Patient Transport

Because the frequency of patient transport from one via Commercial hospital to another is increasing and the popularity of air travel continues to rise, physidans should be aware of the procedures for patient transport by commercial airlines. Major airlines in have experienced personnel and established procedures that facilitate the ANDREW JOHN MACNAB, MD, FRCPC transportation of patients with special medkol needs. By working with the aidine medicol health officers and using up-to-date equipment, physicians can achieve sofe, cost-effective transport of NY PHYSICIAN CAN BE CALLED bulance, while more stable patients can be appropriate patients via A *upon to determine a pa- transported by commercial airlines. Trans- commercial aircraft. tient's fitness for air travel: port by air ambulance is necessary when it might be necessary to transit time must be minimal, when a pa- organize commercial air tient requires special equipment or atten- Puisque l'on assiste a une transport for a seriously ill or injured dants, or when there is a high risk of dis- augmentation de la frequence du transport interhospitalier patient; a patient with a significant medical rupting commercial service for an des potients et a un condition might want to undertake a trip unscheduled landing to obtain emergency occroissement de la popularite involving air travel; a seriously ill patient medical care. des voyages aeriens, les might need treatment or ongoing manage- When the patient's condition is stable medecins se doivent d'etre ment at a different center and need to be and no longer requires the special facilities bien sensibiises oux transported to that center via air; or a air ambulances provide, commercial air protocoles appliques par les patient might need to be transported to an transport is often the preferable alternative compagnies commerciales organ transplant facility for assessment or because the cost is substantially less than a d'aviction pour le transport for a transplant procedure. As patient charter flight. This is particularly true for des patients. Au Canada, la when plupart des grandes transport from one hospital to another be- long-distance transfers: for example, compagnies aeriennes ont a comes more frequent, practitioners should repatriating a patient who becomes ill or in- leur emploi un personnel be aware of the procedures that must be jured while visiting a foreign country or experimente et des followed when planning for patient trans- when a patient requires assessment at a dis- protocoles etablis pour port on commercial airlines; practitioners tant transplant center. Recent advances in fadliter le transport des should also understand how the flight envi- the design of medical eqtipment make it patients necessitant des soins ronment can affect their patients when possible to administer relatively complex medicaux spedoux. C'est en elective travel is planned. care during a commercial flight, provided collaborant avec le personnel In Canada, most emergency air medical there is appropriate preflight planning. As m6dical des compagnies are air ambulance, although technology continues to improve and as ef- aeriennes et grace a un transports by equipment moderne que les commercial flights are occasionally used. forts to contain health care costs intensify, mWecins pourront determiner The condition of the patient usually deter- commercial aircraft will likely play an in- quels patients peuvent etre mines the mode oftransport; seriously ill or creasing role in medical transports. transportes de facon injured patients are transported by air am- securitaire et rentable dans Passengers with special les appareils de l'aviation Dr Macnab is Medial Dictor of the Paediati medical needs commerciale. Transpw Pmrogramme at Britsh Colnbiafs Child=nIs The information in this article pertains only 6on Famn P1y.dn 1992;38:1441-1447. Hospita4 . to Canadian commercial flights; airlines in

