Safety … safety … ‘a mantle of safety’.
We shall cast our mantle of safety over the Inland.
[The Very Reverend John Flynn, Founder of the Royal Flying Doctor Service.]
Introduction: trauma systems
Trauma systems were developed following the experiences of American surgeons and the US military, first, in the first and second World Wars, and then in the Korean and Vietnam conflicts. The latter two wars demonstrated that straightforward retrieval of injured soldiers was much more difficult in the challenging terrain of the Far East than it had been in Europe, and the availability of helicopters contributed to management much more focused on rapid retrieval of patients to definitive surgical care, with 20,000 soldiers being evacuated from the combat zones by helicopter in Korea.
Mean times to transport patients from the battlefield to this surgical care fell from 240 min in WWII to 27 min in Vietnam, with associated reductions in mortality from 4.5 to 1.9%. Although helicopter retrieval gained prominence in the later conflicts, much of the increased survival may also be due to the other systematically organized elements, such as appropriate and well-prepared receiving facility, a short time to definitive surgical care and the availability of whole blood transfusion. The medical care system was designed, however, to ensure that no soldier was more than 25 min away from resuscitation and definitive trauma care.
In civilian practice, studies appeared to support the regionalization of trauma care, with West et al. showing that only 1% of deaths from a system in California based around a single trauma centre were judged to be preventable, whereas 73% of deaths were similarly categorized in a Californian system with 40 centres managing trauma. Reduction in time to definitive care, effective airway management, and haemorrhage control have been considered critical to outcomes in serious trauma.
A trauma system has been defined as that which encompasses a continuum of care that provides injured persons with the greatest likelihood of returning to their prior level of function and interaction within society. This continuum of care includes intentional and unintentional injury prevention, Emergency Medical Services (EMS), dispatch, and medical oversight of pre-hospital care, appropriate triage and transport, emergency department (ED) trauma care, trauma centre team activation, surgical intervention, intensive, and general in-hospital care, rehabilitative services, mental and behavioural health, social services, community reintegration plans, and medical care follow-up.
The organization of community health resources into trauma systems offers an opportunity to substantially improve health care outcomes for the severely injured. An important concept, which is fundamental to this approach to improvement, is that of a system. In one dictionary definition a system is defined as both ‘a group of interacting bodies under the influence of related forces’ and ‘a group of body organs that together perform one or more vital functions’. What ties together these definitions is the idea of multiple individual elements forming a harmonious whole, in order to serve a common purpose. If the goal of the system is to maximize the efficient delivery of trauma care, and all available evidence suggests that this is achieved by the most rapid delivery to definitive treatment, then the common purpose is to ensure this. Thus, we need to design our trauma systems to achieve a specific goal, which may usefully be thought of the best possible outcome for each individual patient suffering serious trauma.
The systems approach is often talked about, particularly in trauma, but it is often not achieved. This is frequently due to a lack of understanding, not only about the necessity to actively plan a system in the knowledge that the parts have to fit precisely together to form a functionally integrated whole, but also that even systems composed of simple parts often produce unexpected results once the simple parts begin to interact. This is called emergent complexity, and is a hallmark of complex systems. The requirement for the construction of trauma systems based on this thinking is not a recently identified need, and in 1973, John J. Hanlon, the Assistant Surgeon General and Coordinator for Public Health Programmes of the US Health Services Administration stated, ‘an effective, efficient, and acceptable emergency medical service program must be built upon a comprehensive systems approach, and it must include the following … systematic planning, organization, administration, and operation … coordination of efforts and resources … uniform communications networks and dispatching procedures’.
It is evident that for a trauma system to work efficiently in the best interests of a seriously-injured patient, the planning must recognize that complexity within the system and between the elements of the system is unavoidable, and that there will always be emergent behaviours that arise from the functions and interactions of these component parts. There must be planning and harmonization on many levels for a trauma system to work well, including in areas such as education, training, and resource management. A common flaw in trauma treatment, for example, is the application of therapies that are performed because they can be done, rather than because they should be done. This is often seen in over-enthusiastic fluid resuscitation, which rather than optimizing the cardiac output and essential organ perfusion, whilst maintaining what vascular homeostasis is present, often is delivered with an aim to achieve a notional normal blood pressure, and may rather produce the consequences of coagulopathy, hypothermia, and acidosis with continued bleeding and organ failure as a result.
