Question 21

College Answer

Syllabus topic/section:

2.1.    Medical Expert.
2.1.1    Structure and process – L1.

Aim:

The candidate is expected to have a good understanding of intrahospital transfer of patients.
The candidate is expected to be able to anticipate and manage issues regarding the transfer of patient with traumatic brain injury and cervical spine injuries.

Discussion:
Candidates generally performed well in this question and good answers were characterised by clear headings with subsequent relevant clinical detail and prioritisation. Candidates who performed below the standard expected, excluded key safety aspects as outlined in the College guideline document "IC-10 Guidelines for Transport of Critically Ill Patients", provided largely unstructured responses, or neglected to identify the specific challenges and priorities posed by transporting a patient with a raised ICP and C-spine injury.

As the question required candidates to outline, they were required to include what they would do and why, rather than just a transport checklist. Candidates should be encouraged to think about the major points, use sub-heading for these and then list or describe relevant detail under each heading.

Several candidates did not address the second part of the question or only put 1 or 2 examples of challenges with little or no detail regarding management. Many easy marks were forfeited in this section. Candidates should look at the allocated marks (in this case 3 marks) and consider that it is likely that a minimum of three or more significant challenges (and their management) would be required for full marks. Examples of challenges would include emergency management for ICP control during transport with limited resources (e.g. in the lift) , the difficult in maintaining C-spine protection, dislodgement of various life sustaining equipment, logistical, staffing, and ventilation issues among others.

Discussion

IC-10 is the definitive guide referred to by the college in their answer, but it contains very little about intrahospital transport, mostly referring to the equiment and preparation required for "medical retrieval", i.e. interhospital transport of the critically ill. 

Preparation:

• Staff
  • ("at least of an appropriately qualified nurse, an orderly, and a medical practitioner with the specific skills and training required for such transport")
  • More staff will be required at the receiving CT scanner, as this patient will need to be log-rolled
• Communication
  • Destination notified of departure (to expedite the preparation of the scanner, contrast, extra staff for log roll, etc)
  • Porters notified of the timing of return transport (so there will be no delay for return)
  • Intubation grade is communicated to the transporting staff
  • Documentation of observations and events during transport
  • Handover to the home team on return
• Emergency equipment
  • Airway drugs and sedation/NMJ relaxants checked and present
  • Airway equipment
  • Mannitol and hypertonic saline
  • Clamps for drains and tubes
• Safety equipment
  • Two oxygen cylinders, full
  • Monitor batteries
  • Spare IV line

Challenges in transporting this patient:

• EVD management
  • Keep the system upright; avoid laying it on the bed
  • Close it for transport (otherwise a disastrous amount of CSF will potentially drain out with changes in posture, as you lay the patient flat and roll them, or air will get entrained into the ventricles) 
• C-spine management in transfer
  • Log roll for transport on/off the CT scanner
• Emergency management of ICP control during transit
  • NMJ blockade and deep sedation for transport
  • Osmotherapy available on hand to manage any crises