Canadian Family Physician VOL 38: June 1992 1441 other countries have different practices and lines have forms that attending physicians procedures: for example, many commer- must complete and sign before medical cial airlines in the will not clearance can be granted. These forms re- transport patients confined to stretchers.' quest information such as the diagnosis, Questions about specific patients should be prognosis for the intended trip, level ofam- directed to the medical department of the bulation, and need for oxygen and for an appropriate airline. attendant. Once these forms are completed Only two large commercial airlines op- and received by the airline medical health erate within Canada: and officer, the officer consults with the attend- International. A number ing physician and the airline's reservation of smaller regional airlines operate under desk to ensure that the needs ofthe patient the umbrella of one or the other of these will be met appropriately. two larger companies; NWT Air, Air BC, Air , Air , , and Supplementary oxygen. Supplementa- are all affiliated with Air Canada. ry oxygen is provided by both major air- , , Canadian Partner, Air lines. Air Canada requires 48 hours' ad- Metro, and are affili- vance notice when oxygen is needed and ated with Canadian Airlines International. can provide oxygen requirements up to 8 L/min. Air Canada charges for supple- Obtaining medical clearance. Passen- mentary oxygen and prefers either that pa- gers with serious medical conditions requir- tients be capable of regulating their own ing special consideration or assistance must oxygen intake or that patients be accompa- be approved for air travel by the airline's nied by an attendant qualified to adminis- medical health officer. Patients wishing to ter the oxygen. The charge for supplemen- travel on one ofthe smaller regional airlines tary oxygen is a flat fee. For flights within must receive clearance through the medical Canada, the fee is $60; for flights to and health officer ofthe parent affiliate. The de- from the United States, the fee is $75; for cision to permit sick or injured people to European flights, the fee is $85; and for travel depends on the circumstances of Asian flights, the fee is $105. Canadian Air- each case. lines also requires 48 hours' notice if In addition to the patient's medical con- supplementary oxygen is needed. The air- dition, the medical health officer also con- line provides supplementary oxygen to a siders the type of aircraft and its facilities maximum requirement of 4 L/min for a and the need for and availability ofa quali- flat fee of $60 within Canada and of $85 fied attendant to accompany the patient. for international flights. Passengers requir- Airlines must be notified of patients who ing supplementary oxygen on Canadian might be at risk in the flight environment, Airlines ffights do not have to be accompa- so that airline personnel are prepared and nied by an attendant. crises can be avoided. The need to work co-operatively with the airline for seriously Patients requiring a stretcher. Both ill or injured patients is obvious. Medical Air Canada and Canadian Airlines accom- clearance, however, should also be ob- modate stretcher cases whenever possible. tained in less serious cases. The process of However, Canadian's 767 aircraft cannot obtaining medical clearance ensures that accommodate stretchers because of their the patient is adequately cared for during narrow aisles. Both airlines use three seat the trip and prevents disruptions to the air- spaces for stretchers and two for portable line's operations or to other passengers. incubators. Incubators need an indepen- When arranging a flight for a patient, dent power source. Both airlines charge for the airline's reservation desk must be con- the number of seat spaces used by the tacted first. The reservation clerk will initi- stretcher or Incubator. Both airlines also re- ate the medical clearance process by ob- quire that stretcher cases be accompanied taining basic information about the patient by a qualified attendant and offer a 50% and the intended flight and forwarding the fare reduction for the attendant. Air Cana- information to the airline medical depart- da needs 48 hours' notice when stretcher ment. Both Air Canada and Canadian Air- cases are to be transported; stretchers and

1442 Canadian Family Physician VOL 38: June 1992 incubators are generally placed near the versely, the presence of the patient should bulkhead, although placement can vary, not affect the safety or comfort of the pas- depending on the class of tickets purchased sengers. To this end, airlines often place pa- and the type of aircraft. Canadian Airlines tients near a bulkhead and away from any needs as much notice as possible when areas where smoking is permitted. The stretcher cases are to be transported. Place- need for unpleasant interventions, such as ment ofthe stretcher or incubator depends suctioning, should be taken into consider- on the type of aircraft. ation when planning the transport.