Roles and responsibilities
Trauma systems essentially consist of two poles, particularly in regions that encompass rural areas. There are the geographic and demographic catchment areas where injuries occur, with a varying degree of distance from a centre, and a central provision of peak levels of care, often referred to as definitive care. The goal of a mature trauma system is to match the needs of the injured patients to the capabilities of the trauma receiving facility, thus maximizing the chances for the best possible outcome.
Following the Vietnam model would mean that the system is designed to take every trauma patient and deliver them directly to definitive care within approximately half-an-hour; however, this is impossible in all but the most centralized of metropolitan trauma systems. There is, therefore, an unavoidable necessity to either delay the provision of definitive care (but with delivery of essential resuscitation and immediate life-saving management), followed by a transfer to the higher-level centre; or to design a system that has a large number of dispersed centres that are all able to deliver definitive levels of care.
The latter choice has not been shown to be practical, as the skills needed to deliver definitive care for trauma are essentially surgical, with allied specialties, such as anaesthesia, emergency medicine, and intensive care. Many countries do not have systems organized to train surgeons specifically for trauma management, and there is often no trauma surgical subspecialty defined as a specialist area of practice. In many areas, trauma surgery is delivered by general surgeons, with either an interest or experience in trauma, or with targeted training to allow them to provide a resource for a system.
A further essential component of the discussion about the roles of trauma centres within a system is centred on the concept of definitive care. If it is accepted that beyond airway management, resuscitation and diagnosis, trauma is essentially a surgical disease, in that the definitive interventions that may alter the prognosis of the severely-injured patient are those performed in the operating theatre, then the availability of immediate surgical competencies are key to these interventions.
Within the paradigm of damage control surgery, the need for advanced skills in both decision-making and surgical intervention means that the requisite competencies are more likely to be found in the hub hospital with a larger trauma load and dedicated surgical trainees. Discussions among trauma surgeons themselves have also suggested that a more distributed, regionalized, de-centralized model of trauma system may benefit the provision of definitive care, and also the clinicians themselves.
Essential components of trauma systems
It is generally accepted that delivery of the highest levels of trauma care will be in the setting of trauma centres or hospitals designated as the hub of the hub-and-spoke model (Fig. 27.1).
The provision of definitive care at the hub (of the hub-and-spoke model) has certain unavoidable consequences. The capability to recognize the severity of injury coupled with the provision of sophisticated imaging modalities, (but also allowing the ability to bypass these diagnostic refinements and take a patient straight from arrival in the ED to a waiting operating theatre complete with anaesthetic and surgical expertise) is concentrated in the hub hospital. This has benefits in that the volume of trauma cases in need of dedicated multidisciplinary trauma care is high and, therefore, the chances of developing staff expertise is similarly increased. It does, however, dilute the chances of smaller regional or rural hospital clinicians accumulating the opportunities to gain practical hands-on experience in trauma definitive care.
None of this means that these smaller hospitals stop seeing trauma, in fact, this is far from the case. Trauma centres remain only one part of many trauma systems, as patients stubbornly resist the attraction of only getting injured within the magic half-hour radius. Smaller rural hospitals serve a community that may be geographically extended and, therefore, may be the only rational choice for many injured patients. Although many ambulance services serving rural areas, particularly in locations such as Australia, have bypass protocols that allow continuing travel to the highest-level centre within a given time frame and, assuming some pathophysiological stability, this may not be useful in especially remote locations.
