to decompress a pneumothorax. The patient who is being transported by air will have expansion of the pneumothorax if it is not treated prior to departure. In cases of an undetected pneumothorax, a flutter valve attached to a one-way valve can be placed to prevent further decompensation in the patient. A closed drainage system should be attached to the chest tube and a one-way valve should be in place to prevent complications should an accidental disconnect occur.

Maintenance of normal vital signs and circulating status is the goal of hemodynamic stabilization. Initially, control of bleeding should be instituted followed by volume resuscitation. Depending on the patient's status, two large-bore IVs should be initiated prior to transport; insertion during transport is very difficult.

Control of bleeding can be accomplished by a number of methods. Pressure dressings can be applied; however, the transport team should ensure that their supply of dressings is adequate in the event that the dressings become saturated and require replacement.

IV fluid resuscitation can be accomplished with one or two IV lines. Murphy's Law applies in the transport environment: if you have only one IV line it will become dislodged, if you have two lines they will both stay in. As noted, plastic IV bags are recommended; the problems of gas expansion are negated and, in cases of significant motion, a glass bottle could easily break.

Blood products can be administered in transport. Care should be taken to prevent the spoilage of blood; a cooler is usually adequate to keep blood cool prior to administration.

Monitoring urine output is one of the best indicators of the patient's fluid status. Insertion of an indwelling catheter will assist the transport crew with frequent assessment of volume status. Additionally, an indwelling catheter will relieve patient discomfort during long transport times.

Cardiac rhythm status should be frequently assessed using a transportable cardiac monitor. Continuous monitoring should commence prior to transport and continue throughout the transfer.

Deterioration of the patient's level of consciousness should be avoided during transport. Many of the stressors of transport induce rises in intracranial pressure. The transport crew should intervene to prevent this occurrence.

Prior to departure, an assessment of the patient's neurologic status should be completed. Utilizing the Glasgow Coma Scale, or other neurologic assessment scales, can assist in providing continuous information regarding patient condition. Medications, such as cranial volume reducers, can be initiated and continued in transport.

Any patient experiencing seizures should receive antiseizure medication. One of the most common causes of prolonged seizure activity is hypoxia; this condition worsens during air transport.

Patients with spinal cord trauma and neurologic deficits need special attention during transport to prevent further deterioration in neurologic status. Spinal precautions should include the use of a backboard and hard cervical collar. As discussed, pressure sore development is a common complication during long transports and care should be taken to pad all bony prominences. Administration of methylprednisolone or similar medication for spinal cord injury is a requisite and should be initiated and subsequently continued throughout transport.

Care in transport of the patient with musculoskeletal injury should include immobilization of fractures, wound care, and the proper administration of medications as ordered or required.

Appropriate splints should be applied prior to departure. Throughout the transport, frequent assessment of distal pulses should be performed. Air splints and pneumatic antishock garments should be monitored for the effects of gas expansion and changes in atmospheric temperature. Traction splints can be utilized; the use of traction weights is generally avoided as the weights can pose a hazard during unanticipated movement.

Extensive wound care is not possible in the transport environment. The transport crew members should act to preserve the integrity of a wound and prevent further contamination. A wound should be dressed and the dressing reinforced as necessary.

Patients requiring transfer for limb reimplantation require special care. The amputated part should be preserved by wrapping it in slightly moistened gauze and placing it into a plastic bag. The plastic bag should then be placed into a plastic container, such as an emesis basin or urine collection cup. This container should then be placed on ice in a cooler. The amputated part should not be allowed to freeze, as tissue destruction can occur, preventing the reimplantation.

Burn wounds causing a disruption of tissue integrity need special attention. The risk of contamination is great and interventions should be undertaken to reduce this risk. Further discussion of the transport of burned patients can be found later in this course.

After the physical needs of the patient who is about to be transported have been met, the emotional and psychologic aspects of transport should be addressed. If the patient and his or her family have fears or questions, intervention prior to the start of the transport can alleviate many of their worries.

It is vital that any counseling or other interventions take into consideration patients' cultural or linguistic barriers. When there is an obvious disconnect in the communication process between the practitioner and patient due to the patient's lack of proficiency in the English language, an interpreter is required. Interpreters are more than passive agents who translate and transmit information back and forth from party to party. When they are enlisted and treated as part of the interdisciplinary clinical team, they serve as cultural brokers, who ultimately enhance the clinical encounter. In any case in which information regarding transport options or expectations during a procedure are being provided, the use of an interpreter should be considered.

Patients who are transported are moved away from their family, friends, and familiar medical care providers. The need to be transported can be interpreted by the patient and family to mean that the patient is dying. While often this is true, patients are transported for a number of reasons with a variety of illnesses and injuries, and most do survive after reaching a healthcare facility that is capable of meeting their needs. The fear of dying is very real to the patient and family and should be addressed immediately after the decision to transport has been made. Healthcare providers cannot overestimate the capabilities of the receiving hospital, but an honest, forthright approach is appreciated by all involved.

The fear of death is only one of many feelings that the patient and family may be experiencing. If the patient is to be transported by air, they may have a fear of flying. The patient and family may be afraid that they will never see their loved ones again, and sometimes the resulting anger and resentment is directed at the referring hospital and healthcare personnel. The patient and/or family may feel that if the transferring hospital was better equipped, the need for the transport would be negated. It is the responsibility of the transporting crew to help the patient rebuild trust in their hospital; if the patient survives, they will most likely return to that home community for further healthcare needs.

The fears that the patient and family feel increase anxiety, which in turn can cause changes in the patient's status. The patient may become tachycardic, hypertensive, and may hyperventilate, all of which will compromise their illness or injury. Another complicating factor is pain; the patient whose pain is not well-controlled is incapable of handling the emotional impact that is placed upon them. It is important that the referring personnel, as well as the transport crew, provide adequate pain relief. The complications of narcotic delivery, such as pupillary constriction, may mask or confuse the signs of hypoxia, but uncontrolled pain is unacceptable and should be managed appropriately.

Family of the patient may develop what has been referred to as "Mecca syndrome." This is an overinflated idea of what can be done for the patient at the receiving hospital. The family wants to believe that the receiving hospital is flawless and can save or cure anyone. While the receiving hospital has greater capabilities than the transferring hospital in terms of diagnostic tools, equipment, and personnel, not all patients can be saved. Again, it is important to openly and honestly discuss the patient's condition and outcome with the patient as well as the family.

A family member may wish to accompany the patient during the transport. While this may initially appear to be a good idea, the transport crew should consider a number of factors prior to giving the go-ahead for an accompanying member. First and foremost, safety should be considered. A family member should have his or her own seat and be able to be secured with approved straps in the transport vehicle. Accompaniment is almost always impossible in a helicopter. Not only is there no room in the cabin for the family, the additional weight may put the helicopter over its operating weight and balance capabilities.

Another important consideration is patient status. A critically ill or injured patient may decompensate during transport and the presence of a family member may be detrimental. The family member will not be able to leave the transport vehicle, and will be present while possibly unsuccessful interventions are performed. Some family members try to be helpful while in reality they are in the way. Another problem is the family member who may develop motion sickness during the transport. The members of the transport team are responsible to the patient who is being transported; they may not be able to assist the family member because they are busy caring for the patient.

If a family member is to accompany a patient, they should receive a complete safety briefing prior to departure. The expectation of what they can and cannot do should be addressed. If time permits, they should be told to gather a few personal items to take with them, as their stay at the receiving facility may be a long one. Family members can be of benefit and included in the transport once these issues have been addressed. A parent is often very beneficial in comforting the pediatric patient. Additionally, once the patient has arrived at the receiving hospital, the parent is immediately available for decision-making and consent. While care is generally not withheld if a parent is not present, their presence is often appreciated by the receiving hospital staff.