Arranging ground transportation. Patient care and For patients travelling on Air Canada, the the flight environment attending physician must arrange ground Atmospheric pressure. Air transport is ambulance transportation if the patient re- distinguished from other forms of patient quires it. It is important to make these ar- transportation primarily by the change in at- rangements at the patient's destination as mospheric pressure encountered with ascent well as at his or her point oforigin. Ambu- to altitude. Although some small aircraft lance access to the aircraft varies depend- used as air ambulances, such as the Lear 35, ing on the airport used; access is coordi- can maintain ground-level atmospheric nated with the aircraft ground crew pressure,2 most large commercial jets have through either the medical officer or the limited pressurization capabilities. While reservations desk. Patients on Canadian they are all pressurized, the atmospheric Airlines who require ground ambulance pressure in the cabin is not usually equal to service can have the airline make the am- the atmospheric pressure at ground level. bulance arrangements. Depending on the type of aircraft and the cruising altitude, the cabin pressure of a Specialized equipment and supplies. commercial aircraft is usually maintained at Special equipment, supplies, or medication an atmospheric pressure equivalent to an al- that a patient could require during the trip titude of 1400 to 2600 m. should accompany the patient. Airlines do Healthy passengers are able to tolerate not necessarily carry specialized equipment such changes in atmospheric pressure with- and supplies as part of their first aid kits. out much difficulty, compensating by tidal Supplies in first aid kits vary depending on volume and heart rate increases, which are the type of aircraft and are usually limited usually noticeable only with exertion or in content; thus, physicians should make with peripheral vasodilation (eg, as a result sure that patients or attendants are pro- of overconsumption of alcohol). However, vided with everything they could need dur- many patients cannot compensate ade- ing the transport. quately, and, because ofthe reduced atmo- The flight environment (eg, cabin pres- spheric pressure, experience a decrease in sure, noise) can affect the function of some arterial oxygen saturation, which can pre- types of medical equipment. It is advisable cipitate severe difficulties. Consequently, to consult with the airline medical health patients in whom cardiopulmonary func- officer well in advance of the flight to en- tion or oxygen transport is already im- sure that the equipment and supplies that paired must be carefully selected and pre- accompany the patient will be useful and pared for travel.3'4 The preparation sufficient for the patient's needs for the du- includes a delay to allow for stabilization ration ofthe flight(s), with allowances being and partial recovery, arrangement for made for the in-flight environment and supplemental oxygen during travel, and possible delays in flight schedules. possibly assisted ventilation if recovery is limited. Table I shows a list of consider- Accommodating other passengers. ations and recommendations for planning When commercial aircraft are used for pa- nonemergency air transport including trav- tient transport, it is important to remember el after severe illness, injury, or major sur- that other passengers share the aircraft. gery; preflight evaluation and preparation; The presence of other passengers should and provision of medications and treat- not affect the condition ofthe patient; con- ments, particularly supplementary oxygen.

Canadian Family Physician VOL 38: June 1992 1443 Tabke 1. PRE FLIGH AND IN-FLGIGH MANAGEMENT OF CONDITIONS WRRANTING| SPECIAL CONSI]DERATION CLINICAL ROBLEM AIANAGEMIENT

C edkor vsWeutirtliomi ng . Codrm ainwqpoenc nd breathing effivenesshove oxygen availabl; (eg, asthma, pneumonia, emboli, ornmuma) monitr oxypn saturarion In ureairdwve * APovI umeicssary exposureandto uce; provide hnmdd;ied oxyen; (eg, phyical weokness, impaired dnve consder dM "entiiiona secondary to nwurologk state or to medication) Riwc ^eivors ventfiion Impaired rterbl oxygmrtlm Insecure okw-y Prov(ide medkol estort ondsudion; (ie,mechanical or secondory to neurologic.state) consider endotraealintubaionwith assisted ventilationa Air lek (puemtlorox or p o umestl) * Ensure there is no undrained trapped air

ASe rcardia lre, ya is ds i * limit alie exposure to <3000 m cabin pressure; bid hyperten (eg, hypotension, lowcardiac oinput, myocardial or hypohnio; optimize preload and ofterload (diurefic) cofi41dly, ischemia, or signMicantarrhythmia) and rhythm; provide oxygen; monitor heart rat, rhytlhm, ond oxygen saturaion; minimize pudlent ankiety; have intravenous access for emnergency modkaons (or heporin lock IV) Severe cordloc fdws, cqnosis, acdosis, . Umit ohihWe exposure to <1200 m cabin pressure or oxygon depeo ny MyoscorlW idrdih Acute (within 8 weeks of infarct) * Povide an emergency ombulnce flight; limit altdude exposure to <600 m cabin pressure thine 8m52 weelk of inford o smst aneitiue exposure to approximnte 1800m coWn pressure (dueto,for examp tq Enle a spare unrt avbiableay

r iau o g/dL,pteducedoxyentroo nspoortsction ity) Transfa Siti coll szmse . Umit olliude to <1800 m cbin p'ressure; odminMuer oxygen; Optimize hydrotion Ativen tc o vdiscrderacdde Use appropan te preront fertreatiment provide; fresh fozen p IVdurin transit.