Trauma management in hospitals with small trauma caseloads and a lack of training in the management of time-critical injury may contribute to errors that lead to poorer outcomes for patients; although some studies in smaller hospitals have suggested that good outcomes may be achieved in this setting. Some early studies suggested equivalent outcomes in the rural setting to that achieved by level 1 trauma centres, although the authors recognized that with a mean travel time to hospital of 4 h the patients with the highest ISS might have succumbed to their injuries, giving a selected group entering the hospital. Later studies suggested that categorization as rural trauma centres was not as relevant as early decision-making and prompt activation of a system to transfer patients. In the State of Victoria, Australia, a 1999 report entitled the Report of Trauma and Emergency Services (ROTES) was produced by the Ministerial Taskforce on Trauma and Emergency Services. This seminal report identified a number of system-wide deficiencies adversely impacting on outcomes for severely-injured patients. Examples of these are given in Table 27.1.
Table 27.1. Common management/system errors (adapted from Evaluation of the Emergency and Clinical Management of Road Traffic Fatalities in Victoria 1997).
No paramedic/delay in arrival of senior paramedics
Prolonged time at scene
No ‘scoop and run’
No/delayed intubation or definitive airway management
Inadequate ventilatory resuscitation
No/delayed/inadequate IV access and fluid resuscitation
Failed intubation/IV access
No/delayed chest decompression
These problems largely related to decreased availability of ATLS officers, most commonly in rural areas
Inappropriate reception by junior staff
Delayed arrival of appropriate consultant
No consultant general surgeon
No/delayed neurosurgical consultation
No/delayed chest decompression
Delayed/inadequate ventilatory resuscitation
Inadequate fluid/blood resuscitation
External haemorrhage control problems
No/delayed CT investigation
Appropriate investigations delayed/unavailable
Infrequent ABG/O2 monitoring
No CVP/inadequate perfusion monitoring
Inadequate management of hypothermia
Delay in despatch to theatre
Delay in interhospital transfer
Intensive Care Unit, Ward/High Dependency Unit
Insufficient/delayed blood transfusion
Insufficient/delayed coagulation factors
No JVP/CVP assessment
Inadequate/inappropriate respiratory support
Inadequate respiratory assessment
Inadequate/inappropriate chest injury assessment
Delayed/inadequate chest drain
Inadequate/delayed abdominal assessment
Delayed/no general surgical consultation
Delayed/no repeat CT brain
No ICP monitoring
Inadequate cerebral perfusion pressure
Delayed/no neurosurgical consultation
No DVT prophylaxis
Fractures not fixed
Delayed transfer to operating theatre
Delayed transfer to ICU
Delayed response of transport
No medical escort/inappropriate escort
Inappropriate form of transport
Transfer of patients suffering from serious trauma has been shown to be associated with a poor outcome. One answer to this challenge is centred on the concept of medical retrieval. This concept refers to the practice of taking highly-qualified medical staff from either a hospital setting, or from a dedicated medical retrieval service, and transporting them to the patient to enable stabilization and life-saving interventions with the degree of sophistication present in larger critical care clinical areas. This concept is distinct from two alternative models that have been used and continue to be used in many places. The model used by many ambulance services, that of employing paramedical personnel with a constrained set of skills and competencies, is seen all over the world and tends to work well in many primary trauma situations. It is not necessarily a useful model to utilize in the inter-hospital transport scenario, however, as the necessarily limited skill set of paramedic staff does not lend itself to the need for more complex interventions. A further model, which has traditionally been in operation for many years, is the junior medical model in which the most supernumerary member of medical staff is sent with a critically ill or injured patient transfer as they are the least needed in the hospital setting. This model has led to some significant errors in patient management, with predictable adverse outcomes.
One early study showed that incidents that could cause secondary brain damage were present in 61 of 150 comatose patients transferred after head injury, and that extra-cranial injuries were overlooked or inadequately treated in 21 of these patients. The commonest incidents were airway obstruction and hypotension. This early paper (Gentleman 1981) recommended a systematic approach to the transfer of head-injured patients that, combined with rapid transport to a neurosurgical unit, would minimize the hazards of transfer, and would reduce mortality and morbidity. These findings were replicated in a further study in 1990, which found that despite more patients having interventions such as endotracheal intubation, and despite more patients being accompanied in their transfer by doctors, 23% had a compromised airway, 15% were hypoxic, 7.5% had a seizure, and 2.5% suffered a respiratory or cardiac arrest.
