Emergency Medical Transportation Guidelines for Nurses in Primary Care

Chapter 1 - Principles and Process of Medical Evacuation

Introduction

General Principles

Primary Modes of Transport

• Aeromedical Evacuation - Special Considerations
• Non-Emergency Road Transportation

Responsabilities of Referring Practioner

• Step 1. Pre-Transport Assessment and Planning
• Step 2. Pre-Transport Initial Stabilization
• Step 3. Preparation of Equipment
• Step 4. Preparation of Client and Escorts
• Step 5. Communication with Receiving Physician and Healthcare Facility and with Medical Escort Personnel
• Step 6. Management during Transport
• Step 7. Termination of Transport

Introduction

Medical evacuation (medevac) usually refers to the transport between facilities of clients requiring urgent or emergent medical care. It can also refer to movement of patients requiring care that is unavailable in their own communities, such as a special diagnostic test or a planned surgery.

Various modes of transport are used for medevac, including aircraft and motorized vehicle (e.g., land ambulance). In more remote areas, medevac may also encompass movement between smaller communities by boat or snowmobile.

In some regions, emergency medical evacuations are carried out by dedicated ambulance services, with trained medical personnel, including doctors, nurses, paramedics and emergency medical care attendants (EMCAs) providing the escort. In other areas and under certain conditions, the community nurse and/or physician may be required to escort the client and provide care during transport to hospital.

Although it can be a life-saving link between remote communities and higher-level medical centers, the medevac process can itself endanger the client's life. The nurse needs additional knowledge about the potential effects of the choice of transport on the client's condition (e.g., the physiological effects of flight) and the corresponding actions required to meet the client's needs in transit.

Although medical evacuation frequently implies an emergency situation, the first requisite is to ensure that the client is sufficiently stabilized to withstand travel. The accuracy of pre-transport assessment of the client's condition is paramount.

There are three main components of interfacility transport. These must be carefully considered before any transport, so as to optimize client care and safety.

• Preparation, which involves stabilization of the client, anticipation of needs and potential problems, and preparation of equipment
• Selection of transport vehicle and medical escort personnel
• Transportation, including medical and nursing care needed en route

General Principles

Safe and effective medical evacuation requires that careful decisions be made regarding the following aspects of the client's condition and the transport itself:

• stability of the client's condition
• priority level (how soon transport should occur)
• requirements for medical and nursing care en route
• most appropriate escort
• most appropriate mode of transport

See Tables 1-1 and 1-2 for guidelines in making these decisions.

Other considerations for transport:

• The client must be stabilized as much as possible before transfer, e.g., airway secure, IV lines started and appropriate medications administered.
• Any kind of transport has the potential to negatively affect a client's condition. Therefore, consider carefully the risks to which the client will be exposed during transport before deciding whether it is medically necessary to transport the client right now rather than keeping the client in the referring facility until stabilized.
• Transport during inclement weather and nighttime medevacs should take place only if the vehicle operator (e.g., the aircraft pilot or ground ambulance driver) feels that it is safe to proceed. The operator should not be subjected to undue pressure from healthcare personnel, from the family or from other community members.
• In many areas and in some emergency situations , it may be more appropriate to bring a medical-nursing transfer team into the community to stabilize and transfer the client. Specialized personnel and equipment, if required, may be requested and brought along.

Source: First Nations and Inuit Health Branch, Alberta Region (October 2001).

Table 1-2: Factors in Decision on Mode of Transport

Main Factors

The decision to transport a client from a particular facility is usually dictated by the inability of that facility to provide the level of care that the client requires. The decision as to mode of transport should be based on the following main factors:

• Diagnosis and medical stability of the client, including analysis of possible complications in his or her condition during transport
  
  
• Urgency of providing a higher level of care
  
  
• Level of medical care that the client is currently receiving
  
  
• Distance and duration of transport to the receiving hospital
  
  
• Geographic characteristics that affect expedient transport
  
  
• Methods of transport available

Time and Distance Factors

In medically urgent or emergent situations, reducing out of hospital time is beneficial to client outcome. Careful evaluation of the time and distance from the client's location to the receiving institution is important. Include the following factors in the calculation:

• Modes(s) of transportation being considered
  
  
• Time necessary to mobilize a medical team
  
  
• Estimated time needed to travel with the client, accounting for distance, terrain, weather and traffic
  
  
• Amount of time that will be spent stabilizing the client
  
  
• Amount of time to return staff and equipment from the receiving institution to their point of origin

Personnel Factors

In communities where the number of healthcare professionals is limited, the following factors should also be considered:

• Ability to replace nursing staff
  
  
• Ability to replace physician
  
  
• Ability to replace local ambulance or other transportation service

The recommendations of the healthcare provider in determining the most appropriate mode of transport should be documented on the client's chart.