nz.sdzures * CbonsWer iedive i'ntubation; provide onticonvulsnts, IV access, on oral airway, Impaiedlevel of consisousness and effkmdsudion (due to, for example, unstable aiiway, breothing., or drculalion or impaired control ofsecreflons)a Reced crbrovnscdr Kcddl * Delay transfer until the parient's condifion stabilizes; provide oxygen during tronsfer M4r trns * Pressurize aircraft to sea level; continue cervical spine precautions if any concerns (eg, recent bleeding or raised intracranial pressure)a persit (ensure the airway remains uncompromised after any color is apphed); consier intubtion, hyperventlation, urnarycatheter, and nasogastric (NG) tube; anticate pressure sores L J

1444 Canadian Family Physician VOL 38: June 1992 Tabk _.Cotne

C PROBLEM Provide appropriate emergency mediatios and appropriate suppot equipment far (PR; miinimiepten anxiuety and provide antiemetics or analgesics; ensure IV fluids are in nonhruabl plsick bag; provide for temperatre stability and warmth Majo InfectIon withl systenk IstabiIy * MUoniltor heart rate, temperatre, oxygen saturaion; consider intubation"; provide IV acess and optimize drcularm whims Slg.lfkunt cu. u bl Inecion * (heck whether tranprt is essential; avoid exposure to at-risk patients; these| patients alre unlikely to he accepted by commercial carriers and often need other

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Canadian Family Physician VOL 38: June 1992 1445 Changes in the partial pressure of oxy- mercial aircraft, stretchers are usually posi- gen are not the only harmful effects of re- tioned at right angles to the plane's direction duced atmospheric pressure. According to of travel. When necessary, special arrange- Boyle's law, the volume of a gas varies in- ments shouid be made with the airline to posi- versely with the pressure; at 2400 m the vol- tion the patient to minimize the harmful ef- ume of a gas expands by 30% from its fects ofgravitational force. Patients with head sea-level volume. Healthy individuals can injuries, cardiac failure, or fluid overload experience this phenomenon only as vague should be placed with their heads to the front abdominal distention or increased flatu- of the aircraft to miniimize the affects ofposi- lence. However, the gas expansion can be tive gravitational forces. Patients with hypovo- hazardous for a patient who has recently lemia, spinal shock, or cardiac ischemia undergone abdominal surgery, has an un- should be placed with their feet to the front drained pneumothorax, has air in the cra- ofthe aircraft to minimize the effects ofnega- nium, or suffers from nitrogen narcosis af- tive gravitational forces. ter scuba diving. Changes in gas volume can also affect medical equipment. Air Equipmentfor en route care. When an splints are contraindicated, as they can pro- attendant is necessary to provide care en gressively impair circulation. The rate of route, the equipment required varies with the administration of intravenous fluid via individual patient's diagnosis, care require- gravity flow can be erratic. The balloons on ments, and the logistics of the journey. Pearl urinary catheters and the cuffs on endotra- et al6 and many others outline general equip- cheal tubes expand and can rupture or ment requirements. Oxygen and equipment cause pressure necrosis unless they are to secure the airway are essential ifthe patient filled with saline instead of air. is likely to be unable to compensate for re- duced atmospheric pressure. Approximately Acceleration, turbulence, vibration, twice the anticipated requirement of oxygen and noise. Additional patient care prob- should be carried in case of ffight delays or lems can occur because ofacceleration, tur- inadvertent oxygen waste. bulence, vibration, and noise. While the The transport environment is "user unpleasant effects from these aspects of air friendly." Limited space and access make it travel have been minimized in modern difficult to perform the physical examination commercial aircraft, they should still be ofa patient; background noise makes auscul- considered at least as potential hazards. tation ofthe chest and heart imprecise; even Some patients are particularly prone to relatively gross signs, such as unequal air motion sickness in aircraft. The use ofpro- entry or arrhythmias, are difficult to assess; phylactic antiemetics should be considered the lighting within different aircraft varies and, ifused, should be administered before but is often poor; changes in oxygenation, travelling. reflected by pallor or cyanosis, must be sub- Because ofthe risk ofturbulence, the pa- stantial to be recognized reliably.7 tient and all equipment must be adequately Fortunately, current technology available secured. Children can be safely transported for monitoring vital functions has improved using car seat restraints in conjuction with significantly the ability ofattendants to antic- the aircraft seat and seat belt. The list ofcar ipate problems during transport. Monitoring seats allowed on Air Canada and Canadian heart rate, respiratory rate, temperature, and Airlines has recently been expanded to in- blood pressure has become standard prac- clude readily available models.5 Any atten- tice, and the use of photoelectric oximeters dants should be provided with proper seat- to monitor oxygen saturation is a recent and ing and seat belts. highly successful innovation.8 Oximeter technology is particularly suited to the trans- Gravitationalforces. Gravitational forces port environment. No invasive line is re- affect the body during phases of acceleration quired; the light source can be readily se- (ascent) and deceleration (descent) and can cured to a digit or ear lobe, and readings of cause fluid shifts within the body. These effects changes in oxygen saturation are instanta- are most marked in patients on stretchers fac- neous. The units are compact. Battery life ing the front or rear of the aircraft. On com- varies but is usually 4 to 6 hours.9