A 1996 survey by the Royal College of Anaesthetists revealed that 78% of hospitals that received neurotrauma had to transfer these patients due to lack of on-site neurosurgery cover. 87% expected their senior house officer (who could be just over 1 year after medical qualification) to escort the critically-injured patients. In this group, although over 93% of hospitals were able to supply equipment to monitor ECG, blood pressure, and pulse oximetry, less than half were able to facilitate the monitoring of end-tidal carbon dioxide. Due to findings like these, in 1996 the Association of Anaesthetists of Great Britain and Ireland (AAGBI) in conjunction with the Neuroanaesthesia Society produced a set of guidelines for the inter-hospital transport of head-injured patients. Sample recommendations from these guidelines are given in Table 27.2.
Table 27.2. Recommendations for transfer standards
Thorough resuscitation and optimization prior to transfer. Patients with altered consciousness should be transported intubated, sedated, and ventilated.
Designated consultants responsible for the conduct of transfers should be identifiable at the referring and receiving hospitals.
Medical escort has ideally 2 years training in anaesthesia. A trained assistant is needed to help with the transfer.
Monitoring during transfer should be of the same standard as that available on an intensive care unit. Paediatric transfers need separate equipment.
Adequate medical indemnity and personal insurance for staff undertaking transfers.
Maintain adequate records. Referring and receiving hospitals should liaise with one another. Recognition of a need for time spent in ensuring training and education.
In 1997, the Intensive Care Society released their own guidelines. In these, two attendants were specified, of which one was defined as a medical practitioner with appropriate training in intensive care medicine, anaesthesia or other acute specialty, competent in resuscitation, airway care, ventilation and other organ support. Further detailed standards and guidance were detailed in areas such as whether to retrieve or send a patient, selection of transport mode, preparation for transport, and monitoring and management during transport. These guidelines are as applicable to the transfer of the critically ill and injured today as when they were written. In Australia collaborative guidelines have been authored and promulgated by the Australasian College for Emergency Medicine, the Joint Faculty of Intensive Care Medicine, and the Australian and New Zealand College of Anaesthetists.
Benefits of organized medical retrieval
Clinical management during transport must aim to be at least equal to the management at the point of referral, and must prepare the patient for admission to the receiving service.
Transport for a patient is a high-risk episode; their illness is either sufficiently severe or worsening to demand transport, but they have often been removed from adequate care and appropriate monitoring, and potentially managed by the most junior staff with the least training. The benefit for the patient of an organized retrieval system is to maintain the level of care at a constant level, or even to increase it by performing interventions that increase the ability to manage the critically ill or injured patient effectively. Fig. 27.2a illustrates the level of care in a poorly organized and managed transfer, often with insufficient equipment and inappropriate levels of training for escorting staff. Adequate planning, organization, equipment, training and competence should attempt to elevate the level of care through Fig. 27.2b to that illustrated in Fig. 27.2c, where there is no diminution of care at all.
Furthermore, essential interventions, such as airway management through rapid sequence induction and endotracheal intubation, chest drain insertion, blood transfusion, and advanced monitoring techniques mean that a retrieval team composed of a critical care trained doctor and another attendant, often a specially trained paramedic, may be able to commence the management of shock and the effects of hypoperfusion, with rewarming, long before they arrive at the definitive care hospital.
The ideal trauma system may be based around the Vietnam model, where all patients are taken to a centre offering immediate, definitive care; however, although this is potentially closer to reality in some States in the USA or in some European countries, it is far from possible in most geographical areas. Countries such as Australia, although offering sophisticated and competent trauma systems based around the cities, is still ruled by the ‘tyranny of distance’. Patients will always have to attend smaller centres with less trauma experience, by virtue of the fact that many people live in rural or remote locations. The irony is that the more urgent the need for transfer of an injured patient, the less stable they often are, and the greater the need for expert assistance. Medical retrieval acts as the integrator of the trauma system.
