Course # 90743 • Transport Methods for Critically Ill Patients


Study Points

  1. Compare the advantages and disadvantages of ground, fixed-wing, and helicopter transport.
  2. Evaluate physiologic changes that occur during transport and list interventions to limit patient compromise.
  3. Describe the current federal requirements and regulations in regard to transporting the ill or injured patient.
  4. List, in order, the appropriate steps in arranging an interfacility transport.
  5. Identify stabilization procedures to be undertaken for all patients requiring transport.
  6. Describe the emotional impact of transport on the patient and/or the family and list interventions to provide psychosocial support for these individuals, taking into consideration cultural and linguistic variables.
  7. List the baseline diagnostic studies to be performed prior to transport, if time and patient condition warrant their performance.
  8. Cite physiologic changes that occur during transport and impact the neurologic, respiratory, and cardio­vascular systems.
  9. Summarize special considerations for transport of burn and multiple-trauma patients.
  10. Identify the problems that may occur during transport of the pediatric patient.
  11. Identify the stressors of transport that impact the elderly patient and cite how to best stabilize the patient to limit these complications.
  12. Describe the impact of transport on the pregnant patient and her fetus and how these problems can be managed.
  13. Describe the steps in caring for a patient in transport.
  14. Describe how transport impacts the choice and use of biomedical equipment.
  15. List actions to take to ensure the safety of the crew, the patient, and the personnel on the ground when performing both a helicopter and a fixed-wing transport.
  16. Cite the medical-legal requirements of providing care to a patient outside of a hospital system.

    1 . Which of the following is a drawback of transport by ground ambulance?
    A) Time-in-transit
    B) Affected by adverse weather conditions
    C) Lack of transport coverage if single ground ambulance is removed from the community
    D) All of the above

    MODES OF TRANSPORT

    Ground ambulance transport is an efficient and appropriate method of transport for most ill and injured patients in this country. The number of ground transports increases annually and the appropriateness of these transports is unquestioned. However, there are instances in which ground transport is at a disadvantage. Adverse weather conditions can impact the vehicle's ability to traverse certain terrain. At the same time, this adverse weather can prevent air ambulances from flying, leaving ground transport as the only viable option. Time-in-transit is another drawback of ground transport. Some critically ill or injured patients cannot withstand the stressors of transport and the shorter the out-of-hospital time, the better that patient's chance for survival. Finally, when choosing to utilize a ground ambulance, the needs of the community should be examined. Some isolated rural areas have only a single ground ambulance to service a largely scattered population base. If this vehicle is taken out of service for an interfacility transport, the people of the community are temporarily left without the medical coverage they have come to expect.

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    2 . Which of the following is considered a benefit of fixed-wing air transport?
    A) Lower associated cost
    B) Ability to reach isolated areas
    C) Ability to travel long distances rapidly
    D) Decreased likelihood of dislodgment of tubes or lines

    MODES OF TRANSPORT

    Air transport should be considered an adjunct to, not a replacement for, ground transport. There are inherent dangers in transporting by air, and it is an expensive alternative. Many third-party providers are withholding reimbursement for flights, which are considered nonemergent. The advantage of fixed-wing transport is the ability to travel long distances at speeds between 250 and 570 miles per hour. Care is usually provided in a pressurized cabin with sophisticated on-board medical equipment. Many aircraft utilized for air transport of patients have the capability of transporting multiple patients, and in some instances, family members are allowed to accompany the patient. All-weather navigational equipment allows for the transfer of patients during inclement weather. Many of the dedicated aircraft utilized in air transports have been referred to as "flying ICUs."

