Transcript Pediatric Transport Medicine

Pediatric Transport
Anjali Subbaswamy, MD
Critical Care Medicine
Children’s National Medical Center
Pediatric Transport Medicine
(MD’s perspective)
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Overview
People
Process
Medical Care
Who and why
• Why – diagnostic or therapeutic
- MD discomfort
- parental request
• Who – any age, any illness
- must be stable enough
Utility vs Futility
• The benefits of transport must outweigh the
risks for the patient
limited space, equipment, staff
separation from family
• The risks/costs of transport must be justified
History
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First AAP guidelines 1986
Goal – to provide a safe envt btw H’s
Most peds is interfacility (US)
<10% of ambulance calls are pediatric
<3% of paramedics see >15 kids/mth
Lack of pediatric expertise
Average EMS provider sees:
• 1 peds BVM case q 1.7 years
• 1 peds intubation q 3.3 years
• 1 peds IO line q 6.7 years
Federal EMS-C program (1984) funds educational
efforts by states
Turn around time
• Emergent – trauma
- where to?
• Urgent – DKA
- ASAP – depends on logistics
• Routine – for subspecialty care
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- 24-72 hours
Reimbursement
• Patient’s insurance
• Taxes
• Out of pocket
Pediatric vs Adult
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Different pathologies
More equipment (sizes)
+/- parent
Early goal-directed rx vs Scoop ‘n run
The players
Sending
Receiving
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Person who calls 911
Referring hospital MD
Referring hospital RN
Pt’s legal guardian
State police
Local EMS
Pediatric transport svc
Referral hospital ER
Accepting physician
Med Control Physician
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PEDS ER OR PICU
Accepts pt, consults subs
Sends appropriate team
Directs stabilization
Provides ongoing direction to transport team
Accepting MD responsibilities
• Legally – when transport team arrives on
scene
can be tricky
(ex) Insulin not started for DKA pt
• Ethically – when you accept the pt on the
phone
TEAM Composition
ALS team (10%)
• MCP
• Paramedic
• EMT
Critical CareTeam (90%)
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MCP
RN +/- RT +/- MD
Paramedic
EMT
Case 1 – 7 yo MVA
~1 hr
The process
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OSH/EMS calls referral center
Accepting physician (aMD) identified
MCP directs transport team
Pt arrives to ED or on unit
• aMD provides feedback to OSH + PMD
Vehicle selection
• Ground – space and option to stop
• Fixed Wing – stability in bad weather
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Helicopter – land at scene, speed
Referring hospital responsibilities
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Call appropriate referral center +/- transport svc
Copy patients chart
Obtain written consent from parents
Document acceptance by referral MD
Stabilize lines, tubes, splints
MD gives report to transport team
RN gives report to receiving RN
Provide parent w/written destination
Case 2 Pneumonia
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2 yo at OSH inpt for 3 days
Nec Pna, Abx – resp distress
Called for PICU admission
3 hr turnaround time
Correct dx? Correct representation of resp distress?
WRAMC contracts with CNMC
• CNMC 5000 per year
• 20% neonatal 80% pediatric
• WRAMC and affiliates - 261 last year
Case 3
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4 yo w/CNS tumor
Obstructive HC, VPS, Sz d/o
Make-a-wish trip to Disneyworld …
Status epilepticus
transferred for social reasons (home)
MEDICAL CARE
• Equipment
• Medications
• Monitoring
Specialized meds
• Come with patient (factor in travel time/delays)
• Pre-ordered at recv’g site if poss.
• chemotx, off-label meds, timed abx, metabolic
cocktails, all gtts
Monitoring
Medtronic Lifepak 12
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Monitor/defibrillator
12 lead ECG
NIBP
Capnography
2 invasive lines
Vital sign trends
Bluetooth wireless
• POC testing
Case 4
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2 yo s/p Fontan admitted to WRAMC for pna
Required Bronch, VATS, intubation
ASA 4 intubation risk
L MS bronchus compression
Predicted LOS 5-7 days
Elective transfer to CNMC
Conclusion
• People
• Process
• Medical Care