The benefits to the system are divided into those seen at a whole system level, and those seen in the local area from which the patient is drawn. The overall system benefits from an organized scheme of medical and trauma retrieval, especially when capabilities are in place to recognize the occurrence of serious trauma very early in the patient journey. This last issue has been addressed in calls to primary trauma with the London HEMS practice of allowing a HEMS paramedic to monitor calls to the emergency 999 number, to interrogate callers, and to task the doctor-paramedic team to respond as a primary resource.
Benefits of an organized retrieval system to the area from which the patient comes are often forgotten or underestimated. Notwithstanding the level of care that the patient may receive from clinicians without specialized trauma knowledge and training, allowing local ambulances with ad hoc medical cover from small hospitals to undertake transfers of critically-injured patients means that the limited, or potentially the only, resources available to a small community are removed for a period of several hours or more. Patients with other time-critical conditions may suffer from a lack of timely care as local medical, nursing and paramedical staff are not available.
The retrieval team
Personnel involved in transport of critically ill and injured patients must ideally be specifically selected and trained in the transport role; they must have training allowing competent management of the patient in the same manner as in hospital, but also must have training in the techniques and requirements for operating in an out-of-hospital environment. In keeping with the standards promulgated by the Intensive Care Society, the Australian College for Emergency Medicine, and others, most retrieval team members are drawn from emergency medicine, anaesthesia and intensive care backgrounds, where specialties have an expectation of expertise in the management of the acutely ill and of procedural capability. These doctors are subsequently trained in the out-of-hospital environment, which has distinctly different imperatives and pitfalls to hospital work. Many training schemes in these specialties allow accreditation for time spent working in retrieval as a senior trainee. Retrieval doctors are often accompanied by paramedics with extended training in critical care, including the operation of non-invasive and invasive monitoring devices, transport ventilators, and invasive vascular pressure monitoring. Critical care nurses are frequently involved in inter-hospital transfer of critically ill and injured patients, although this professional group need specific training in operating in potentially austere environments.
Equipment for retrieval may be divided into two types, life support and monitoring, and clinical intervention equipment.
Life support and monitoring
Complex life support equipment, such as transport ventilator and syringe pumps, and monitoring equipment including ECG, pulse oximetry, end-tidal carbon dioxide, and both non-invasive and invasive intravascular pressure monitoring, are ideally organized and made stable on a ‘bridge’. This arrangement has had many incarnations, but was described in 1990 as the CareFlight Stretcher Bridge, a compact, mobile intensive care unit. This is a multi-story tray, which locks on to the patient stretcher, and onto which essential equipment may be secured. These bridges also facilitate the provision of a single power supply to all equipment via the fabric of the bridge, and allow the mounting of an oxygen cylinder and a suction device.
Clinical intervention equipment
Clinical interventional equipment consists of similar equipment to that found in an emergency department or intensive care unit, but is often stored and transported in a dedicated, compartmentalized bag, which may be carried as a rucksack. This bag is often organized with sub-packs within it, such as cannulation kits, intubation rolls and drug packs, to separate and make conveniently available equipment used for specific interventions (Fig. 27.5). Thus, there may be a collection of equipment for the purposes of airway management, including laryngoscopes, a collection of varying-sized endotracheal tubes, Magill forceps, stylettes and gum elastic bougies, lubricant gel and tube ties. A full list of the contents of a typical retrieval pack is given in Box 27.1. A full range of interventional drugs is also carried, listed in Box 27.2.
Other important aspects of the retrieval system are the transport platform and the organization of a bed at a trauma centre. Transport platforms for retrieval of critically ill and injured patients may take place using fixed wing (Fig. 27.6) or rotary wing aircraft, or potentially using road ambulance. Generally speaking, the factors that determine the mode of transport are geography, weather and urgency.
In countries with remote areas, fixed wing retrieval is common with services such as the Royal Flying Doctor Service. Helicopters have a shorter activation time, but a reduced radius of operation (Fig. 27.7). Fixed wing aircraft provide a relatively stable environment in which to manage a patient, although there are disadvantages of fixed wing transport, such as the need for a suitable landing strip, and the subsequent requirement for ambulance transport at either end of the flight. Much of the vulnerability for transferred patients is present at the times of transfer between one stable environment to another, although this definition may be relative, and therefore the number of extra transfers greatly increases the risk for the patient.