The final decision as to whether a family member may accompany a transport is at the discretion of the transport crew. Often, individuals at the referring hospital tell family members that they can, only to be told at the last minute that they cannot accompany the patient. In an air transport, the pilot-in-command has the final decision-making authority. The decision is based upon weather and aircraft performance capabilities. In a ground transport, the transport crew member in charge is responsible for making this decision.

If a family member chooses not to accompany the patient, or is told that they are not allowed to be part of the transport, time should be made available for the family to say their good-byes to the patient. This may be the last time that the family sees the patient alive; the few seconds that it takes to share a last kiss or hug may make a tremendous difference in the family's ability to recover from the death. Prior to departure, the family should receive as much information as possible about the receiving hospital. Maps, telephone numbers, and plans for patient admission should all be included in this information. Additionally, the family should be informed of the estimated time of the transport and when they can expect to be notified of the safe arrival of their loved one at the receiving facility. It is imperative that the transport crew takes into consideration the weather, unexpected delays, and time zone changes. When providing the family with the estimated arrival time, it is always better to overestimate the time rather than to underestimate it. A telephone call that comes 10 minutes later than expected may seem like a lifetime to the waiting family. During this time, the family has imagined all types of horrible things that may have gone wrong in the transport, adding needless stress to their lives.

Studies performed prior to transport depend upon a number of factors. Prehospital transports do not usually have the luxury of diagnostic tools. Patient stabilization is performed with consideration of the airway, breathing, and circulation (ABC), the mechanism of injury, and the history of the illness or injury. Interfacility transports have the time and more capabilities available to the patient.

The patient's illness or injury and current status will impact which studies are performed. The patient's airway should be examined and stabilized. Chest x-rays may be obtained to rule out any pulmonary complications that can compromise the patient during transport. Arterial blood gases will detect any abnormalities in oxygenation that the patient may be experiencing. Baseline blood studies, including hematocrit, will allow for determination of the patient's hematologic status. In emergent situations, only the basic studies that affect ABC should be performed, as time permits. Studies that should be performed if time permits include:

Copies of all laboratory results, electrocardiogram, and radiographs should accompany the patient. These should be well labeled with the patient's name, time of the test, and notation of abnormal results. Additionally, samples of the patient's blood, peridialysis fluid, and spinal fluid should accompany the patient so that further testing may be instituted on these samples at the receiving facility. Any information that is not readily available at the time of the patient's departure patient should be telephoned or electronically transmitted to the receiving facility.

Documentation for transport includes information obtained during the prehospital period, the hospital phase of care, and during all phases of transport. Prehospital transport documentation should include, but not be limited to:

Documentation and information that should accompany the patient who is being transported from one healthcare facility to another should include:

The American Association of Neurological Surgeons recommends expeditious and careful transport of patients with acute cervical spine or spinal cord injuries from the site of injury by the most appropriate mode of transportation available to the nearest capable definitive care medical facility. Whenever possible, the transport of these patients to specialized acute spinal cord injury treatment centers is recommended.

(https://www.cns.org/guidelines/browse-guidelines-detail/3-transportation-of-patients-with-acute-traumatic- Last Accessed: July 22, 2022)

Level of Evidence: III (Strategy for patient management for which the clinical utility is uncertain.)

The neurologically compromised patient is placed at great risk during transfer. Although there are many complications that can develop, the need to transfer the patient prevails, and the transport crew should intervene to limit these untoward problems.

Neurologically compromised patients are greatly impacted by the stressors of flight, including hypoxia, gas expansion, and decreased temperature. Hypoxia causes an increase in intracranial pressure and should be avoided by providing supplemental oxygen. A patient with an open skull fracture and air in the cranial cavity is at risk of herniation with gas expansion. Barotrauma within the ears, caused by gas expansion, will not be apparent in the unconscious patient. A decreased environmental temperature can cause shivering, which increases the patient's oxygen requirements up to 300% greater than normal. Obviously, in a previously compromised patient, this is to be avoided. Dehydration is generally not a problem, unless the patient has been placed under severe fluid restrictions in an effort to limit intracranial pressure. In this instance, the added effects of dehydration may be enough to cause cardiovascular collapse due to an inadequate circulating volume.

The effects of acceleration and deceleration forces on intracranial pressure have previously been presented. The transport crew should be cognizant of these forces and intervene to limit their effects. Patients with a decreased level of consciousness are not able to protect themselves by turning to avoid pressure sore development during long transports. Vomiting, associated with motion sickness, is generally not a problem; unconscious patients do not seem to experience the same responses as conscious patients. However, if the patient who is alert complains of nausea, measures should be taken to prevent the patient from vomiting, which increases intracranial pressure. Finally, noise and vibration increase anxiety and fear and have a detrimental effect on neurologic status.

Stabilization of the patient requires the use of supplemental oxygen, often at 100%. Intubation should be considered for all neurologically compromised patients, and oxygen saturations and end-tidal carbon dioxide levels should be monitored. Fluid status should be monitored to prevent dehydration. Guidelines for the management of cerebral trauma recommend maintaining the systolic blood pressure at 90 mm Hg [9]. Patients with suspected cervical spine injury should be transported on a hard backboard with spinal immobilization precautions. Positioning the patient with the head of the stretcher elevated, if tolerated, will reduce the effects of acceleration and deceleration forces. Prior to transport, pressure areas should be padded, and during transport, the patient's position should be changed within the confines of the transport vehicle. The use of cotton ear plugs can reduce extraneous noise; however, the effects of vibration are unavoidable. Neurotrauma patients receiving mannitol should have a Foley catheter placed for urine drainage and measurement of output volumes.

The use of paralytic agents in the transport environment has come under a great deal of scrutiny. The loss of respiratory drive accompanying neurologic compromise requires that the patient receive continuous ventilatory support. The beneficial effects of neuromuscular blocking agents on intracranial pressure often support their use. A patient who is comfortable and secure can be safely transported, while agitated patients who are out of control can be a danger to themselves as well as the other crew members. It is important to remember that paralysis can cause the patient to appear calm; however, their psychologic needs remain great. Patients who are chemically paralyzed should receive supplemental sedation and analgesia [10].

Because many of the stressors of flight directly impact the respiratory system, the patient with respiratory compromise can be difficult to care for during transport. The predisposition to oxygen desaturation and respiratory failure is high.

Hypoxia is an enormous problem for the respiratory patient. The illness or injury may have caused the patient to experience the four types of hypoxia: hypoxic, histologic, anemic, and stagnant. Coupled with anxiety, fear, and pain that the patient may be experiencing, the patient is at risk for further respiratory insufficiency. Hypoxic hypoxia that occurs during air transport reduces the diffusion gradient for the oxygen molecules. The patient with fluid in his or her alveoli has a greater distance for diffusion, and the patient becomes more hypoxic at altitude. Increasing the oxygen percentage that the patient is receiving will increase the oxygen diffusion gradient, thereby minimizing the effects of atmospheric changes.

Gas expansion within the pleural and abdominal cavities compromises ventilatory effort. Undetected or untreated, pneumothoraces will expand at altitude, leading to worsening respiratory status. Gas expansion in the stomach causes pressure on the diaphragm, limiting respiratory excursion effort and subsequent ventilatory limitations.

Pulmonary secretions increase in tenacity in a low humidity environment. If the patient is prone to developing plugs in the respiratory tree, transport at altitude will enhance plug formation. Patients who hyperventilate lose additional insensible water through their respiratory tree, increasing the risk for volume depletion. This is an additional problem for the patient with a decreased body temperature whose compensatory response to cold stress is to hyperventilate. A decrease in body temperature of 2 degrees centigrade causes oxygen consumption to double. Therefore, the problems of decreased temperature and hypoxia potentiate one another.

