Pediatric emergency medicine trisk 83

FIGURE 11.8 An example of “Welcome Pamphlet” given to families of transport patients of The Children’s Hospital of Philadelphia (Used with permission, © The Children’s Hospital of Philadelphia, Philadelphia, PA.) Regardless of their degree of involvement, physicians should be aware of the air medical transport resources and capacities in their region Two basic types of air transport exist: RW helicopter and FW aircraft RW aircraft are common in both rural and urban EMS systems, are typically hospital based, and usually carry a nurse, respiratory therapist, or physician as one (or more) of their crew members, while some services have a paramedic (EMT-P) as a primary crew member The unique capabilities of rapid, direct scene response give the RW craft a distinct advantage over FW aircraft and ground units in some cases Helicopter EMS (HEMS) have allowed for the provision of ALS services to larger rural areas incapable of sustaining independent ALS units, and have provided access to tertiary care centers for patients in regions without such centers In both rural and crowded metro and suburban areas, RW aircraft offers the benefit of time saved in transit—a significant benefit in cases such as trauma and surgical emergencies However, recent research has suggested that direct air transport from an accident scene to a trauma center for pediatric patients may not improve survival when compared with local hospital stabilization prior to air transfer Moreover, Engbrecht et al noted that interfacility transport of patients by RW aircraft was generally not predictive of need for acute intervention in their study population, but recognized a subgroup where rapid transport was useful (epidural hematomas, vascular compromise/open fractures, and penetrating neck/trunk injuries) Safety of the transport personnel must also be a priority Avoiding the use of RW transport in bad weather is a good example of a safety decision in the transport environment Improvements in HEMS safety profiles were recognized when pilots were isolated from specific patient care information for transport requests Instead of being informed that a critically ill child might die without their intervention, pilots now should make “go” or “no go” decisions based solely on weather, flight personnel, and equipment issues If an appropriate “no go” decision is made, this should not be questioned or countermanded by medical or administrative personnel If a “no go” decision is made based on weather considerations, another mode of transport or other patient care options must be considered Competition between transport programs or aeromedical providers can be a safety hazard In efforts to gain a competitive advantage, programs (or specific personnel) may be willing to consider circumventing weather and safety rules Optimal policies for safety-conscious systems include when a transport is denied by one air service for weather-related issues, those same transports are not offered to another air service unless it is located in a different environment that may not be subject to the same weather issues Unfortunately, the HEMS industry has seen periodic increased accident and fatality rates Compared to ground ambulance transport (15 million annual patient exposures), the fatal accident rate is greater for helicopter transport by approximately 13.5 times, however in the last three decades the accident rate in HEMS has declined by 71% In 2006, the National Transportation Safety Board (NTSB) critically reviewed 55 HEMS accidents and found that over half of the fatalities could have been prevented with systematic corrective actions This review resulted in safety initiative recommendations, which are outlined in the NTSB publication, Special Investigative Report on Emergency Medical Services Operations, available at www.ntsb.gov The following recurring safety issues were noted: (i) Less stringent requirements for EMS operations conducted without patients on board, (ii) lack of aviation flight risk-evaluation programs for EMS operations, (iii) lack of consistent, comprehensive flight dispatch procedures for EMS operations, and (iv) no requirements to use technologies such as terrain awareness and warning systems (TAWS) to enhance EMS flight safety Interventions by the FAA have resulted in safety improvements, including certification of night vision goggles (NVG) for helicopter use Other recommendations include TAWS, more stringent flight operation requirements, improved preflight risk management and hazard identification, and mitigation programs with formalized dispatch procedures to include up-to-date weather information and assistance in flight risk-assessment decisions Although there is not a singular intervention or assessment tool that will guarantee risk-free air transport, accreditation by the CAMTS demonstrates adherence to the safety standards proposed for the air medical transport industry Vehicle Safety Accidents involving ground ambulances are tragically common In these accidents, the rear compartment of the vehicle is an extremely dangerous place Every patient must be safely restrained in the vehicle with shoulder and body straps, in a position that minimizes further injury and protects the airway; however, this can pose a significant challenge with pediatric patients Current guidelines for the safe transport of children in ground ambulances have been published by the National Highway and Traffic Safety Administration (https://www.nhtsa.gov/staticfiles/nti/pdf/811677.pdf ) Every ambulance should have the capacity to secure a child or infant safely If the patient is an infant and his or her medical condition permits, the use of an approved child safety seat (CSS) should be encouraged in a forward facing seat without an airbag However, these are not available in most ambulances and not allow for ease of continuous monitoring In some ambulances, there is a seat in the rear of the vehicle that can be opened into a CSS that may be appropriate For infants and small children who are to be secured on the ambulance cot, there are techniques that can be used to make this practice as safe as possible to reduce the chance of another injury if the vehicle is involved in an accident either using a commercial car seat in accordance with manufacturer guidelines or a commercial device approved for medical transport ( Fig 11.9 ) New products are available, many of which have been crash tested to establish their safety capabilities, that can safely secure a child to the ambulance cot, such as a restraint developed by Ferno (Wilmington, Ohio) (https://www.fernoems.com/us/en-us/ems/pediatrictransport/pediatric-restraints/pedi-mate-plus-pediatric-restraint-system ) These devices can be used for children too large to fit in a CSS or as an alternative to a CSS The transport provider must take great care to ensure that the patient is properly attached to the cot, and that the child’s head, torso, and pelvis are appropriately secured to prevent injury in an accident It is important to keep in mind that many of these products may not have established crashworthiness, and the degree of protection they provide is unclear The family’s own car seat, if able to be secured properly in the ambulance, may be an excellent choice for noncritically ill patients without special needs This also encourages a safe discharge home from the hospital, by already having the child’s safety seat available Most critically ill patients are not appropriate candidates to be transported in a car seat FIGURE 11.9 A, B: Diagram of a car seat attached to an ambulance cot A: Recommended method for restraining children up to about 18 kg who can tolerate a semiupright seated position, showing belt attachment to the cot and routing through the convertible child restraint B: Recommended method for restraining infants who cannot tolerate a semiupright seated position, showing belt attachment to the cot and routing through the car bed loops (From Bull MJ, Weber K, Talty J, et al Crash protection for children in ambulances, recommendations and procedures In: Proceedings of the 45th Annual Association for the Advancement of Automotive Medicine 2001:353–367 Reprinted with permission from the Association for the Advancement of Automotive Medicine.) Transport providers and passengers must also be properly restrained in the ambulance Sixty percent of the fatalities in a study of ambulance crashes were ambulance personnel who were unrestrained in the patient compartment Additionally, all monitoring equipment must be secured to the frame of the ambulance, because even a low-speed collision can turn loose objects into fatal missiles for a child, provider, and/or passenger It is unacceptable to transport a ... developed by Ferno (Wilmington, Ohio) (https://www.fernoems.com/us/en-us/ems/pediatrictransport /pediatric- restraints/pedi-mate-plus -pediatric- restraint-system ) These devices can be used for children... Association for the Advancement of Automotive Medicine 2001:353–367 Reprinted with permission from the Association for the Advancement of Automotive Medicine. ) Transport providers and passengers... initiative recommendations, which are outlined in the NTSB publication, Special Investigative Report on Emergency Medical Services Operations, available at www.ntsb.gov The following recurring safety