    Fixed-wing transport requires suitable airfields to ensure the safety of the crew and patient. Accessibility to such fields may be a problem in isolated areas. Optimally, a 5,000-foot paved runway located near the site of the patient would erase the disadvantages of air transport. However, because hospitals are located a considerable distance from most airfields, ground transport is utilized at the beginning and the end of the air transport. (Note: A unique situation exists in Anchorage, Alaska, where a regional referral medical center is located on the edge of an appropriate airfield and the patient can be off-loaded from the plane and wheeled directly into the hospital. This is far from the norm.) The patient should be moved in and out of the aircraft to a waiting ground ambulance and then transported from the referring hospital or to the receiving hospital. This increases the likelihood of the dislodgment of tubes, lines, etc. There is an additional cost associated with this supplemental ground transport.

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    3 . Which type of hypoxia develops at altitude with the drop in atmospheric pressure?
    A) Anemic
    B) Hypoxic
    C) Stagnant
    D) Histologic

    TRANSPORT PHYSIOLOGY

    Hypoxic hypoxia, also known as altitude hypoxia, occurs when changes in atmospheric pressure are encountered. As an aircraft (both fixed-wing and rotor-wing) ascends in altitude, the partial pressure of oxygen (PO2) decreases, causing a decreased diffusion gradient for the oxygen molecule to cross the alveolar membrane. Table 1 shows the effects of altitude on the PO2.

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    4 . At an altitude of 6,000 feet, the partial pressure of ambient, humidified oxygen is
    A) 118 mm Hg.
    B) 150 mm Hg.
    C) 609 mm Hg.
    D) 760 mm Hg.

    TRANSPORT PHYSIOLOGY

    EFFECTS OF ALTITUDE ON PARTIAL PRESSURE OF AMBIENT HUMIDIFIED OXYGEN

    Altitude (feet)Atmospheric Pressure (mm Hg)Partial Pressure of Oxygen (mm Hg)
    0760150
    500746147
    1,000733144
    1,500720141
    2,000707139
    2,500694136
    3,000681133
    3,500669131
    4,000656128
    4,500644125
    5,000632123
    5,500621121
    6,000609118
    6,500598116
    7,000586113
    8,000564109
    9,000543104
    10,000523100
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    5 . One cause of anemic hypoxia is
    A) hemorrhage.
    B) hypothermia.
    C) heavy smoking.
    D) carbon dioxide poisoning.

    TRANSPORT PHYSIOLOGY

    When a patient has an inadequate amount of circulating hemoglobin, he is said to have anemic, or hypemic, hypoxia [2]. Causes of anemic hypoxia include anemias and hemorrhage. A drop in hemoglobin to 10% or a hematocrit of less than 30 is most often associated with anemic hypoxia. These patients should be monitored for an adequate oxygen level to prevent further compromise in the patient's status. A commonly utilized monitoring technique is oxygen saturation. However, it is important to remember that oxygen saturation is only a measurement of the hemoglobin saturation. As an example, a patient with an oxygen content of 19 volume percent with a 20 volume percent capacity will have an oxygen saturation of 95%. This same patient could lose half of his blood volume so that the oxygen capacity would be 10 volume percent. If his oxygen content is 9.5 volume percent, his oxygen saturation is also 95%.

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    6 . Which of the following is NOT a sign/symptom of developing hypoxia?
    A) Lethargy
    B) Confusion
    C) Pupillary dilation
    D) Changes in vital signs

    TRANSPORT PHYSIOLOGY

    Signs and symptoms of hypoxia include changes in vital signs, tachycardia, pupillary constriction, confusion, disorientation, and lethargy. Insidious and gradual in development, these signs may also be caused by a number of other illnesses and injuries, making the diagnosis of hypoxia more difficult. Astute observation of the patient is necessary to detect and correct the problems of hypoxia.

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    7 . The Federal Aviation Administration requirements mandate that a pilot utilize supplemental oxygen when flying for any duration above a cabin pressure altitude of
    A) 3,000 feet.
    B) 14,000 feet.
    C) 15,000 feet.
    D) 23,000 feet.