If the patient's volume status is compromised, acceleration and deceleration forces can reduce venous return to the heart. This leads to a subsequent decrease in pulmonary circulation, further hampering oxygen diffusion. Additionally, deceleration forces can precipitate pulmonary venous pooling and pulmonary stasis.

Patients transported on stretchers should be secured with safety straps, usually placed over the chest. If these straps are too tight, full lung expansion is prevented. This immobilization also promotes atelectasis and pulmonary stasis.

Motion sickness can be avoided by the insertion of a nasogastric tube. Vomiting, if it occurs, can lead to shortness of breath and respiratory compromise. Both noise and vibration affect the respiratory patient; increased anxiety can increase respiratory rate, leading to further hypoxia and insensible water losses. Noise also limits the ability to fully auscultate breath sounds. An important part of assessment is lost in the transport environment, but efforts at assessment can include monitoring for chest expansion and placing the patient on a pulse oximeter to monitor for signs of oxygen desaturation.

In long transports, respiratory patients may require mechanical ventilator support. During air transport, a ventilator should be continually checked. Tidal volumes can be affected by gas expansion; commonly, the tidal volumes delivered will increase incrementally. For most patients, this increase in tidal volume is tolerable. However, there are some patients who cannot tolerate these minor changes in volume and they subsequently develop pneumothoraces. Additionally, ventilators require up to 15 liters/minute of air flow to function properly. This high flow rate rapidly depletes oxygen supplies, which, if not closely monitored, can be life-threatening to the patient.

Sickle cell patients are at increased risk during air transport as hypoxia predisposes the patient to a crisis. This patient's oxygenation status should be maximized to prevent this occurrence.

Stabilization interventions require that the patient with respiratory compromise be administered supplemental oxygen with an increased oxygen percentage. Restoring optimum circulating blood volume with blood products, if needed, will improve the oxygen-carrying capacity of the blood. The patient should be positioned for best oxygenation and gas exchange. If tolerated and feasible, the head of the stretcher should be elevated. This will allow for improved lung expansion and prevent pulmonary stasis. A pneumothorax should be treated with either a flutter valve, or preferably, a chest tube attached to a one-way (Heimlich) valve. Humidification of the delivered oxygen will reduce the incidence of plug formation; sterile saline can be instilled through the endotracheal tube prior to suctioning. Methods should be employed to limit heat loss in patients, including warming the oxygen, covering the patient with an adequate supply of linen, and maintaining an ambient temperature that is comfortable for the patient instead of the crew.

Cardiovascular patients requiring transport generally fall into two categories: those who are experiencing acute myocardial infarction or acute coronary syndrome, or patients with rhythm disturbances. The stressors of transport are debilitating to these patients if interventions are not performed to minimize the harmful effects.

Hypoxia is a significant complication to these patients due to a compromised myocardium. The compensatory response to hypoxia is tachycardia, which will lead to an increased cardiac oxygen demand. This demand is further enhanced by fear, anxiety, and pain, and supplemental oxygen is a requirement for these patients. Stagnant hypoxia caused by a damaged myocardium further intensifies the damage sustained. Continual real-time cardiac and respiratory monitoring to detect further hypoxic complications should be employed at all times throughout the course of care.

The altitude-induced problems of gas expansion, decreased temperature, and dehydration may or may not impact the patient. Gas expansion within the stomach can lead to vomiting, and this can limit blood flow back to the heart. The insertion of a nasogastric tube would solve this problem. However, the insertion of the tube may be more stressful and harmful to the patient than the risk of vomiting. Patients in severe cardiogenic shock with poor peripheral perfusion may exhibit cool and clammy extremities; core temperature would worsen in this state. During transport, most cardiovascular patients are placed on fluid restrictions. If the patient's condition is severe, the dehydrating environment that occurs in air transport could restrict their fluid status to the point of experiencing cardiovascular collapse.

The effects of acceleration and deceleration forces are prominent in this patient population. Compromised circulation is worsened in the presence of these forces. It is critical that these patients be positioned for maximum cardiac return and function. Cardiac congestion is common with both acceleration and deceleration forces and should be avoided if at all possible.

Patients with a lengthy cardiac history are predisposed to circulatory complications, both centrally and peripherally. The peripheral venous congestion that occurs enhances the risk of pressure sore development during long transports. The application of antiembolism stockings or other types of devices can limit thrombophlebitis formation in the lower extremities.

Cardiac patients require continuous monitoring and cardiac support. The transport team should utilize a cardiac monitor that is not affected by radio transmissions. Pacemakers should be functional in all environments and shielded from emissions. Defibrillators should be used with caution so that damage does not occur to the vehicle or other medical equipment.

In severe cases of cardiac failure, a patient may require an intra-aortic balloon pump. There are transportable pumps now available that have been used with great success. The most important parameter to assess when using a balloon in a patient during air transport is the balloon itself, as the balloon can be affected by gas expansion. Another device utilized in transport to stabilize the critically ill cardiovascular patient is the biventricular assist device, which requires extensive pretransport training and expertise on behalf of the transport crew.

Patients requiring continuous infusions of cardiac support medications are often transported. It is imperative that the crew be aware of this requirement prior to the transport to ensure that an adequate supply of medication is available. This supply should take into account unexpected delays. Transportable infusion devices are useful in delivering the prescribed amount of medication required. One of the classes of medication for which these concepts are critical are thrombolytic agents. Should the team be delayed, additional medication should be available, or, if the supply of the primary medication is exhausted, alternative drugs should be administered according to protocol.

Stabilization of the cardiac patient requires efforts to maximize cardiac function without compromising cardiac reserve. These patients have a fine line under which they can function and all interventions should be instituted to stabilize the patient prior to transport.

Because burn patients who have concomitant trauma have greater risk for morbidity and mortality, the National Expert Panel on Field Triage recommends transfer to a burn center. If the nonburn injury presents a greater immediate risk, the patient should be stabilized in a trauma center and then transferred to a burn center.

(https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6101a1.htm Last Accessed: July 22, 2022)

Level of Evidence: Expert Opinion/Consensus Statement

Burn patients require transport to a burn center whenever they have large, deep burns or burns that involve the face, hands, feet, or joints. The American Burn Association/American College of Surgeons Committee on Trauma published classifications of patients requiring treatment at a burn center, including [11]:

Burn patients are transferred daily from the scene of a fire (or injury) to the local medical care facility. Prehospital care of the burned individual should include:

Airway management is critical in the early moments following a burn injury. Airway edema develops rapidly and early intubation is recommended in patients with signs of impending airway compromise. If intubation is delayed, airway swelling will prevent placement of an appropriate size endotracheal tube and a smaller diameter tube must then be utilized. It is difficult to ventilate a patient through a smaller size tube, thus hindering ventilatory assistance. Patients should be administered 100% oxygen. Oxygen will break the chemical bond between carbon monoxide molecules and hemoglobin, thus improving the patient's oxygenation status.

Patient stabilization also includes circulatory support with either oral or IV fluids. Utilizing IV fluids in burns of greater than 20% TBSA is usually recommended because large volumes of oral fluids are neither tolerated nor absorbed. The 20% TBSA recommendation is simply a guideline. Interventions should be based on each patient's individual needs. Starting IV fluids in the prehospital care environment offers two advantages. First, IV line placement may be more easily obtained as peripheral swelling has not had sufficient time to develop. Secondly, the formulas for fluid resuscitation utilize the time of the burn injury as the starting point for resuscitation; delay in placing the line will make resuscitation efforts more difficult.

Lactated Ringer's solution remains the fluid of choice for fluid resuscitation, although other solutions are utilized in some parts of the country [12]. Fluid needs are based on the patient's weight in kilograms and the percentage of body surface area injured.