Primary Modes of Transport

Aeromedical Evacuation - Special Considerations

Although aeromedical evacuation is often considered just another way of transporting a client, there are great differences between this kind of transport and ground transport.

The existence of these differences does not mean that clients at risk should not be transported by air. In fact, aeromedical evacuation is safe for transporting almost any client, even those who are seriously ill or injured, if the following conditions are met:

• well-prepared, well-trained medical or nursing escort
• medical equipment that is qualified as "safe for use" in an aircraft

A client may be exposed to some specific risks during flight. Therefore, the accompanying medical and nursing personnel must have a good understanding of the basics of aerospace medicine and the specific interactions that might occur for a particular illness or injury. See chapters 2, 3 and 4 of these guidelines for more details regarding aeromedical evacuation.

The following clients require special consideration in flight, and, whenever possible, pressurized aircraft should be used and the cabin pressure carefully controlled (see chapters 2, 3 and 4 of these guidelines for more details):

• Clients who have or who may develop airway compromise (e.g., moderate to severe lung disease or airway problem, such as chronic obstructive pulmonary disease [COPD], pneumonia, respiratory distress syndrome, asthma, chest trauma)
• Clients with congestive heart failure, unstable angina or acute myocardial infarction (MI) and those who have had MI in the past
• Clients with severe anemia: hemoglobin < 70 g/L (7.0 g/100 mL) or RBC < 2.5 × 1012/L (2.5 million/mm3)
• Clients with gas trapped within any body cavity (e.g., pneumothorax)
• Clients who have had thoracotomy or laparotomy (if possible, such clients should not be moved within 10 days after the surgery except in pressurized aircraft)
• Clients whose jaws are wired together (such clients must have an escort who can, if necessary, use an appropriate wire cutter to remove the tie wires, should the client become air sick)
• Newborn and premature infants

Unpressurized aircraft should be used for seriously ill or injured clients only when there are no pressurized aircraft available for the transport.

See chapter 2, "Aeromedical Evacuation," for more information on types of aircraft.

Non-Emergency Road Transportation

Healthcare professionals must be aware that an ambulance may not be necessary for all clients undergoing interfacility transfer. Clients can be safety transported in a vehicle other than an ambulance, such as a taxi or private automobile, if the following conditions are met:

• The attendant or driver will not be expected to provide any medical attention to the client.
• The client is considered medically stable, and the act of transportation and (if they are to return by the same mode of transport) any diagnostic or therapeutic intervention at the receiving institution are not expected to change the level of stability.
• The client is not using any device (e.g., stretcher or splint) or treatment modality (e.g., IV line) unless such a device or treatment modality is a part of the client's lifestyle and/or the client (or a companion such as a parent who will accompany the client) has been trained to care for the device or treatment modality.

If a client does not meet these criteria, or if there is any uncertainty as to the most appropriate transfer method, the client should be transported by ambulance.

Source: Saskatchewan Health Ambulance Services, 1994.

Responsabilities of Referring Practitioner

Step 1. Pre-Transport Assessment and Planning

The need for medical evacuation and the care provided before and during transport of a particular client are usually determined by the nurse at the local facility, in consultation with a physician. The ultimate decision to evacuate lies with the most qualified person on the scene.

The client should be completely assessed in a systematic fashion and all the potential problems identified and managed.

The following should be considered or performed before the transport of any client:

• An appropriate SAMPLE history should be obtained: Symptoms (history of the current illness or injury), Allergies, Medications, Past medical history, Last meal and Events before illness or injury.
• An appropriate systematic physical examination should be performed, with particular attention to assessing and securing ABCs.
• The results of appropriate (available) diagnostic tests and results (e.g., ECG and blood work), if performed, should be made available for review by the transporting medical personnel and should be transported with the client.
• The nurse must try to anticipate any problems that might develop during transport, so that steps can be taken to prevent them. If prevention is not possible, the nurse should be prepared for the problems to occur during transport and should have available appropriate medications, supplies and equipment.
• A physician should be consulted to determine the appropriate care, the urgency of the transport, the appropriate level of escort (see Table 1-1, above) and the appropriate mode of transport (see Table 1-2, above)

Step 2. Pre-Transport Initial Stabilization

This is the most important step in determining the safety of the transport. Avoid the "scoop and run" approach, unless there is danger at the originating scene for those involved.