Helicopters alleviate many of the problems in terms of taking off and landing that make fixed wing retrieval problematic, but are often cramped, noisy environments, with little temperature control and challenging working conditions (Fig. 27.8). Part of efficient and good quality medical retrieval relies on planning to identify the potential of these adverse conditions to affect the patient, and to prepare adequately to prevent these effects. Whilst managing a relatively stable patient in the rear of a small helicopter may be merely demanding, a cardiac arrest in the same situation may be catastrophic.
Road retrieval is often undertaken with a standard road ambulance, and in large cities this may occur much more often than helicopter or fixed wing retrievals. The disadvantage of road ambulance retrieval is the short distance over which it may operate in a given time frame.
Inter-hospital patient transport generally occurs in two circumstances:
• Emergency inter-hospital transport: acute life-threatening illnesses and lack of diagnostic facilities or staff for safe and effective therapy.
• Semi-urgent inter-hospital transport: moving a critically ill or injured patient to a higher level of care or for a speciality service.
Retrieval of trauma patients may often occur when a seriously injured patient has been taken to a small hospital with little capacity to manage severe trauma.
Training in medical retrieval involves consideration of the approach to transporting patients who may be physiologically unstable and whose injuries may mandate particular care and stabilization, such as head or spinal injuries. Many experienced retrieval trainers will suggest that the novice imagines their worst nightmare that could occur with each patient, and then takes all reasonable precautions to minimize the likelihood of its occurring.
Recognition of the need for retrieval
The critical message is that retrieval should be initiated sooner, rather than later. For those working in a remote, rural, or even outer metropolitan hospital, that does not have the facility to manage serious trauma, the time to think about transferring a patient is when they arrive, not when their deterioration heralds disaster.
Many ambulance systems use a trauma triage tool based around the acronym MIST. In this instance, it stands for
• Mechanism of injury.
• Injuries seen and suspected.
• Signs and symptoms.
• Treatment required/transport decisions.
These decision tools are used to sort trauma cases into their potential or actual severity, and their possible need for urgent intervention. Being aware of the scheme used by the ambulance service in your local area, or of a scheme such as the one shown below, will allow you to assess the need for help early. Awareness of the predictive value of mechanism of injury, the injuries that are seen and the abnormalities in physiological signs that may be present is very useful to help in making this decision. It is important to be aware that many patients, particularly children, compensate efficiently for injury and blood loss, and the severity of injury is often only recognized when their ability to compensate is eventually overwhelmed.
The principles of safe retrieval are expressed in the following list:
• Right patient.
• Right time.
• Right people.
• Right place.
• Right transport.
• Right care.
• Transport of patients is HIGH RISK.
• Planned transfer or retrieval DECREASES RISK.
• Possibly the most important parts of patient transfer and retrieval are to THINK EARLY and CALL EARLY.
Whatever the transport platform, the retrieval process for critically ill and injured patients builds in unavoidable delay (Fig. 27.9). As the pathophysiology of trauma starts at the time of injury, it is vital to the patient to minimize these phases as much as possible, whilst still maintaining the safety of patient and staff. The best periods to try to safely minimize in this timeline are before calling, i.e. call early on suspicion of need, rather than wait for obvious deterioration; and reducing patient preparation and packaging time. Although retrieval specialists will have their own practiced techniques, methods, and equipment, paying attention to adequate analgesia and splinting, making clear notes, collecting X-rays, and getting the results of blood tests will make the job of the team much easier and faster (Fig. 27.10).
Preparation for retrieval
The patient can be safeguarded from potential harm by planning ahead, communicating early, and performing meticulous preparation. Almost all potential mishaps or deteriorations may be prevented by painstaking preparation before transfer:
• Planning and organization.
• Patient evaluation and preparation.
The first communication with the retrieval team may be to a medical retrieval co-ordinator, an ambulance controller, or a speciality trainee or consultant. All communications should be planned in advance, and it is important to find out who is the most appropriate person to talk to, not to simply ring the first person you think of. Even as the person performing the retrieval the same principles of communication apply. The ubiquity of mobile phones means that there is usually a constant ability to maintain contact and to ensure all concerned are prepared, updated and aware of any changes in a patient’s condition.