The fluid resuscitation formula most commonly utilized for adults with severe burns is the Parkland formula [12]:

4 cc x weight in kilograms x % BSA injured

Half of this calculated amount should be delivered in the first eight hours after the injury, the remainder over the subsequent sixteen hours. As an example, an 80-kilogram man with a 40% TBSA burn would require 12,800 cc during the first 24 hours (4 x 80 x 40). To receive half of this volume in the first eight hours, the patient should receive fluids at a rate of 800 cc/hr. During the second sixteen hours, the fluids would be infused at 400 cc/hr. It is important to calculate this volume correctly and ensure that adequate fluids are available throughout the transport of the patient. Monitoring blood pressure and weight-based urine output should ultimately guide fluid volume administration.

After evaluation of the burn injury, the decision to transport the injured patient to a burn center should be made. Based upon the criteria listed above, referral to the physicians at the facility should be initiated. Further stabilization of the patient, prior to transport to a burn center, should take into consideration the stressors of transport. Interventions should be instituted to limit these problems.

Air transport of burn patients is common as burn centers are often located many miles from the scene of the injury. Inhalation burns and burns of the face, head, and neck all predispose the patient to significant hypoxia. The hypoxia experienced in air transport potentiates this problem significantly. It is crucial that the patient have a secure airway. If the patient is intubated, the tube should be well secured. Burns of the face will weep fluid and render standard adhesive tape ineffective, leading to easy dislodgment of the endotracheal tube. Trach tape is often used to tie the tube in place, preventing this devastating complication.

The patient's head should be elevated as much as possible to limit edema formation. Supplemental oxygen should be continued with 100% oxygen, and cooling and humidifying the oxygen will help prevent airway edema formation. A patient who does not require intubation should be monitored continuously for ventilatory compromise, which may be developing secondary to smoke inhalation. This patient should always have an intubation set readily available at the bedside.

Gas expansion in the abdominal cavity is complicated by the development of an ileus. Ileus formation is quite common following a burn injury and will prevent the passage of gastric contents. A nasogastric tube and suctioning will help limit these effects, reducing the risk of vomiting and aspiration.

Hypovolemia is one of the most common problems occurring after a burn injury. Patients with partial thickness burns are at greatest risk of significant fluid loss. This loss of fluid, coupled with the dehydration that occurs in air transport, further compromises the patient's volume status. Evaporative losses are enhanced in the dry cabin environment, further increasing the patient's need for hydration. Prior to transport, a patient should be stabilized with IV fluids and all wounds should be covered with absorbent dressings. The transport team should be aware of the patient's fluid requirements. When determining how much fluid to take in transport, the patient's needs are calculated and that amount is increased again by half. A Foley catheter should be placed to monitor urine output, as this is the best indicator of the patient's response to fluid resuscitation efforts [13].

One of the biggest problems for the burn patient that occurs in all modes of transport is a subnormal temperature. With the loss of skin from the burn injury, the patient has lost his or her temperature regulating mechanism. In the best of situations, most burn patients become hypothermic, and the transport environment is not considered to be optimal for these patients. It is important that efforts be undertaken to keep the patient warm. This includes covering the wounds with dry dressings. When these dressings become saturated they should be reinforced with additional dry dressings. The patient can be wrapped in a rescue blanket; however, there are reported cases of patients becoming overheated in these blankets when wrapped too tightly. Additional blankets and linen will also help keep the patient warm. Covering the head with a hat is beneficial, especially in children and the elderly.

The hypovolemic shock that develops after a severe burn predisposes the patient to complications of acceleration and deceleration forces. The patient should be adequately fluid resuscitated to assist in combating these forces. Positioning the patient with the feet elevated will prevent blood from pooling in this region.

Immobilization of the burned individual enhances edema formation and can cause the extent and depth of the burn to increase. Lying on burn wounds is not only uncomfortable for the patient but limits circulation to the injured area. All wounds should be dressed prior to transport; these dressings need to be checked periodically to ensure that they have not become too tight from increased edema formation. Elevation of dependent limbs will limit edema formation, and it is important to check that all rings, necklaces, and other constricting devices were removed in the prehospital environment.

As noted, ileus formation promotes nausea and vomiting; however, a nasogastric tube to suction will limit these effects. The noise and vibration from the transport may increase the patient's stress level and efforts should be made to limit as much environmental input as possible.

Additional considerations in the transport of burn patients include pain control and the prevention of infection. Burn patients have a significant amount of pain, coupled with the devastating psychosocial and emotional impact of being burned. Small frequent intravenous doses of narcotics are useful in controlling some of the pain the patient is experiencing. Burn patients have very high metabolic rates that increase the metabolism of the narcotics, causing their length of action to decrease dramatically. Administering doses every 15 to 20 minutes is not uncommon. Therefore, it is important to have an adequate supply of narcotics available for the estimated length of transport. Most transport programs carry a limited supply of narcotics, so securing additional narcotics from the transferring hospital may be necessary. Additionally, the patient may be administered sedative agents to decrease awareness of the environmental input.

The transport environment is not a clean, sterile environment. Meticulous care should be provided to limit contamination of the patient's wounds. Applying topical antibiotics has the advantage of limiting the risk of wound contamination; however, these topical agents should be removed upon arrival at the burn center, delaying other interventions. In determining if topical agents should be used, each individual case should be considered and recommendations from the burn center should be utilized.

Transporting the burn patient requires a significant amount of preplanning and stabilization, as well as a great deal of work during transport. With proper stabilization and interventions, most burn patients tolerate the transport without complications.

The multiple trauma patient has many problems that impact most body systems, thereby increasing the chance that the stressors of transport will be harmful to the patient. Transporting the patient by air is often required due to the large distances between trauma centers. This mode of transport increases the risk of compromise, and interventions need to be performed to reduce these risks.

Hypoxia is common in any patient sustaining chest trauma. Pneumothorax will compromise ventilatory effort and the patient should be decompressed with either a flutter valve or chest tube. Patients with chest wall injuries will have a decreased chest excursion effort and will need to be positioned for maximal ventilatory function. Dyspnea may be a sign of increasing hypoxia, but the transport team should also rule out the possibility of a pulmonary embolus as the cause of the hypoxia.

It is important to remember that gas expansion can compromise physiologic functioning of the patient, but it can also impact equipment such as air splints. During transport, these pieces of equipment should be continually checked for an increase in pressure on the involved extremity, which may harm neurovascular function. Wounds (e.g., bowel rupture) that lead to the formation of free air within the body cavities should be decompressed as the free air will expand causing further damage. Gas expansion within the stomach will predispose the patient to vomiting associated with motion sickness.

Hypovolemia, secondary to blood loss, is a common complication of trauma. Additional fluid loss in the form of evaporative losses in a pressurized aircraft will further jeopardize circulatory function. Patients in hypovolemic shock are also predisposed to the complications of acceleration and deceleration forces. Ensuring adequate fluid replacement prior to departure will prevent this complication.

Patients with traumatic injury to the central nervous system may have lost their thermoregulatory capabilities, enhancing the risk of hypothermia in transport. IV fluids should be warmed prior to administration and patients should be adequately protected from evaporative and radiated heat losses. Removing any wet or saturated clothing or linen should be done prior to departure.

Trauma to the musculoskeletal system requires the placement of splints and other stabilizing devices. Casts should be bivalved to prevent edematous compromise and traction devices should be monitored for causing circulatory impairment. As mentioned, traction weights should not be utilized in the transport environment, as these become a hazard during turbulence and motion.

Most trauma patients will have a nasogastric tube inserted during initial resuscitation. This tube should remain in place for transport to limit the risk of vomiting with motion. Any trauma patient who has had their jaw wired shut should be transported with a pair of wire cutters at the head of the stretcher.

With a multitude of equipment, lines, and interventions, multiple trauma patients require a tremendous amount of care during transport. Administering fluid, blood, and medications is time-consuming. When coupled with frequent vital sign checks and checks of equipment function, the transport crew is constantly working to stabilize the patient. To have a family member accompany the patient in this situation can be a benefit and a detriment. On the positive side, the family member can assist with the emotional needs of the patient, while on the negative side, they may be in the way of the crew, preventing their attention from being focused completely on the patient.