The following steps must be considered when stabilizing a seriously ill or injured client for transport. Some of these procedures (e.g., inserting IV lines) may be performed by the referring healthcare practitioner. Others (e.g., intubation) are not within the CHN's scope of practice; therefore, if they are needed, they must be carried out by other qualified medical personnel.

A For Airway

Airway management is always the first priority. The airway must be opened and maintained (ensure protection of the cervical spine and take appropriate precautions in the injured client).

If the airway is compromised, if there is any potential for airway compromise en route or if there is a need for therapeutic interventions such as hyperventilation, intubation before transport is indicated. This procedure is not within the CHN's scope of practice and must be performed by authorized emergency transport personnel (e.g., physician, emergency flight nurse or paramedic).

Proper immobilization in clients with suspected C-spine injury is especially important, in view of the number of movements that may be required in loading and unloading the client from the transport vehicle.

B For Breathing

Breathing must be assessed and assisted as necessary.

Respiratory emergencies such as pulmonary edema, hemothorax, flail chest, open chest wound or pneumothorax must be stabilized as much as possible before transport. For example, it may be necessary to insert a chest tube if there is any evidence of significant pneumothorax, especially if transport is by air in an unpressurized aircraft.

Inserting a chest tube is not within the CHN's scope of practice. This procedure must be carried out by authorized emergency transport personnel (e.g., physician, emergency flight nurse or paramedic).

C For Circulation

Stabilization of the cardiovascular system before transport, including control of any bleeding, is essential. Transport should not be initiated until the pulse and blood pressure are stabilized through fluid volume replacement or medication (or both).

It is advisable to institute a minimum of two large-bore IV lines for all seriously ill or injured clients before transport. Hypovolemia can be treated initially with crystalloid IV fluid replacement (e.g., normal saline or Ringer's lactate).

D For Disability

Neurological status must be assessed before and during transport. The Glasgow Coma Scale is a useful tool for such assessments.

Assess for increased intracranial pressure and manage in consultation with a physician. This may entail initiating a controlled airway, hyperventilation, elevation of the head on the stretcher, administration of an osmotic diuretic or a combination of these strategies.

Other Considerations

Consider inserting a nasogastric or orogastric tube to straight drainage for clients with gastric or GI distension, major GI disorders, diminished or absent bowel sounds, or artificial airways in situ.

Consider inserting a urinary catheter for all seriously ill or injured clients, unless such is specifically contraindicated (e.g., suspected injury to urinary meatus). Also consider a urinary catheter for any client who has received a diuretic. Document urine output.

Institute cardiac monitoring (if available) for all clients with potential for arrhythmias, ischemia or other cardiac abnormalities.

Consider administering analgesia or sedation before transport as required. Discuss use of these medications with a consulting physician if possible.

Step 3. Preparation of Equipment

Prepare an inventory of all necessary supplies and equipment for the transfer, and test all equipment to make sure it is operating properly before the transport.

The dedicated aeromedical and ground ambulance transport services available in many regions usually have most of the required equipment. However, they may not have some of the specialized equipment required for interfacility transport. See chapter 6, "Equipment and Supplies."

Step 4. Preparation of Client and Escorts

Arrange for an appropriate escort(s) to accompany the client. See Table 1-1, above, for information on choosing an appropriate escort according to the client's needs. The safety of the client and the escort(s) during transport must be a priority at all times.

Prepare the client and escort(s) for transport (e.g., proper clothing and wrapping, especially in cold weather).

In remote areas, review survival procedures before the transport, especially during the colder seasons. In addition, review the policy in your area regarding access to and use of survival gear when traveling significant distances between communities in remote areas, especially if traveling in smaller, unpressurized aircraft, boats, or motorized vehicles such as trucks or snowmobiles. Transport Canada requires that all aircraft flying in remote regions carry survival gear appropriate for the terrain and environment over which they are flying. However, if flying routinely with a specific airline, the passengers (including escorting nurses) should ask specifically about what survival gear is carried on board and should be familiar with its use.

Have safety equipment and supplies available and use as indicated (e.g., wear seat belts whenever possible, wear life jackets at all times when transportation is over water).

Secure all passengers, equipment and supplies within the transport vehicle.

Do not take along too much equipment.

Know how to operate the emergency exits.

