Question 11

You have been asked to retrieve a 40-year-old patient, intubated with COVID pneumonia, from a small regional ICU. The clinical condition has deteriorated in the last two days with worsening oxygenation.

a) Discuss the considerations for this patient with regards to preparation and planning, to ensure safe transport. (70% marks)

b) Outline the factors that will dictate the choice of transport including the advantages and disadvantages of each.
(30% marks)

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College answer

Not available.

Discussion

a) "Considerations for this patient with regards to preparation and planning" could mean a whole range of possible things. We do not have a college answer to help us guess what the examiners wanted. Instead, here is a list of possible things to "consider" while planning and preparing a retrieval:

Disease factors
- Planning and preparation is dependent on the urgency of the transfer, which is dependent on the severity of the condition, and the rate of deterioration.
Patient factors
- Weight and girth need to be measured for aeromedical retrieval
- Ideal patient is intubated, ventilated and paralysed
- Stabilised on a transport ventilator for some time before departure
- Vascular access should be secure
- If there is a pneumothorax, it should be drained
Personnel
- At least two people to accompany
- Medical staff with training in airway management and advanced cardiac life support
Equipment
- Airway equipment
- Suction
- Ventilator
- Oxygen supply (in excess)
- Defibrillator
- Thermal insulation
- Monitoring equipment
- All drugs checked and labelled
Monitoring
- Pulse oximeter
- Capnometer
- ECG
- NIBP or arterial line
- Airway equipment must have disconnection alarms
Communication
- Bed availability
- Accepting service consultant
- Accepting unit (ICU)
- Next of kin
- Documentation travels with the patient
- Receiving unit receives updates on transfer status

b) Only three minutes of frantic scribbling was allocated to this part, which means the following "model answer" is much longer than what is possible. Everything was included here mainly in order to include the maximum range of different possible answers which might be generated by the readers in the course of their revision. Most of this was taken directly from this excellent summary by shakEM.co.nz

Advantages	Disadvantages
Road transport by ambulance
Quickest to arrange Cheaper Less danger to crew No complications of altitude Not affected by inclement weather Able to pull over to perform a lifesaving procedure, if needed	Range is limited Speed is limited Road access is required A lot more vibration, depending on the road surface
Air transport by helicopter
Faster to organise than fixed wing Rapid transit time VTOL: does not need an airport (flexible with landing sites, eg. corn field) Less turbulence, smoother ride	Range is limited Highly weather-dependent Expensive Noisy for crew and patient; communication possible only via headset Small cabin, limited room Complications of altitude (albeit mild); cabin not pressurised
Air transport by fixed wing aircraft
Highest range Fastest speed Less weather dependent than helicopter Large cabin, more equipment is available Better temperature and noise control than helicopter Can be pressurised at altitude	Slowest to organise Most expensive Need to load into an ambulance, then load onto aircraft at the airport, then disembark at an other airport and load into another ambulance (i.e. in effect three separate transfers)

References

ANZCA "Guidelines for Transport of Critically Ill Patients

CICM "Minimum Standards for Transport of Critically Ill Patients" (IC-10, 2010)

Milligan, J. E., et al. "The principles of aeromedical retrieval of the critically ill." Trends in Anaesthesia and Critical Care 1.1 (2011): 22-26.

Koppenberg, Joachim, and Kai Taeger. "Interhospital transport: transport of critically ill patients." Current Opinion in Anesthesiology 15.2 (2002): 211-215.

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