Transport crews will often say that the most challenging and the most rewarding transport is the trauma patient. The time in transport goes quickly and a number of interventions are performed. Being involved in a transport that can mean the difference between life and death of a patient is a very exhilarating experience and one on which many transport crew members thrive.

Transporting the pediatric patient offers a unique set of challenges for the transport crew. Patient size is an advantage, as children weigh less and are more easily moved from one place to another. However, because they are small, children are at risk for more rapid decompensation, without the reserves to help them tolerate the stressors of transport.

Hypoxia develops more rapidly in the pediatric patient. Children have smaller vital capacities and a smaller surface area for gas exchange. An additional complicating factor can be that the child will refuse to utilize an oxygen mask. This potentiates the hypoxia as well as increases the risk of combativeness that is precipitated by hypoxia. If a child refuses a mask, oxygen tubing can be held in front of the child's face and oxygen blown at his oral and nasal airways.

The child's gastric cavity is relatively small; therefore, the child is more prone to complications of gastric gas expansion. Gastric and bowel function are irregular, and it may take a long period of time for food to pass into the bowel, increasing the risk of aspiration. Most pediatric nasogastric tubes available do not have a sump attached; these tubes can clog and suction is more difficult to apply. Occasionally flushing the tube with a small amount of water will assist with emptying the gastric cavity.

Pediatric patients are mouth breathers, which predisposes them to dry mucous membranes. The dry environment in a pressurized aircraft will potentiate this problem. For example, a child with respiratory syncytial virus who has thick tenacious mucous will have increasing difficulty in clearing secretions in this type of transport. Instilling saline into the nasal and pharyngeal passages will assist in thinning the secretions and opening the airways.

Children have a large body surface area to body mass ratio. This predisposes the child to increased evaporative heat losses and subsequent hypothermia. Transporting a child in a cool environment will enhance hypothermia development, and it is crucial that efforts are made to keep the child warm. With the large surface area of the head, placement of a stocking cap is quite successful in keeping the child warm. Rescue-type blankets can be utilized. However, with the large radiated heat loss a child produces, it is easy for the child to become overheated while wrapped in such a blanket. If a rescue blanket is used, it should be placed over the blankets that cover the child, and the edges should not be tucked in around the child.

Children are prone to the same effects of acceleration and deceleration forces as adults. The advantage of transporting a child is that their position can be more easily changed within the confines of the transport vehicle, including elevating the head of the child during landing (deceleration) to limit these forces on intracranial pressure.

Immobilizing the pediatric patient is often challenging, as the child may be too small to fit within the approved stretcher securing belts. Therefore, the crew members should be inventive in their immobilization of the child. Restraining devices need to be secure enough to provide for the safety of the child, while at the same time, not compromising the child's cardiovascular function. Restraining devices that are too tight across the chest of a child can hinder respiratory function and should be avoided. One method of transporting the very small child is to utilize a child's car seat. This offers two advantages. First and foremost is that the child is well secured and safe in the car seat. Secondly, most children feel comfortable in their car seat and may be more cooperative with this increased sense of security.

Noise, vibration, and motion sickness present the same complications in the pediatric patient as are found with adults. Providing diversionary activities to a child may help remove some of these stressors. Fully explaining all noises and procedures to a child may also reduce their fear and anxiety.

Ensuring adequate oxygenation of the child may require that the patient be intubated prior to departure. The challenge of intubating children in a controlled environment is increased many times in the transport environment and should be avoided at all costs. Insertion of a nasogastric tube may be at the discretion of the transport crew; consideration of the child's condition and time since the last meal can be included in the decision-making process. Ensuring that the child has at least one good IV line should be undertaken. Providing the young child with dextrose-containing maintenance fluids will prevent hypoglycemia from developing in transport. Keeping the child warm with hats and blankets will often provide comfort to the child. Transporting with the child's own blanket can also help keep the child warm and provide a sense of security. When placing the child on the transport stretcher, location of the safety straps should be double-checked to prevent placement over the child's chest wall.

Neonates often require transport when born prematurely or when diagnosed with congenital abnormalities. These small individuals are predisposed to hypoxia, hypothermia, and fluid overload states. Specialty-trained neonatal nurses are commonly utilized in these transports as their expertise allows them to carefully monitor the child and the effects of transport on that child. The use of a transport isolette unit provides the child with a safe, warm environment that can limit the harmful effects of transport.

Transporting children requires that the transport personnel be aware of the unique anatomic and physiologic variances of children. With consideration of these special needs, children can be safely transported long distances with minor impact upon their condition.

Adult trauma victims older than 55 years of age are at increased risk for injury and death, and low-impact mechanisms (e.g., ground-level falls) might result in severe injury in this population. The National Expert Panel on Field Triage concluded that advanced patient age should lower the threshold for field triage directly to a trauma center.

(https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6101a1.htm Last Accessed: July 22, 2022)

Level of Evidence: Expert Opinion/Consensus Statement

The increased incidence of acute and chronic illnesses in the elderly makes them frequent candidates for transport. For many years, when the elderly became sick, they remained at their local healthcare facility. However, as more sophisticated medical therapies have been developed and are being utilized in the elderly population, these patients are being transported. The multitude of health problems in this population increases their risk for developing complications during transport.

With advanced age comes an increase in underlying disease processes, which should be considered when assessing the elderly patient. A decrease in pulmonary compliance and total lung surface area enhances the risk of hypoxia. Coupled with pre-existing poor respiratory function, elderly patients need aggressive therapies to prevent the problems of hypoxia. Confusion, a sign of developing hypoxia, is often misinterpreted as senile dementia and therefore determined to be acceptable. The transport team has a short interaction with the patient and is not able to fully assess the patient's neurologic status. An accurate history regarding the patient's status from the referring hospital staff will assist the transport members in precisely assessing changes in the patient's condition.

The problems of gastric gas expansion are commonly not reported by the elderly patient, as abnormal bowel function and increased gastric gas are common to this population. Dehydration can potentiate a pre-existing contracted fluid volume state in the patient. It is imperative that adequate fluids are provided, while avoiding fluid overload states. Often fluid status is difficult to assess in the elderly patient, and this difficult assessment is increased in the transport environment. If the ability to assess heart and lung sounds is lost, other parameters, such as skin turgor, blood pressure, and urine output, can be utilized as indicators of fluid status.

The loss of subcutaneous tissue that occurs with aging predisposes the patient to hypothermia. The patient should be kept warm with blankets, clothing, and hats. Limiting out-of-hospital time will decrease the environmental changes that a patient experiences in transport. The better stabilized the patient is prior to transport, the more efficient the transport process.

As the vascular system stiffens, cardiac return and output become compromised. Peripheral circulation decreases, and the ability to withstand acceleration and deceleration forces is diminished. Significant fluid shifts can compromise both cardiac and respiratory function. Additionally, the patient's protective mechanisms are less adaptive, preventing self-protection measures. Positioning the patient to diminish these effects is beneficial. The head of the stretcher should be elevated if possible, and during acceleration, the feet can be placed on pillows.

A unique challenge in the elderly patient with pronounced curvature of the spine is immobilizing the patient on a backboard, should a spinal column injury be suspected. This increased curvature prevents the patient from being secured in a position of good cervical alignment. Additionally, this curvature increases the risk of pressure sore development in areas that are not normally at risk for this complication.

Immobilizing the elderly patient also increases the risk of the patient developing poor venous return and edema formation. Stabilization measures can include the application of antiembolism stockings to assist with circulatory support in this patient population.

