This is the most important stage in the whole patient transfer. If done right then it can make the transfer a relatively smooth and worry free process. If done wrong the transfer can turn into an event you may never forget and, more importantly, put your patient’s life at risk.
Before you go you must be happy that the patient is in the right state to get into the ambulance. You may have several important decisions to make and perhaps the best way to organise your thinking is in a systematic approach to create a patient pre-transfer checklist. So we will use the ABCDE method.
Do you have to consider whether or not the patient might need intubation? If their GCS is less than 8 then this should almost always be the option you choose. If their GCS is fluctuating then they should be intubated. If you are struggling to maintain their oxygen levels then you might also need to consider intubating the patient.
Do you have the right equipment with you to maintain that airway? If they are intubated do you have the equipment and the drugs to manage that tube if it becomes problematic? Often these days we take bags specifically designed for the transfer of the patient. Are you familiar with its contents or at least know where the most needed pieces of equipment might be within that bag?
Are you happy with the drugs you are taking with you? I would strongly suggest that you have them made up in the strengths and syringes required before you leave. It really is no fun trying to draw up drugs in a hurry.
Do you have a self-inflating bag as well as a waters circuit? If you (god forbid) run out of oxygen you will need the self-inflating bag as the waters circuit relies on an oxygen supply to inflate. The self-inflating bag will not deliver much oxygen but it will deliver something in case of catastrophe.
Do you have suction with you? The ambulance will have it, but some hospitals have alarmingly long corridors to walk before you get to your destination, and also lifts that might break down. You may be glad of your portable suction then!
What is the status of the patient’s neck? Has it been cleared by CT if necessary? If not and you are in doubt then you will need to collar and block as a precaution. This is also going to make re-intubating the patient more interesting!
If they are ventilated how long have they been on the transport ventilator? The patient’s condition can sometimes change when you get them on the transport ventilator especially on some of the most basic ones. They need to have been on that ventilator for at least 15 minutes prior to transfer and you MUST take a blood gas before you leave to ensure that their respiratory function is not becoming compromised.
Have you listened to their chest? Are you happy with what you hear? Have they had a chest X-Ray that you have seen? Not only are you checking for things like a pneumothorax, but you will need to be checking tube and NG positions before you leave. If there is a pneumothorax then you will have to have a chest drain inserted before you leave.
In a half empty bottle fluids will shift in a moving vehicle as it brakes and accelerates. The fluid in your hypovolaemic/dry patient will do the same! It is better to travel with the full patient to try to minimise some of these fluid shifts.
Assess the patient’s perfusion before you go and give fluids if you think they might benefit from more. Aim for a MAP of greater than 75 and a heart rate of not more than 12o bpm.
Ensure you are happy with the patient’s IV access. You may have a central line to play with, make sure all the ports are working and that it is well secured. If you don’t have a central access you need a minimum of two wide bore cannula which both flush well and are secured. I will always wrap these up with a bandage, making sure I have access to the ports. Its amazing what can get pulled out when moving the patient!
If in doubt about the patients blood pressure then start a vasopressor if appropriate. Ensure you have this going at least 10-15 minutes before you leave to ensure that the patients blood pressure is responding. At the very least it would be wise to have a syringe of metaraminol made up in case you need it!
Don’t forget the glucose. If its a relatively short trip then you can probably get away without taking the insulin infusion. Its important to try to rationalise the pumps if possible. You do need to know what the blood sugar is before you go and treat accordingly.
If the patient is a neurological concern, then the status of the pupils may become a concern. Your parameters are going to be a little different for this type of patient:
- BP- aim for MAP of 80mm/Hg
- PaO2 greater than 13kPa
- PaCO2 between 4.5 – 5.0 kPa
You might also want to consider having some mannitol with you in case one of those pupils does blow, and also sitting the patient up by at least 30 degrees. Something which you should also be considering to help prevent any reflux.
Seizures might also be a possibility so you might want to consider an anticonvulsant.
The patient is at risk of getting cold during the transfer so should be well wrapped against this possibility (bearing in mind you still need to get access to their cannula) and ensure that you cover their head.
When the patient is on the ambulance trolley make sure that their pressure points are well protected. The ambulance trolley can be quite tight and the side panels may well cause a problem unless measures are taken.
I also like to curve a rolled up towel around their head. this horseshoe then helps stop their head from rocking too much during the transfer.
Have you checked their electrolytes and corrected if needed? Are they catheterised?
They should have an NG tube inserted. The travel can cause some reflux and the intubation may well have pushed some air into the stomach. The NG tube needs to be checked on X Ray before leaving to ensure it is in the correct place.
- Do you have money, phone, food?
- Patients notes?
- Lab results?
- Enough oxygen?
DO THEY KNOW YOU ARE COMING???
Deep breath….get in the ambulance….if you have done it right you are ready to go……
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