Re: Advice / Opinions

[SUllrich@att.net]

Ken, I have a few thoughts on this transport and they 
may not be very popular.
1.  Single caregiver is rarely acceptable.  If you are 
putting yourself into this environment, quit your job.  
Marc Manly is right, the GP is nothing more than 
additional liability.
2.  This flight should never have been accepted.  I know 
that we instinctively launch and are in the mode to get 
to the patient as quickly as possible.  Especially in 
the perinatal setting, preflight planning is paramount.  
You need to assess the risk to the mother and baby, as 
well as the liability to all parties involved. This can 
put you into some tough risk/benefit scenarios but the 
only reasonable thing for the mother, the baby and 
everyone involved is to deliver and then transport.  
Anything else is disaster.
3.Take the time to establish written guidelines for 
accepting/declining such missions.  Once you launch, it 
is too late, you have accepted responsibility to the 
patient and could be liable for any bad outcomes.  Make 
sure you have good sound criteria and support from your 
medical direction.

Perinatal missions are often the most difficult we 
encounter from a logistical standpoint.  In addition,we 
probably are pressured more to accept these missions by 
referring facilities.  In almost every case, pre-
planning and allowing the mother to respond to treatment 
or fail treatment is the only way to avoid inflight 
disaster.  This may not sit well with many, but it is 
the best thing for everyone involved.  

Steve Ullrich
> 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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