While it may seem that diminished hearing and eyesight may be an advantage in reducing noise and vibration input, the opposite is true. A patient who cannot fully comprehend the environment will become increasingly confused and disoriented. The patient may not have heard the briefing offered by the transport crew. Elderly patients' pride may prevent them from admitting to this deficiency. Continual reorientation and explanation can help lessen this confusion.

Elderly patients also have a decrease in both the primary response and cellular immunity that acts to protect them from infection. While this is not a significant problem in transport, it should be considered and all interventions should be performed with this concept in mind. Minimizing the risk of infection is formidable in the transport environment, as handwashing is not feasible and the disposal of contaminated items is not possible. Limiting the patient's exposure to potentially infectious situations should be considered at all times.

Stabilizing the elderly patient for transport is quite similar to that for other patients. Supplemental oxygen should be administered, IV lines should be started and well-secured, and Foley catheter and nasogastric tube placement should be considered. Keeping the patient warm and in a position of comfort will improve the patient's ability to withstand complications as well as provide a sense of security. Optimum long-term outcomes of the elderly are less frequent than in younger populations; therefore, it is crucial that the family members be allowed time with the elderly individual prior to transport. The referring hospital personnel can include these individuals in preparations for transport to provide the family members with a sense of being able to do something for their loved one.

Transporting the elderly patient is not tremendously difficult. However, when the patient does decompensate in transport, it is important that the transport crew be aware of the medical-legal aspects of their care when determining what interventions will be utilized to further stabilize the patient. Awareness of the patient's wishes and advance directives should be an important part of the medical report given by the referring hospital personnel to the transport crew.

According to the National Expert Panel on Field Triage, all pregnant women at greater than 20 weeks' gestation who suffer trauma should be transferred to a trauma center or hospital capable of timely and thorough evaluation and initial management of potentially serious injuries.

(https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6101a1.htm Last Accessed: July 22, 2022)

Level of Evidence: Expert Opinion/Consensus Statement

Transporting the high-risk obstetrical patient involves the stabilization and transport of two patients, the mother and the fetus. The sudden, precipitous delivery of the fetus is always a possibility and should be prepared for. If possible, delaying the delivery would be preferable to all individuals involved in the transport. Contraindications to transport, including acute fetal distress, uncontrolled maternal bleeding, and imminent delivery, may postpone the transport until such time that both the mother and fetus (or newborn) are stabilized.

During pregnancy, increased oxygen consumption occurs, predisposing the woman to hypoxia during times of stress. Hypoxia causes uterine irritability and predisposes the patient to premature labor. For the patient being transported for premature labor, this is a significant consideration. Providing supplemental oxygen throughout the transport and positioning the patient in the left lateral decubitus position will enhance the patient's oxygenation status. If exposed to hypoxia for a short duration, the fetus will experience minimal effects. However, as maternal hypoxia increases, fetal distress will develop as evidenced by a decrease or increase in fetal heart tones.

Gastric gas expansion causes pressure on the diaphragm, which is elevated during the third trimester. This leads to the development of dyspnea, and further increases the risk of hypoxia development. Gastric gas expansion can also place pressure on the uterus, increasing uterine irritability. Insertion of a nasogastric tube to suction will help relieve this development as well as reduce the risk of vomiting during turbulence.

During pregnancy a woman develops a 40% to 50% increase in circulating blood volume, although this is mostly an increase in plasma. Dehydration can cause a woman to become volume depleted rapidly, and volume depletion predisposes the uterus to preterm labor. Increased fluid volumes are required during pregnancy, and this volume should be increased even further during transport.

Of all patient types transported, the one who prefers the decrease in ambient temperature is the pregnant patient. Massive vasodilation occurs during pregnancy so the woman is continually complaining of being warm. This cool environment has little effect upon her physiologic functioning and will increase patient comfort. However, should the fetus be delivered, this cool environment can be harmful to the neonate's outcome. The neonate should be immediately dried and wrapped in blankets to help maintain body temperature.

Fluid volume shifts associated with acceleration and deceleration forces can lead to a decrease in uterine blood flow. Physiologically, the uterus is considered a nonessential organ in the body's response to shock and low-flow states, thereby leading to fetal distress when circulating volume is shifted towards the core circulation and away from the uterus. Placing the patient in the left lateral decubitus position will improve venous return and the ability to withstand these forces.

Most stretcher securing devices are designed to function properly when the patient is in the supine position. The pregnant patient who is transported in the left lateral decubitus position is more difficult to safely secure to the stretcher. Additionally, if the stretcher is located on the right side of the transport vehicle, the patient will be facing away from the transport crew during the transport. This obviously presents difficulties in assessing the patient. Turning the patient may seem the obvious answer; however, this is nearly impossible in many helicopters and airplanes used in air transport. Therefore, immobilizing and securing the pregnant patient presents one of the more challenging problems in transport.

A decrease in gastric motility that occurs during pregnancy predisposes the patient to vomiting with motion. This can be avoided with the insertion of a nasogastric tube, as previously discussed. Patients with pregnancy-induced hypertension (toxemia of pregnancy) are at increased risk of experiencing nausea and vomiting with motion. Hypertension, which can accompany vomiting, is to be avoided in these patients, and efforts to reduce this untoward complication should be considered a high priority.

Noise and vibration also can compromise the patient with toxemia of pregnancy. The patient may be increasingly sensitive to environmental input, predisposing her to seizure development. Reduction of noise with ear plugs can help reduce this input and limit her exposure to increased risk. Dimming the cabin lighting will also help in reducing the risk of seizure activity, although this may hamper the transport team's capabilities in accurately assessing patient color.

Stabilization prior to transport requires accurate assessment of the patient's status and interventions to maximize her physiologic functioning. High-flow oxygen, preferably by non-rebreather mask, and appropriate management of her fluid status will heighten her ability to withstand these stressors. Medications to control preterm labor can be instituted and continued throughout the transport. Seizure precautions should be initiated prior to transport and antiseizure medications should be readily available.

Delivery of an infant is also a consideration. The transport crew should have sufficient training in the delivery of an infant, as well as training in stabilization measures necessary to support the life of the child. Delivery of a child requires that the transport be diverted to a closer facility if additional stabilization measures are required for the infant. Knowledge of the resources available en route is imperative during the pretransport planning. Appropriate size equipment for airway and circulatory management should be easily accessible in the transport environment; this should include, but not be limited to, infant size laryngoscope blades, infant endotracheal tubes and suction catheters, infant intravenous catheters, and intravenous fluids used for neonates. Methods of maintaining the child's body temperature should be available, including rescue blankets and stocking hats.

The emotional impact of transport on the high-risk obstetrical patient is extreme. Time for interactions with other family members should be made available. The woman's original birth plan is no longer a reality and the patient and her family should be assisted in understanding the necessity of transport. While most individuals want the transport to occur because they believe that it is best for the outcome of the child, removing the patient from her loved ones remains difficult. The family that is left behind needs assurance that they will be notified immediately upon the patient's arrival at the receiving facility. If the patient's condition warrants, she can be the one to place this important telephone call.

During the transport itself, it is difficult to fully assess the patient. As mentioned earlier, she may be facing away from the transport crew. The ability to hear fetal heart tones with a fetoscope is negated by the noise inherent in the transport vehicle. An obstetrical Doppler monitor should be considered an essential piece of equipment to allow for the monitoring of fetal heart tones. Fetal heart tones are the only indication of fetal status available and are crucial to ascertain, at a minimum of 15-minute intervals.

Preparing for a high-risk obstetrical transport requires a great deal of planning. Equipment should be readily available, training should be current, and the transport crew should be prepared to deal with all consequences. Fortunately, the majority of obstetrical transports occur without utilizing all of this preparation. When the patient is stabilized appropriately and thoroughly, the majority of transports occur smoothly.

As discussed, continual assessment and interventions during transports are performed to keep the patient as stable as possible. The transport crew's responsibilities are performed with limited resources in a less-than-optimal environment. The advantage of transport is that there are usually no other distractions, and the patient is the crew's sole medical responsibility.