    TRANSPORT PHYSIOLOGY

    A great deal of research has been performed upon the effects of hypoxia on normal individuals. The military uses this information to establish guidelines for pilot performance. This research demonstrates what is referred to as time of useful consciousness (Table 2). This is the time in which a person subjected to a hypoxic environment can function to protect themselves from the harmful effects of hypoxia. Most commercial aircraft and aircraft utilized in air transport fly below 41,000 feet, indicating that the pilot will have a little less than 300 seconds to protect themselves from these detrimental effects in the event of cabin depressurization. Utilizing this information, the Federal Aviation Administration (FAA) has set requirements for oxygen use among pilots and occupants that state that oxygen use is mandatory for pilots when cabin pressure altitude is 12,500 to 14,000 feet for durations of more than 30 minutes or any duration at cabin pressure altitudes greater than 14,000 feet, and that oxygen must be available for all persons on board if the cabin pressure altitude is greater than 15,000 feet [3]. In a pressurized aircraft with two pilots at the controls, pilots must have their oxygen masks readily available to them in the cockpit (quick-donning type, ready within 5 seconds, and able to be placed on face with one hand) if flying at an altitude between 35,000 and 41,000 feet [3]. If at any time there is only one pilot at the aircraft controls and the altitude is above 35,000 feet, he or she must wear and use supplemental oxygen until the second pilot returns to his/her controls.

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    8 . Which of the following is NOT a proper intervention for preventing hypoxic hypoxia during patient transfer?
    A) Transfusion
    B) Providing a calm environment
    C) Providing supplemental oxygen
    D) Elevating the head of the stretcher

    TRANSPORT PHYSIOLOGY

    Prevention is the best approach to dealing with possible hypoxia development. Before transporting a patient by air, stabilization measures can be undertaken to help reduce the effects of hypoxia. Supplemental oxygen should be provided. If the patient has previously required oxygen, the oxygen percentage can be increased. This increase in oxygen delivery is performed as a prophylactic, temporary measure, and upon arrival at the receiving institution, the oxygen can be decreased or terminated as the patient's condition warrants.

    Proper positioning of the patient combats the effects of hypoxia. The head of the stretcher may be elevated if not contraindicated by the patient's condition. However, in rotor-wing aircraft this elevation is often not possible due to the size of the cabin and placement of the patient within the helicopter.

    Patients experiencing anemic hypoxia can be transfused to increase the hematocrit and improve the oxygen carrying capacity of the blood; however, this measure should not cause a delay in commencing the transport. Additional interventions include providing a calm environment while explaining all procedures and noises to the patient. Often, the patient's hypoxia worsens due to anxiety precipitated by the psychologic stressors associated with transport. Monitoring the patient's vital signs and observing for the signs associated with hypoxia will allow the transport personnel to monitor the patient's response to hypoxia. Portable arterial blood gas analysis may be available in certain transport programs; however, machinery does not replace assessment, and astute observation is paramount.

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    9 . As an aircraft ascends, gas expansion occurs. One hundred cc of gas at sea level would expand at 18,000 feet to
    A) 105 cc.
    B) 200 cc.
    C) 300 cc.
    D) 400 cc.

    TRANSPORT PHYSIOLOGY

    As an aircraft ascends, atmospheric pressure decreases and gas expands (Boyle's law). Gas expansion can be directly measured; 100 cubic centimeters (cc) of gas at sea level will expand to 130 cc at an altitude of 6,000 feet, to 200 cc at 18,000 feet, and to 400 cc at 34,000 feet. Gas expansion is a potential problem in all transports that ascend, but is especially harmful to patients transported in unpressurized aircraft flying above 12,000 feet.

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    10 . Which of the following patients is most likely to experience the stressors of altitude-induced complications?
    A) A patient transported by helicopter
    B) A patient transferred in a pressurized aircraft
    C) A patient transferred in an unpressurized fixed-wing aircraft flying above 12,000 feet
    D) A patient transferred by ground ambulance that must traverse a mountain pass at 4,000 feet.

