Re: Advice / Opinions

["Marc Manley" <flyinrn@charter.net>]

Ken,
First and foremost, as you already know, SAFETY would be 
the most important issue regarding this flight request and 
why I would heavily consider turning this flight down.
These are some of my thoughts:
1. Despite your very applicable training and your aircraft 
being stocked and outfitted with appropriate equipment, 
you are "by yourself" when it comes to treating the 
patient (and baby) during the transport. Medical Director 
unavailability, receiving Surgeon not willing to 
participate and the GP from the sending facility likely 
has no or very little extensive training in patient 
management in the prehospital environment. Not to mention, 
he most likely has never even seen or been inside your 
aircraft. This situation alone places you behind the so 
called 8-ball and would lead to a safety nightmare should 
the patient deliver (now 2 potentially sick patients) or 
decompensate enroute to receiving facility.
2. Pt transport in this type of positioning is extremely 
difficult if not impossible.  The GP sounds as if he 
intends to handle all patient care and you are just along 
for the ride to handle logistical issues. We all know that 
this is ludicrous and in the end, we all know who will be 
held accountable for a poor patient outcome?

Just my opinions. VERY tough situation and tough place to 
be in.  I'm looking forward to hearing more about this 
case.

Marc
Flight Nurse
On Fri, 1 Mar 2002 23:33:47 -0800 (PST)
  Ken Lawson-Williams <Macgyver@FlightMedicMail.com> 
wrote:
>SITUATION: 300# 39y/o native, some prenatal care, EDC/LMP 
>unknown. No ultrasound done this pregnancy. P3G7 @34 wks 
>(est from fundal height). Active labour since 0300, 
>presented to hospital 0900, PV=frank bleeding from 
>cervix, unable to assess dilation as entire vaginal vault 
>filled by intact membranes/fluid, bulging and tense. 
>Transverse lie. Previous PROM/Prem labour at 27 weeks 
>(didn't survive). Obese and pendulous abdomen. 25 bed 
>community hospital calls at 1009 for fixed wing Medevac 
>(45 response and 45 min flight each way, add 10 min 
>ground time at destination and 5 at sending) to 
>semi-regional 100 bed center (GP-anethestethist, general 
>surgeon, GP who does lots of OB, pediatrician) with 
>available OR. Closest NICU/level 1 trauma centre 2 hours 
>flight time away with 20 min ground. NICU team response 
>to sending 4 hours and won't come pre-delivery. GP 
>attending to come with patient. 
>
>ON ARRIVAL AT 1145: "Crowning"-like bulging membranes, 
>dilation not assessable. MgSO4 running at 2.5G/hr. N/S 
>via 16 at TKVO. Foley and high flow O2 in situ. EFM 
>reassuring with Q20 mild contractions Fetal tones good. 
>VS stable. Dexamethasone IM on board. L lateral 
>Trendelenberg with feet 30 degrees elevation (40" above 
>head) GP attending adamnant that position be maintained 
>"if we lie her down wthe membranes will rupture and we 
>will lose the baby and then the mother".
>
>AVAILABLE RESOURCES: Flight medical crew = GP from 
>sending and solo CCEMT-P/final semester RN with 
>ALSO/ATLS/NRP/PALS and instructor level 
>ACLS/AMLS/PHTLS/BTLS certifications. Off-line protocols 
>very liberal and comprehensive. Medical director 
>unavailable at the time. No transport coordination 
>medical director. Recieving MD = surgeon and unfamiliar 
>with flight issues / unwilling to get involved untill 
>patient is in his facility. Ohio transport incubator with 
>opaque heat retention cover (the old style incubators). 
>BLS ground crews at both ends. 3 seats on BE-B200C. FERNO 
>#9 and 25yr old medevac sled (brand unknown, not Spectrum 
>or Lifeport). single channel MTP pump, Zoll PD1400 with 
>pacing. Bird Avian III. Minimed 911 NIBP/SPO2/ETCO2 
>monitor, doppler, Jackson-reese (anesthesia style flow 
>through bag) with manometer, pressure infuser bags and 
>standard ACLS meds including MgSO4 x 50mg, oxytocin x 
>100mg, no Ergot or Hemabate or indocid, RSI 
>meds=sux/pavulon/versed/morphine. Flight crew advise only 
>room for 2 attendants due to weight/balance issues. FD 
>has FERNO basket and cargo straps available.   
>
>OTHER INFO: Trauma center / teaching hospital has never 
>sent out a surgical team to a small community hospital, 
>would take 4 to 6 hours minimum to set up. Sat-phone U/S. 
>Cell coverage minimal (25 min dead spot mid-flight). 
>Ambient temp -25 Celcius at sending with 8 knot wind, 
>outside ambulance bay, no hanger available. -30 Celcius 
>at receiving with no hanger available, 4 knot winds, 
>enclosed EMS bay. 4 units 0- available (entire supply) at 
>sending. Altitude sending/recieving 800' and maintainable 
>throughout flight. MD remains ABSOLUTELY INSISTANT on 
>maintaining trendellenberg at minimum of 25 degrees (30") 
>despite explanations of risks during both ground and air 
>transport of trying to secure patient in that position 
>"She's my patient, your job is to get me, and her, to an 
>OR where we can deliver surgically. How you do it is not 
>my concern. I'm responsible for her care, you for the 
>mechanics of the transport. Find a way and make it 
>happen". 
>  
>Suggestions? Alternatives to flight? Packaging hints? 
>Sympathies?
>
>Will followup with outcomes / trip report later
>KLW
>
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