child on the lap of a parent in an ambulance, regardless of how the child is secured to the parent or stretcher Lights and Siren Use There are few times when a higher-speed transport with lights and siren (L&S) will be of benefit to a sick or injured child—in fact, this practice may introduce more danger than benefit to the patient In 2019, Watanabe et al demonstrated that the increased odds of collision is 1.5 with L&S when compared to without Although in some communities it is legal for emergency vehicles to exceed the speed limit and pass through red lights, this does not mean that it is safe to so A NAEMSP position paper recommended that EMS services should develop a policy on L&S use, which should be reviewed by the services’ medical directors It should be noted that accidents while running with L&S are a common cause of litigation Multiple vehicles responding to an incident using L&S is another practice that is frequently done, but is likely unnecessary Emergency vehicle accidents are an area of high, and frequently unnecessary, liability in EMS that are borne more out of a tradition of L&S use, than a medical necessity for the patient This is a good example of a nonmedical aspect of a transport system that may adversely affect patient care STABILIZATION FOR TRANSPORT The patient care paradigm of most interfacility transport teams stands somewhat in contrast to that of prehospital care systems EMS providers are usually bringing a patient from an environment without medical care (e.g., home or accident scene) to a hospital In many of these cases, the patient is better served to have the minimum stabilization necessary at the scene, followed by rapid transport to an appropriate hospital, with further intervention being performed en route or on arrival In contrast, the interfacility transport team is most often taking a patient from a hospital, usually an ED or another monitored setting, to a monitored bed within a higher level or specialty care center The transport team, therefore, is responsible for maintaining an appropriate advanced level of care between the two centers Ideally, the transport team should provide the level of care that the patient will receive at the receiving facility At a minimum, the transport team must maintain the patient’s present level of care Stabilization before transport is the key to this process Initial preparation for transport often begins when the referral caregivers recognize that the patient requires care beyond the capabilities of their personnel or center Appropriate advice and suggestions from transport personnel or the receiving physician ideally will enable much of the necessary stabilization, interventions, and preparation for transport to be accomplished before the team arrives Telemedicine can improve the pretransport assessment availability of visual and auditory data and should offer a more individualized, higher level of initial assessment and advice When the transport team arrives, after a concise medical handoff, they should review the medical history, including all therapeutic maneuvers and interventions performed at the referring hospital Ideally this handoff is part of a standardized process as described in 2013 by Weingart et al An efficient and focused physical examination is mandatory During this pretransport process, endotracheal tubes, chest tubes, IV and intra-arterial catheters, and other indwelling devices should be checked for proper placement and stabilization When doubt exists, devices should be resecured or replaced After this initial assessment, the transport team, in concert with the medical control physician, should decide if any, additional medical interventions are required to be initiated and/or continued before leaving the referring center Such interventions are most appropriate when they may have a direct impact on patient outcome For example, the child who may have meningitis should receive antibiotics before or during the transport process, but a lumbar puncture may be deferred until arrival at the receiving hospital The appropriateness of interventions will, to some degree, be dictated by the distance to the receiving hospital For example, a child with a circumferential burn of an extremity may require an escharotomy to minimize or prevent vascular compromise If the receiving hospital is minutes away, this might be appropriately deferred However, if the receiving hospital is hours away, it may be prudent to have the procedure performed before departing from the referring center Again, transmission of images or materials to the receiving center or medical control physicians can help in the patient management This could include images of the patient, computed tomography scans or x-rays, as well as copies of ECGs or other assessments Availability of point-of-care testing is helpful for continued patient assessment during transport After the patient is optimally prepared for transport, he or she must then be moved from the referral facility’s bed to the transport stretcher, and then to the vehicle Such movements represent