Intensive care transfers often have some central co-ordination, but the patient still needs a ‘home team’ to accept care, often a specialist team, such as neurosurgery or cardiothoracic surgery.
Notes must be made about the key issues in the patient’s presentation and course, clearly and logically describing the need and reason for transfer. All appropriate test results must be to hand, but investigations must not delay transfer for inessential testing.
People who need to be consistently informed about a transfer are:
• Consultant responsible for current care.
• Consultant responsible for future care.
• Intensive Care Unit consultant.
• Ambulance control or medical retrieval unit.
Key elements of this communication are:
• Who is calling.
• What the relevant patient details are.
• What the problem is.
• What has been done to address the problem.
• What is needed from the listener.
• What the level of urgency is.
Planning and organization
It is essential to think about the potential needs of the patient during transfer. Do they need an ambulance crew, a nurse escort, a medical escort, or a medical retrieval team? If there is no retrieval team available locally, will it be possible to organize transport? In which case, the appropriate person, rather than the most easily available person should be dispatched.
An estimate should be made of how long the transport will take, and discussed with nursing staff—it may be possible to wait for a shift change or to get staff from other areas. Ambulance availability and timing must be determined. Ambulance control will want to know perceived urgency—lights and sirens, immediate transport or delayed transport. If a trauma patient is being transferred, it is likely that the patient will need more urgent, rather than less urgent transport.
Similar planning and organization is essential for the receiving clinician. This involves estimating the time required to complete the transport, envisioning potential hazards and pitfalls, and ensuring that all eventualities have been considered and prepared for, including timings, assistance needed, transport availability, power, medications, monitoring, temperature, noise, notes, and relatives.
Patient evaluation and preparation
This is a dynamic process, beginning with the initial patient contact, and involving elements of the primary and secondary survey. Requirements are an assessment of current physiological status, and awareness of previous trends and treatments, responses to therapy, current and planned interventions, and physical environment. It is important to minimize risk in all areas.
Retrieval of the critically ill or injured patient means that not only must there be an awareness of actual failure or compromise of anatomical and physiological systems, but also need to assess for:
• Potential airway compromise.
• Potential respiratory failure.
• Potential circulatory failure.
• Potential neurological failure.
It is vitally important to identify when any patient approaches the end of their ability to compensate for illness or injury, and it is important to realize that just because a clinical variable is normal does not mean that it still will be in 5 min time. It is much better for both patient and doctor to intervene early, for instance, by performing a rapid sequence induction and endotracheal intubation in the warmth and light of a resuscitation room, rather than trying to perform the same procedure in the back of an ambulance in the dark. Patient preparation, like so much else in patient care, is usefully implemented using ABCDE:
• Consider the need for intubation or replacement/repositioning of tube.
• If the patient is intubated, check security of ETT (always re-tie tube). Consider Leucoplast® ‘trousers’.
• Add secondary fixation to ETT and ventilator tubing to prevent traction.
• Insert orogastric or nasogastric tube if intubated.
• Assess ventilation using repeated primary survey components of effort, efficacy, and effectiveness, respiratory rate, oxygen saturation by pulse oximetry, venous (or arterial) blood gases, and chest X-ray.
• Assess whether the patient needs a chest drain before transport (e.g. for pneumothorax and positive pressure ventilation).
• If a drain is present, ensure it is well sutured, and apply secondary fixation.
• Change underwater seal drains for closed urinary drainage bags.
• If bleeding into drain, measure and record. More than 200 mL/h suggests the need for an urgent transfer for thoracotomy if not available at the sending hospital—consult surgeons urgently.
• Assess need for further peripheral or central IV access, fluid boluses, inotropes, or vasopressors.
• Insert urinary catheter if needed. If a urinary catheter is already in situ, empty the bag, and note the volume. Apply secondary fixation to catheter tubing.
