Choices in Intra-Facility Transfer

Louis Scrattish

Assistant Medical Director-UW Med Flight

University of Wisconsin School of Medicine and Public Health

December 3rd, 2015

Overview:

Vehicle Options

Crew Configurations

Equipment Variation

Know Your Local Options

Our Transport Mantra

• Right Vehicle• Right Crew• Right Equipment/Products• Right Destination

Our Transport Mantra

• Right Vehicle• Right Crew• Right Equipment/Products• Right Destination

Intra-Facility Transport Options

• Private Vehicle• BLS• ALS• Critical Care Ground• Air• Specialty Ground• Specialty Air

Vehicle-Ambulance Advantages

• More Room– Larger Medical Crew– Larger Patient– Continuous CPR– Access to Whole Pt

Eurocopter 135 Interior

Ambulance Advantages

• Larger Weather Window

• Don’t Need a Helipad

• More of them-May be Closer

• No Issues with Elevation Changes

Ambulance Advantages• Much More Affordable

– Ambulance $800-2500– HEMS $11,000-54,000

• Better Temperature Regulation– Pt Temp– Lines Freezing– Medication Issues (Mannitol)

Helicopter Advantages

• Faster– Average Speed 140-150mph

• Must Figure Warm Up/Cool Down Time of HEMS

• Longer Transports Favor HEMS– If speed only concern:

» <20 min ground transport-drive» 20-30 grey zone» >30 min ground transport-air

Helicopter Advantages

– Can Travel in a Straight Line• Traffic Jam?• Inefficient Route?• Going Through Large Urban

Area?

– Smoother Ride• Consider in Unstable Spinal

Injuries

Helicopter Advantages

• Safety– 1993 Houston study: Ambulances 13x

more likely to get in an accident based on number of accidents per miles traveled

Ambulances 5x more likely to get in an accident that resulted in injuries

Conditions Where Time Critical

• STEMI• Strokes where Lytics running, possible• Intracerebral Hemm

– Deterioration– Midline Shift

• Trauma’s Where Blood Products Infusing

Timing Possibly Less Critical

• Digit amputations where implantation not an option

• Burns (without airway compromise)• Improving Sepsis

Other Timing Considerations

• Crew Launch Time Critical– Varies Widely by Agency– For HEMS Longer at Night

Our Transport Mantra

• Right Vehicle• Right Crew• Right Equipment/Products• Right Destination

IFT Crew Configurations

• Most ambulance crews for IFT:– Mix of EMT-B, EMT-I, EMT-P– Critical Care Ground Often Includes Critical

Care Paramedic or RN

• Vast Majority of HEMS:– EMT-P/RN– A few EMT-P/EMT-P– <5% Physicians

Specialty Crews

• Respiratory Therapy• Neonatal Provider • PICU Provider• OB provider• Perfusionist

• Can be utilized by ground and air

In an Ideal World….

• Mode of Transport and Crew Completely Independent on Each Other

• Mix and Match

• Why doesn’t work?

When can RN/Physician be helpful?

• On Board Medical Control• Airway Needed, Rescue Airway in Place• Advanced Ventilator Settings• Medication Infusions

– Ie Pressors, Flolan• Pt deteriorating• Pediatrics

When can RN/Physician be helpful?

• On Board Medical Control• Airway Needed, Rescue airway in place• Advanced Ventilator Settings• Medication Infusions

– Ie Pressors, Flolan• Pt deteriorating• Pediatrics

Overview:

Right Vehicle

Right Crew

Right Equipment/Products

Right Destination

Know Your Local Options

ALS Equipment

• IV access• IVF• Many IV medications• Vital Sign Monitoring (incl SpO2)• Can Gain Airway if Needed (+/- VL)• +/- Ventilator

Critical Care Ground

• ALS plus the following:– Ventilator– Broader Array of Meds (Pressors, Paralytics)

– Invasive Monitoring• Arterial Line• ICP

HEMS

• ALS plus Critical Care plus:– pRBC’s– Video Laryngoscopy– +/- On Board Labs– On Board Chest Tubes– +/- TXA– Advanced Communications Centers

Med Flight

• pRBC’s, TXA, FFP• On board labs (ePOC)• Glidescope, CMAC

Overview:

Right Vehicle

Right Crew

Right Equipment/Products

Right Destination

Know Your Local Options

Summary

• HEMS Speed Advantage not a Simple Calculation

• HEMS a Safe Alternative• Crew and Equipment Needs often

Overlooked• Local Knowledge of Agencies Critical

Questions?