Step 5. Communication with Receiving Physician and Healthcare Facility and With Medical Escort Personnel

Before the transport begins, contact the receiving physician and healthcare facility where the client is being transferred:

• Ensure that they can accept the client
• Discuss the relevant clinical information and additional steps that can be taken to further stabilize the client
• Advise them of the estimated time of arrival

If outside medical personnel will be arriving in the community of origin to take over the care of the client during transport, they will need some information in order to provide appropriate care. Initial contact is often by telephone, followed by a verbal report in person at the time of the transfer. They will need the following information:

• Names of referring and receiving facilities and physicians
• Name and phone number of a contact person familiar with the case
• Client's name and age
• Chief complaint and history of present illness
• Significant past medical history, including allergies
• Treatment given in local facility while awaiting transport
• Present clinical status (stable or unstable); for a child, report body weight
• Names of any passengers who will be traveling with the client
• Specific concerns, considerations and client needs (e.g., deafness, blindness, need for an interpreter)
• Type of medical escort personnel required
• Special equipment or supplies that may be needed (e.g., transport incubator)

Medical personnel who are taking responsibility for care of a client during transport must have an opportunity to assess the client before transport. The transport team may find that further stabilization is required before moving the client. Airport transfers should be performed only if the client's condition is very stable.

Step 6. Management During Transport

The aim is to have the client well prepared and stabilized for transport, so that only monitoring and supportive care are required during transport. Stabilization must always incorporate attention to ABCs.

A For Airway

• Protect and monitor airway.
• Ensure that appropriate-sized resuscitation equipment is available on all transports, and ensure that transport personnel are familiar with the use of each item.
• Carefully secure airway devices to prevent displacement during client movement. The airway should be reassessed whenever the client moves to ensure that any problems, especially during loading and unloading, are identified early.
• Ensure that suction is available and functioning during all phases of transport (including land transport), to assist with basic airway maneuvers that may be required.
• Have wire cutters available for any client whose jaws are wired shut.

B For Breathing

• Deliver oxygen liberally through a non-rebreather mask with reservoir bag to ensure good oxygenation.
• Monitor oxygen saturations with a pulse oximeter (if available); oxygen saturations may be inaccurate in the presence of carbon monoxide poisoning.
• Humidify the oxygen if possible.

Significant respiratory emergencies, including pneumothorax, hemothorax, open chest wounds and flail chest, must be adequately managed before transport.

C For Circulation

• Maintaining adequate IV access is critical.
• Make sure all IV tubes and other attached lines are secured well. Monitor them closely during transport, especially after loading and unloading. IV tubes can be coiled and secured to prevent them from being dislodged.
• During loading and unloading from the transport vehicle, consider saline locks for IV lines that are not needed for volume replacement or administering medications. A locked IV can be reopened once the client is on board or in the receiving facility.
• IV lines may freeze in cold temperatures. Use body heat (yours or the client's) to prevent freezing (e.g., place the line under your parka or in a sleeping bag).
• Monitor vital signs closely. Blood pressure may have to be checked by palpation if non-invasive technology is not available, as the noisy environment will interfere with auscultation.
• Remember that edema and bleeding increase during aeromedical transport.
• Elevate injured parts and monitor color, warmth, circulation and movements of injured extremities.

For aeromedical transfers in a fixed-wing aircraft, ensure that loading and unloading of the client are as smooth as possible, without excessive movement or rotation of the stretcher. Load the client in an attitude that will lessen the effects of gravitational forces (see chapter 4, "Primary Care during Transport," for details). Always ensure that the client's position allows access to the head and other body areas of concern.

Other Factors

• Motion sickness: Ensure that equipment to deal with motion sickness is readily available, including sick sacs, kidney basins, and suction and tonsil-tip suction devices.
• Dressings: Be prepared to reinforce wet dressings; avoid changing them during medical evacuation.
• Narcotic analgesia: If administration of narcotic analgesia is required during transport, dispense the drug and document this action according to the region's policy on narcotics and controlled substances.
• Documentation: Throughout the transport, clearly and concisely record, on the appropriate forms, all clinical observations, interventions and medications given.

Step 7. Termination of Transport

The following guidelines apply if the community nurse is providing escort

• Supervise disembarkation of the client, any documents, and supplies or equipment.
• Accompany the client to the receiving medical facility and provide hospital staff with a complete report of the client's condition and pre-hospital medical treatment provided. Provide a copy of the medical record to the receiving practitioner.
• Ensure that all equipment and unused supplies are checked and returned to the originating facility in a usable state. Ensure that the address of the originating facility is clearly visible on all equipment and supplies.