Pediatric Transport Medicine(MD’s perspective)

Pediatric TransportAnjali Subbaswamy, MD

Critical Care MedicineChildren’s National Medical Center

• 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

• 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 expertiseAverage 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• - 24-72 hours

Reimbursement

• Patient’s insurance

• Taxes

• Out of pocket

Pediatric vs Adult

• Different pathologies• More equipment (sizes)• +/- parent• Early goal-directed rx vs Scoop ‘n run

The players

Sending

• Person who calls 911• Referring hospital MD• Referring hospital RN• Pt’s legal guardian

Receiving

• State police• Local EMS• Pediatric transport svc• Referral hospital ER• Accepting physician

Med Control Physician

• 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%)• MCP• RN +/- RT +/- MD• Paramedic• EMT

Case 1 – 7 yo MVA

~1 hr

The process

• 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

• Helicopter – land at scene, speed

Referring hospital responsibilities

• 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

• 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

• 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• Monitor/defibrillator• 12 lead ECG• NIBP• Capnography• 2 invasive lines• Vital sign trends• Bluetooth wireless

• POC testing

Case 4

• 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