Ben Burke is a Critical Care Paramedic for South East Coast Ambulance Service. He shares with the hub his practical tips when transferring critical care patients via ambulance.
For anyone who is not familiar with undertaking critical care transfers or for staff looking for a brief refresher, here are a few notes that I hope will help any clinical staff (please note, these are my views and not necessarily those of my employer's).
Planning: Despite normally being stable prior to transfer, by nature, critical patients are unstable and may deteriorate. Plan for this and know where you are going, expected journey time accounting for traffic conditions and what hospitals are along the route in case of emergency.
Equipment: If a team is not travelling, you ideally won’t take unfamiliar devices. If you do, the least you should know and plan for/discuss is how to manage failure; i.e. a syringe pump giving inotropic support or ongoing sedation that may be able to be given manually.
Equipment: Is different in subtle ways and it won’t be a simple case of copying hospital settings. If moving a patient from hospital equipment to yours, don’t leave straight away. Give the patient time to “settle” on your equipment and make any changes to setting necessary to maintain the patient.
Vehicle: Ensure normal vehicle checks are complete, you know where your own equipment is and that it is working. Also make sure that electrical/12V/USB ports all work in case they are needed for transfer equipment. Have all rescue kit (airways, BVM etc.) to hand.
Oxygen: An oxygen dependent or ventilated patient can use a lot of O2 and this needs to be calculated along with extra in case of delays. Formulas that can be used:
- 2 x flow (L/min) x length of transfer (min)
- 2 x transport time in minutes x (minute volume x FiO2) + ventilator driving gas.
Airway: Always important but vital for a patient who has an airway adjunct in place prior to transfer. Plan for immediate actions if the patient loses this adjunct during transfer. Have emergency kit laid out PRIOR to transfer and allocate pre-planned roles in case of an airway emergency during transfer.
Breathing: A patient on a ventilator will have a ventilation strategy depending on their condition. Try to have a basic understanding of this in case you need to take over with a BVM in the event of a ventilator failure. ALWAYS have rescue kit laid out and to hand in case of emergency enroute.
Circulation: The patient may be on some sort of circulatory support (fluids, pressors, inotropes etc) dependent on their underlying condition. Again, try to understand their current fluid status and support needs in case you need to intervene or have an equipment failure enroute.
Disability: If a patient is sedated/anaesthetised, be vigilant for signs this may be wearing off. Some signs to look for are tearing, increase in heart rate or BP or a Curare cleft on waveform capnography. Be aware that patient sedation needs may change due to movement during transfer.
Monitoring: In the sedated/anaesthetised patient, monitoring may be your first indicator that something is changing. Don’t just assume strange values are due to movement and constantly check your patient. If something changes, start at the patient and work back to the monitor to look for issues.