1446 Canadian Family Physician VOL 38: June 1992 Compact, battery-powered, com- plans and coordinates the transfer by Requests for reprints to: Dr Andrew puterized infusion pumps that can de- following a few simple procedures Macnab, Paediatric Transport Programme, liver fluid from a regular plastic (Table 2). After arrangements have British Columbial Childrenl Hospital, 4480 intravenous bag and can maintain a been made at the points ofarrival and Oak St, Vancouver, BC V6H3V4 constant flow at any preprogrammed departure and with the airline, the References rate regardless of pump position are physician must ensure that the patient 1. Merlone S, Hackel A. Care of patients dur- now available. Another valuable item is stabilized, that all appropriate med- ing long-distance transport. Int Anesthesiol Clun 1987;25(2): 105-16. is a portable suction device. Suitable ications have been given, and that 2. Macnab AJ, Vachon J, Susak LE. Transpo- equipment can be available on loan specialized equipment, medication, lar transport for heart-lung transplant using from the physician's local ambulance supplies, and attendants are provided the Lear 35. Hosp Aviat 1989;8:26-7. service or can be rented from a medi- as required. By providing the airline 3. Aerospace Medical Association. Medical cri- teria for passenger flying. Aerospace Med 1961; cal equipment company. Efficient, medical officer with the proper pa- 32(5):369-82. low-cost, hand-operated units are tient information and anticipating 4. Parsons CJ, Bobechko WP Aeromedical available. preflight, in-ffight, and postflight transport: its hidden problems. Can Med Assoc Equipment used on commercial problems, the physician will be able J 1982;126:237-43. aircrafts should be as to transport the patient safely and 5. News and Appointments. Can Paediatr Soc battery-powered, News Bull 1990;21(4):5. it is usually impossible to connect with with minimal difficulty. U 6. Pearl RG, Mihm FG, Rosenthal MH. Care the aircraft's main power source. Spare of the adult patient during transport. Int batteries for all equipment should be Acknowledgment Anesthesiol Clin 1987;25(2):77-103. carried. does not I thank Dr M.S. Moore and Dr D. Rothon, 7. American Academy of Pediatrics Commit- who are both Medical Officers at Air tee on Hospital Care. Guidelines for air and allow liquid lead-acid batteries in pas- ground transportation of pediatric patients. senger compartments, but does allow Canada, and Dr W Doughty, a Medical Officer at Canadian Airlines, for their assis- Pediatrics 1986;78:943-50. sealed gel or nickel cadmium batteries. 8. Frankel LR. The evaluation, stabilization tance in providing information about airline and transport of the critically ill child. Int policy. The Paediatric Transport Programme Anesthesiol Clin 1987;25:77-103. Conclusion is sponsored by 's Children' 9. Macnab AJ, Smart P. Lightweight monitor- Safe patient transport via commer- Hospital and the BC Lion' Socieyfor ing equipment for paediatric transport. Inten- cial airline is possible if the physician Crippled Children. sive Ther Clin Monitor 1990;May/June:92-6.

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