To maintain patient stability, the transport crew functions under standing transport protocols as well as physician orders. The interventions that can be undertaken include, but are not limited to, airway stability, suctioning, fluid management, performing advanced life support measures, administering medications, and either chest tube or flutter valve insertion. Monitoring the patient involves the utilization of a cardiac monitor, pulse oximeter, and capnography. Doppler monitors are employed to assess pulses when auscultation is difficult. Analysis of blood results is possible utilizing transportable bedside testing devices.

Vital sign assessment should be completed at frequent intervals to allow for early detection of patient deterioration. The patient's level of consciousness should be frequently monitored; hypoxia is a common cause of neurologic decline. Fluid intake and output should be frequently checked, as gas expansion occurring in air transport can cause changes in the fluid infusion rates.

The transport team is involved in the stabilization of the patient as previously discussed. The stressors of transport are reviewed and the patient stabilized to minimize these effects. During transport, the team should continually assess for the effects of these stressors and intervene as necessary. Releasing a small amount of air from the air splints during ascent in air transport will need to be followed with inflation during descent. Prevention of these untoward complications is the goal the crew works to attain.

All care during transport should be documented. The transport form should become a permanent part of the patient's chart at the receiving facility. The receiving staff should be familiar with its design in order to obtain information regarding the patient's response to transport. Any unusual events should be noted and the patient's response to these events recorded.

Throughout the transport, the team should be prepared to deal with the worst possible outcome. Without ancillary help or extra equipment available to the crew, they should be able to act and intervene rapidly and efficiently within the confines of their working environment. In unforeseen emergencies, when sophisticated medical equipment and personnel are critical, diversion to a closer facility may be necessary. It is important that the crew knows the location of these facilities to prevent unnecessary delays.

The communication loop begins when the transport is initiated. It is complete when the report has been given at the receiving hospital and the documented paperwork is integrated into the patient's chart. This process includes a number of individuals, and effective communication at each level is imperative. A break in this process can increase the risk of complications.

When a call for transport is placed to a transport program, whether it be air or ground transport, information regarding the patient's status is shared and should be based on physician-to-physician contact. Although direct physician communication may take place at a later time, the medical control individual responsible for the transport is taking on the legal ramifications mandated by law. Once the patient's status has been provided, the requirements for pretransport stabilization should be communicated to the care providers. The transport team should be informed of any special needs that the patient will require. This may include the use of specialized equipment, which is not normally carried in the transport vehicle. The transport team should receive a complete report from those individuals who are providing the initial stabilization measures to the patient. During transport, the transport team may or may not be in direct contact with their base station. The team is directed to function under standing orders and written protocols. Should the team need to deviate from these protocols, accepted standards of practice and safe and reasonable actions should be employed.

Upon arrival at the receiving facility, the transport crew should provide information about the patient's condition from the time of the initiating event to the time of arrival of the patient at the receiving hospital. Much of this information is secondhand, so the communication process should be flawless to ensure that important pieces of information are not lost. Finally, all information should be fully documented as a permanent form of communication.

As noted, before this process is complete, the patient's family and the referring facility should be notified of the safe arrival of the patient. Only after all involved persons are notified is this loop considered complete.

Communication techniques and technology are too extensive to be covered here; the reader is referred to a number of excellent references if more in-depth information is desired. Regardless of the technology utilized, every effort should be undertaken to protect the patient's confidentiality based upon the Health Insurance Portability and Accountability Act (HIPAA) requirements. The patient's name should not be used, and other identifying features should be avoided. This is especially difficult during an incident with a high-profile patient or during a media event.

All transport programs have a medical control officer. The organization of this control varies from system to system. On-line medical control is the direct communication between the transport personnel and the physician (or physician-surrogate) via radio or telephone for the purpose of providing orders for patient care.

Off-line medical control includes those administrative functions that are necessary to ensure the quality of care. Each medical control officer is a physician who is directly responsible for the transport crew and their actions. It is the medical control officer's responsibility to ensure proper training, orientation, development of protocols, and ongoing continuing education.

Most transport programs have recurring "run reviews" in which the transport is reviewed for appropriateness, timeliness, and care delivered in transport. These run reviews are directed by the medical control officer and assist in providing ongoing education for the crew members. Additionally, this review allows for a critique of current protocols and can provide the impetus for change that may be necessary to meet the changing technology of medical care.

Ground transports are unique in that they can be initiated by the general public through emergency medical care systems, such as the 911 system. Air transports are generally initiated by healthcare providers after initial evaluation of the patient's status. Public request for medical care often puts the transport crew members at a disadvantage, as the information they receive may be inaccurate and/or incomplete. Therefore, ground transport crew members should perform astute assessments while under the watchful eye of the patient's family, friends, and the general public. To work in this type of job, the individual should be self-assured about their abilities and confident of their responsibilities.

Emergency medical care systems are well developed in the United States. Patients are often within minutes of being treated by individuals trained in basic life support measures. A tiered layer of response is generally utilized; if the patient's condition warrants more intensive treatment, individuals trained in advanced life support measures are rapidly called to the scene. This system maximizes healthcare resources without wasting limited healthcare dollars. In 2019, the Centers for Medicare and Medicare Services (CMS) introduced the Emergency Triage, Treat, and Transport (ET3) model, a voluntary program in which Medicare will pay participating ambulance suppliers to either transport Medicare beneficiaries to the emergency department, transport to a primary care or urgent care clinic, or provide care at the location. This model is intended to give ground transport and local 911 dispatches greater ability to triage patients, and is designed to prevent unnecessary emergency department admissions, thereby improving quality of care and lower costs [17].

Ground transport may also be utilized in transporting a patient from a small facility to a larger hospital with more sophisticated resources. These transports require personnel with a more advanced level of training; it is important to remember that a patient cannot legally be transported in an environment that does not provide the same level of care as the patient had been previously receiving.

While ground transports do not have to contend with the stressors of altitude changes that occur in air transport, the other stressors (e.g., acceleration, deceleration, prolonged immobilization) remain factors throughout the transport. It is the feeling of many seasoned transport personnel that caring for a patient while going across town in a ground ambulance is equally as difficult as caring for a patient in a helicopter. The constant forward, backward, and lateral movements of both environments make caring for the patient a true challenge.

Most established transport programs utilize pressurized aircraft for the transport of patients. This pressurization system allows for the maintenance of a reasonable cabin pressure altitude, minimizing the effects of altitude-induced changes on the patient. However, there are still patients who are transported in unpressurized aircraft, and it is these patients who are greatly impacted by altitude changes.

If a patient is to be transported by a fixed-wing aircraft, the patient should be stabilized with consideration of the stressors of altitude. The length of the transport is also an important consideration; the longer the transport time, the longer the exposure to the stressors of altitude and the greater the risk of complications. It is also generally true that the longer the transport, the higher the altitude at which the aircraft will travel, increasing the risks of hypoxia and gas expansion. Each patient should be continually assessed for these risks as they can develop insidiously.

Caring for the patient in a fixed-wing transport is often easier than in other transport environments. The cabin space is larger than in a helicopter, allowing for additional equipment and increased room to maneuver. Many fixed-wing aircraft dedicated to air transport are retrofitted with mechanical ventilators, large oxygen and air tanks, hospital-grade suction, and alternating current (AC) power sources. These aircraft are often referred to as flying ICUs. This sophisticated environment demands that the transport crew has additional training in the use and care of the equipment on board. Many transport programs utilizing mechanical ventilators include a respiratory therapist as a part of the transport crew. This individual is responsible to care for the patient's airway and ventilatory status.

Fixed-wing transports require the use of ground ambulances to transport the patient from the hospital to the airfield and back to the hospital at the receiving end. This system requires good communication with ground-based personnel to prevent unwarranted delays in the arrival of these ground units. Time is of the essence and the ground ambulance should be present to assist with moving the patient in an expeditious manner.