    TRANSPORT PHYSIOLOGY

    As an aircraft ascends, atmospheric pressure decreases and gas expands (Boyle's law). Gas expansion can be directly measured; 100 cubic centimeters (cc) of gas at sea level will expand to 130 cc at an altitude of 6,000 feet, to 200 cc at 18,000 feet, and to 400 cc at 34,000 feet. Gas expansion is a potential problem in all transports that ascend, but is especially harmful to patients transported in unpressurized aircraft flying above 12,000 feet.

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    11 . After one hour of flying time, the ambient humidity in a pressurized aircraft is less than
    A) 1%.
    B) 5%.
    C) 15%.
    D) 30%.

    TRANSPORT PHYSIOLOGY

    A drop in ambient humidity also occurs with an increase in altitude. This loss of humidity is enhanced in a pressurized aircraft; cabin pressurization is achieved by introducing compressed air from the engines, recycling the air, and removing moisture to protect the aircraft and its electronic systems from corrosion. Ambient humidity in a pressurized aircraft after one hour of flying time is less than 5%.

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    12 . Temperature drops as altitude increases. This drop continues
    A) to negative 25 degrees C.
    B) to negative 55 degrees C.
    C) to an altitude of 15,000 feet.
    D) indefinitely.

    TRANSPORT PHYSIOLOGY

    The standard lapse rate for temperature is that for each 1,000-foot gain in altitude there is a 2 degree centigrade drop in temperature, until the temperature reaches negative 55 degrees centigrade. The harmful effects of a decreasing temperature arise when the fuselage of the aircraft becomes cold. This cold is transmitted through the cabin walls causing the interior to cool. The coldest area in the aircraft is against the outside walls, where the patient stretcher is usually secured. An unconscious patient will not be able to report being cold and the effects of hypothermia may be subtle. An additional factor that impacts this concept is that the transport personnel are working and producing heat; their body temperature may actually feel warm and, therefore, they do not recognize that the environment has cooled significantly.

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    13 . Cold environments impact IV solutions and medications, most notably those containing
    A) water.
    B) glucose.
    C) mannitol.
    D) antibiotics.

    TRANSPORT PHYSIOLOGY

    Cold environments also impact IV solutions and medications, most notably those containing mannitol. Solutions stored in the aircraft are quite cool and should be warmed prior to administration. Mannitol may crystallize when cooled, rendering it useless. These solutions should be stored in the warmest spot in the cabin (usually the cockpit) and, if necessary, rewarmed. Warming of IV fluids can be done by utilizing a heat pack that is wrapped around the IV bag and part of the tubing. While this method will not assist in rewarming a hypothermic patient, it will prevent the administration of cold fluids. Mannitol is usually not stored in the aircraft in cold locales; it is considered to be one of the items that is loaded into the aircraft immediately prior to departure.

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    14 . Negative G forces are most harmful to the patient with
    A) diabetes.
    B) hypothermia.
    C) hypertension.
    D) increased intracranial pressure.

    TRANSPORT PHYSIOLOGY

    Deceleration forces occur upon slowing down, stopping, or during a rapid descent. As most patients are positioned in the transport vehicle with their head forward, these forces produce negative G forces, or "red-out," which is a rush of blood to the head. The term red-out was coined when this phenomenon was noted to produce a momentary reddening of the sclera in the eye as intraocular blood volume increased. Negative G forces are most harmful to the patient with increased intracranial pressure. This rush of blood to the cranial cavity causes a sudden, abrupt rise in intracranial pressure and subsequent deterioration in the patient's level of consciousness.