• Ensure at least two IV routes are available, are well secured, and have easy access, especially if transporting in cramped situations with poor patient access, such as in a helicopter.
• Ensure running maintenance fluid lines on both IV access points, with ports for medications. All running fluids should be administered via blood sets to enable volume resuscitation and prompt medication use.
• Intravenous lines, monitor leads, catheters, nasogastric tubes will all get tangled, will always catch on the end of the bed oxygen/suction/other obstacle, and may pull out the ETT, CVP or other very valuable tube!
• Cap off all unnecessary lines.
• Secondary fixation is very important for all tubes, and strong adhesive tape is needed (paper tape/IV dressings are not enough; see Fig. 27.11).
• Check (and record) patient Glasgow Coma Scale. AVPU is too insensitive for trend monitoring in these circumstances.
• Check pupil reactivity and assess fundi if possible, especially in neurosurgical transfers.
• Perform focused neurological examination, concentrating on identifying deficits.
• Estimate how much further medications and fluids will be necessary. Always be conservative and take too much, rather than too little.
• Get all essential infusions made up in syringes that can fit onto a syringe driver. Infusion pumps are heavy, awkward, and a recipe for disaster in transport, especially for those not adequately trained to use them.
• Sufficient sedation and paralysis for infusions, and for boluses if needed must be available. Although paralysis has associated problems, it is preferable to a patient pulling out an ETT in transit.
• If a patient is paralysed, it is vital to be very aware of the potential for apnoea/disconnection from the ventilator.
• Ensure spinal and limb immobilization is maintained when appropriate.
• Develop a checklist for all equipment before connecting patient - e.g. ventilator checklist will include:
• adequate oxygen;
• secure connection to oxygen (cylinder key);
• securely fitted tubing without leaks (cycle ventilator with patient end blocked; check airway pressure meter);
• alarms functioning and audible/visible;
• check battery life on ventilator/monitor/pumps
• ‘Mummy wrap’: use an insulating blanket or a sheet to wrap the patient from head to toe; held together with towel clips or artery forceps (Fig. 27.12).
• Remaining leads and tubes may be threaded through one end of the wrap nearest the monitors. Leads and tubes may also be fed through a split piece of ventilator tubing or ‘umbilicus’ to ensure safety.
• Remember—one line is always left out for immediate access.
• End tidal CO2: essential in assessing ventilation and disconnection. Waveform shape may indicate spontaneous breathing.
• Pulse oximetry: attempt to place on well-perfused digit, use adhesive probes if possible. Do not tape on fingers as this may lead to pressure necrosis. If there is a well shaped waveform, the SpO2 is likely to be reasonably accurate.
• Invasive and non-invasive blood pressure.
Although minimizing the time to definitive care is essential, allowing experienced assessment, appropriate resuscitation and timely surgical intervention, this is frequently not possible in the context of the many geographically diverse health systems. By necessity, injured patients are often taken to local services where there may be an inconsistent level of training and experience in the management of the seriously-injured patient and, therefore, inter-hospital retrieval of these patients is necessary.
Inter-hospital retrieval of the seriously-injured patient requires timely recognition, not only of actual injuries and the pathophysiological responses to these, but of the potential for occult injury. To enable this, trauma systems need to put in place educational and operational infrastructures that give clear criteria for transfer, and make the processes of calling for assistance and of bed-finding straightforward and routine. A systematic method of patient assessment, the use of decision and triage aids such as MIST, and effective, structured handovers encompassing early and comprehensive communication, are needed to ensure system efficiency and effectiveness. There are few instances of this holistic system approach in evidence.
Adequate patient preparation and successful retrieval are based on an appropriate sense of urgency combined with the recognition that the period of inter-hospital transport is when dangers are at their highest. Success also rests on the principles of comprehensive planning, and of performing necessary pre-emptive interventions to ensure the opportunity for disaster never occurs.
Grateful acknowledgement to the Media Unit, Ambulance Service of NSW for the use of the photograph of the Air Ambulance King Air; and to Alan Garner and CareFlight for the use of the photographs of the retrieval pack and contents, and of the CareFlight equipment lists.
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