One of the most important aspects of helicopter transports is the safety of the individuals on the ground when the helicopter is landing and taking off, which is discussed later in this course. Transporting the patient in a helicopter is a challenging and difficult responsibility. Access to the patient is limited; often only the patient's upper torso and head are accessible. Thorough pretransport stabilization is critical if the patient is to be transported safely. While the length of transport is generally short (as compared to fixed-wing or ground transports), the patient is at risk during the entire transport.

The effects of altitude on the patient can be minimal to extensive. As mentioned, helicopters are not pressurized. Therefore, if the helicopter must ascend in altitude to clear mountain passes or other obstacles, the patient will experience both hypoxia and gas expansion. Generally, the pilot of the helicopter will choose a flight path that has minimal altitude changes, thereby limiting patient complications. However, care in transport requires that the transport crew be aware of these risks and intervene as necessary should they become a factor.

With restricted access to the patient, in-flight care is limited, requiring the crew to perform frequent assessments. Care in-flight is often limited to ABC support, as well as medication administration. Changing patient position and other comfort measures may need to be withheld. However, the crew should remember, as in all transports, that if the patient is anxious and frightened, measures to calm the patient should be performed as part of routine care.

Statutory law regulates the equipment required in ground transports. In many states these statutes also regulate the operation of air ambulances. The minimum equipment needed for maintaining the stability of the ill or injured patient is listed in Table 3. Additional items can and should be included as the patient's condition and needs dictate. Equipment utilized in the transport environment should meet specific criteria, including but not limited to being: lightweight; portable; easy to secure; easy to clean; able to be utilized with battery backup; able to be used both in and outside the transport vehicle; and able to withstand the stressors of altitude and movement.

Medical crew members should be familiar with the operation of the equipment in the transport vehicle, as well as be able to repair the equipment should it fail. The crew members should ensure that an adequate supply of disposable equipment is available to last for the length of the transport, with consideration of possible delays that may extend the projected transport time.

All equipment utilized in the transport environment should be easily secured. Equipment packs made of soft material are generally utilized for disposable equipment. If the equipment requires a power source, a backup battery source should be available if the power fails. The team could utilize hand-powered devices, such as resuscitation bags for ventilating the patient, if a ventilator failure were to occur. All equipment should be protected from electromagnetic interference. If not, radio transmissions may render the equipment nonfunctional.

In air transport, equipment weight is also an important factor. Placement of heavy items is at the discretion of the pilot-in-command; the weight and balance of the aircraft should be maintained for safe performance. Equipment that is permanently secured to the aircraft (e.g., ventilators, suction units, oxygen tanks) are placed in a position offering the crew some leeway in the placement of other disposable equipment packs.

It is important that the oxygen source in the transport vehicle be operating appropriately. The volume remaining in the tanks should be checked prior to each departure. These tanks can be replaced with full tanks to ensure an adequate oxygen supply throughout the transport. Attachments for the humidification and warming of the oxygen are available and should be utilized as the patient's condition warrants.

Altitude impacts flow rates of oxygen cylinders. Table 4 demonstrates this effect on flow rates. If transporting the patient by air, it is important that the crew utilize this information when calculating oxygen supply. If standard sea level flow rates were utilized, the oxygen supply would run out before the calculated time, putting the patient at significant risk.

Other transport equipment that may be utilized includes infusion pumps, Doppler monitors, pulse oximeters, and cardiac monitors. Monitoring of oxygen saturations and end-tidal carbon dioxide levels is critical when auditory cues are diminished. The crew should know the limitations of each piece of equipment and not depend solely on the equipment but rather on their assessment of the patient when making decisions regarding interventions.

When equipment packs are prepared, the crew generally packages items together to maximize the efficiency of their actions. For example, a nasogastric tube is packaged with an aspirating syringe, gel for insertion, adapters for connecting the tube to the suction source, as well as tape. When a nasogastric tube is to be inserted, the team has everything together in one package and does not need to open numerous packs in search of a piece of equipment.

Medications are usually removed from their standard packaging. The boxes that most medications come in are bulky and, in the event of a respiratory or cardiac arrest, make a large mess in a small place. It is important for the crew to check the medication labels closely, as should be done for any patient anywhere.

Transport packs are usually developed for individual patient needs. Many programs have developed a pack for burn patients, neonates, obstetrical patients, and pediatric patients. Knowing that the patient is 8 years of age alerts the transport crew to the need for the pediatric pack, and this can be loaded on the transport vehicle prior to departure. This limits the amount of excess equipment transported on each and every transport. Additionally, equipment is commonly placed in a backpack style pack so it can be easily carried into and out of remote locations.

Safety in transport should be the primary concern of all individuals at all times. Most accidents occur during helicopter transfers; however, a high level of risk is associated with all types of transports. Safety concerns should focus on all aspects of the transport, including both patient and crew safety issues. It is imperative that all personnel develop a strict policy to ensure their safety and the safety of others.

Safety restraints should be utilized at all times. This means that the patient should have restraining straps secured throughout the transport and that the crew wears seat belts at all times. Crew members often become complacent about seat belt use, removing the belt during the transport to allow for more movement around the transport vehicle. In an aircraft, the pilot should always ensure that everyone is secured prior to takeoff and landing; it is during the transport when these measures are neglected. Clear air turbulence can cause significant injury to unrestrained individuals at any time during a flight.

All equipment should be secured, and securing devices should be double-checked throughout the transport. Equipment that can present danger to the patient or crew should be placed away from individuals' heads, placing it either near the patient's feet or, preferably, on the floor. Disposable equipment in soft packs will limit the dangers inherent in hard objects.

The crew should brief everyone prior to each departure. The pilot should be informed of the patient's condition, and the patient should be informed of his or her responsibilities in the event of an emergency. Family members who accompany a transport should be briefed as to the location and function of emergency exits and the need to utilize safety restraints throughout the transport.

No smoking should be allowed in or around a transport vehicle. The team should know where fire extinguishers are located and how they work. Crew members should avoid flammable clothing such as nylon and polyester, which, if ignited, can cause deep, full-thickness burns.

The crew should be trained in the proper functioning of emergency exits and emergency procedures. The emergency exits should be clearly marked and should be kept clear of extraneous equipment. Emergency procedures should be practiced on a regular basis as part of continuing education.

The transport crew's first responsibility in an emergency is to themselves and then to the patient. The crew should remain safety conscious at all times. It is worth mentioning that the occupational injury rate for EMS workers in the United States is the highest of any reported to the Department of Labor [14,15].

As previously discussed, in 1985 the transport of patients was addressed in the Consolidated Omnibus Reconciliation Act (COBRA). Subsequently, in 1995, these regulations were amended as a part of the EMTALA to clarify specific aspects of patient care.

The most significant impact from these regulations is that ever more patients are being transferred to facilities that can provide specialized care. This has increased the number of transports, which has caused a proliferation of transport programs. As these transport programs were developed, the expertise of transport personnel has improved and patients are now safely transported both on the ground and in the air.

Additional issues facing the transport team include transport delays, traversing time zones, traversing international borders, and infection control. While these issues are not a part of everyday transports, they do arise on occasion and should be prepared for prior to departure.

As health management continues to expand and develop, more patients will require and/or desire access to new therapies. It will be necessary for those involved in transporting patients to keep abreast of these therapies in order to provide advanced care during transport. Education and training programs dealing exclusively with aspects of transport care are being developed. Case Western University offers an educational program, the Dorothy Ebersbach Academic Center for Flight Nursing, specifically for those nurses involved in patient air transport. Programs such as this are coming to the forefront of education of transport nurses. Emergency department physicians are also being trained and made more aware of the parameters associated with patient transport.