great risk to the patient, so staff should exercise extra vigilance during patient transfer IV catheters and endotracheal tubes are most likely to be displaced while the patient is being moved Consequently, patients should be subjected to the fewest transfers necessary to get them from the referring hospital to the definitive bed/location they will occupy at the receiving hospital Personnel should be assigned to secure lines and tubes, and the patient movement should be coordinated by a team leader, similar to the coordinated effort required to move a patient with a potential cervical spine injury Precautions, such as planned, temporary disconnection of the ventilator from the endotracheal tube, may need to be considered during these moves Finally, the patient must be carefully reassessed immediately after each movement The team must be assured that the airway is stable, immobilization is secure (if appropriate), and potentially lifesaving tubes, lines, and medications have not become dislodged or disrupted Monitoring is imperative during the transport process Observation and palpation may be hindered by patient position relative to the provider within the vehicle This may be especially evident in a transport helicopter Auscultation may also be impaired in a noisy transport environment The air transport environment may be 50% louder than a comparable ground transport Therefore, more reliance is placed on sophisticated monitoring tools, including cardiorespiratory parameters, pulse oximetry, capnography, gas delivery monitors with audible and visual alarms, ultrasound, and point-of-care laboratory testing ALTITUDE PHYSIOLOGY AND THE AIR MEDICAL ENVIRONMENT When pediatric patients are transported by helicopter or FW aircraft, one must be cognizant of issues regarding altitude physiology An increase in altitude brings with it a decrease in ambient oxygen as well as the potential for an increase in the size of air spaces For most patients, however, these are not major issues For patients with severe hypoxia at sea level, diving injuries, or large, enclosed pockets of air, air transport can be dangerous Two gas laws are important in the transport process Boyle Law states that with a constant temperature, the volume of a gas varies inversely with the pressure (P1 V1 = P2 V2 ) ( Fig 11.10 ) As altitude increases, barometric pressure decreases; therefore, the volume of the gas increases Dalton Law (the law of partial pressure) says that the partial pressure of a gas mixture is the sum of all the partial pressures of the gas within the mixture (PT = P1 + P2 + P3 …) ( Fig 11.11 ) For example, the total pressure of air is The partial pressure of nitrogen is 0.78, oxygen is 0.21, and other gases is 0.01 The partial pressure of oxygen will always be 21% At higher altitudes, air becomes less dense and the partial pressure of oxygen, while still 21%, offers diminished oxygen availability FIGURE 11.10 Boyle law (P1 V1 = P2 V2 or P1 /P2 = V1 V2 ) As altitude increases, barometric pressure decreases and volume of gas increases The diagram illustrates enclosed gas expansion at specific altitudes “Atmospheres” is compared with the amount of pressure exerted by an overlying 1-square-in air column At sea level, this equals 14.7 lb/square in (psi) and one-half that amount (7.35 psi) at 18,000 ft (From Woodward GA, Vernon DD Aviation physiology in pediatric transport In: Jaimovich DG, Vidyasagar D, eds Pediatric and Neonatal Transport Medicine Philadelphia, PA: Hanley and Belfus, Inc; 1995:40, with permission.) These issues can be important during the air medical transport Entrapped air, if not vented, can be painful (middle ear sinus, teeth, bowel), annoying (flatus, belching), and dangerous (pneumothorax) Use of tight-fitting earplugs in flight can cause an artificial air pocket that may trigger similar consequences More significant air space issues include simple pneumothorax and pneumocephalus, which can become symptomatic at high altitudes Patients with bowel obstructions may have increased gas volume, potentially leading to vomiting, aspiration, and even ischemia Inflation volume in air splints may vary with altitude, as will the air in blood pressure cuffs, fluid bags, and pressure bags Air in endotracheal tube cuffs and Foley catheters may also be affected and might need to be adjusted during flight (slightly deflated at higher altitudes) Patients with air embolisms from diving injuries or other causes are especially prone to ... (From Woodward GA, Vernon DD Aviation physiology in pediatric transport In: Jaimovich DG, Vidyasagar D, eds Pediatric and Neonatal Transport Medicine Philadelphia, PA: Hanley and Belfus, Inc;... ultrasound, and point-of-care laboratory testing ALTITUDE PHYSIOLOGY AND THE AIR MEDICAL ENVIRONMENT When pediatric patients are transported by helicopter or FW aircraft, one must be cognizant of issues...interventions, and preparation for transport to be accomplished before the team arrives Telemedicine can improve the pretransport assessment availability of visual and auditory data and should