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    15 . Which patient is at greatest risk for compromised circulatory status secondary to prolonged immobilization?
    A) Pediatric patient
    B) Cardiovascular patient
    C) Patient with spinal cord injury on a backboard
    D) Patient with neurologic compromise

    TRANSPORT PHYSIOLOGY

    The patient at greatest risk is the patient with a spinal cord injury requiring transport on a backboard. It is important to remember that the time of immobilization is not only the length of the transport; ground transport times, unexpected delays, and transfer times should also be considered. As an example, a patient is injured in a motor vehicle accident at a remote site and is secured to a backboard to protect the cervical spine. The patient is then transported to the local hospital for stabilization and evaluation. The decision is made that the patient requires the expertise only available at a trauma center and arrangements for transport are initiated. During the evaluation of the patient, the x-rays are inconclusive and the patient is to remain on the backboard until a definitive diagnosis can be reached. Subsequently, the patient is taken by ground ambulance to the local airfield, flown to the airfield near the trauma center, and is again transferred by ground ambulance to the trauma center. The length of time from the scene of the accident to the trauma center may exceed 5 to 6 hours, although flight time was less than 1.5 hours.

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    16 . All of the following are appropriate measures for minimizing motion sickness, EXCEPT:
    A) Supplying oxygen
    B) Warming the interior of the vehicle
    C) Ensuring that the individual is supine
    D) Encouraging the patient to stare at a fixed object

    TRANSPORT PHYSIOLOGY

    To prevent or limit the effects of motion sickness, transport personnel should apply oxygen and ensure that the individual is in the supine position. Staring at a fixed object will help reduce the inner ear imbalance that precipitates the problem. Cooling the interior of the vehicle also will help reduce the symptoms. In severe cases, insertion of a nasogastric tube to suction will reduce gastric contents and vomiting.

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    17 . If a loss of aircraft cabin pressurization occurs, the crew should first
    A) secure equipment.
    B) put on their oxygen masks.
    C) increase or begin oxygen to the patient.
    D) assess the patient for decompression sickness.

    TRANSPORT PHYSIOLOGY

    Initially, when a loss of pressurization occurs, the crew is trained to put on their oxygen masks and protect themselves first. The pilots will don their oxygen masks and put the plane into an immediate descent. The crew should ensure that all equipment is secured and does not pose a hazard during this descent. The patient should have oxygen administered, or increased if he or she had previously been receiving oxygen. Symptoms of decompression sickness can be treated with oxygen therapy, or in severe cases, a decompression chamber with hyperbaric oxygen therapy.

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    18 . Air ambulance operations are regulated by the Department of Transportation Federal Aviation Administration and must comply with the requirements of a
    A) Part 61 operation.
    B) Part 91 operation.
    C) Part 121 operation.
    D) Part 135 operation.

    THE TRANSPORT PROCESS

    Air ambulance operations are regulated by the FAA and should meet the requirements of a portion of the aviation regulation known as Part 135. These regulations stipulate the qualifications of the pilot-in-command and other flight crew members, maintenance requirements, and aviation management. Part 135 contains some of the most stringent of all the FAA regulations. Additionally, air transport crew members should be cognizant of the Federal Aviation Regulations (FARs) concerning in-flight safety and emergency procedures.

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    19 . The transfer of a patient from one facility to another requires preplanning in order to ensure that
    A) federal requirements are met.
    B) the medical needs of the patient are met.
    C) physician-to-physician contact is made and guidelines for care are established.
    D) All of the above

    THE TRANSPORT PROCESS

    The transfer of patients requires preplanning in order to ensure that both the medical needs of the patient and federal requirements are met. Referring facilities should first assess their capabilities and recognize their limitations for patient care. When a patient is admitted who exceeds these capabilities, an interfacility transport should be effected. Assessment should include, but not be limited to, staffing, equipment capabilities, advanced diagnostic techniques, and the availability of in-house specialty care. Most patients' needs are well within these capabilities; however, it is important to recognize those patients whose needs exceed the available resources.

    The receiving facility should also be assessed as to their capabilities for caring for the needs of the patient. As an example, trauma patients are best cared for in facilities that are designated trauma centers as verified by the American College of Surgeons Committee on Trauma. It is important that each area of care be individually assessed as to how they will meet the individual patient's needs.

    Transferring a patient from one facility to another must meet the federal mandates of COBRA. Each institution should have protocols established for the referral and acceptance of transported patients. Physician-to-physician contact should be initiated prior to departure of the patient to the receiving facility. These physicians jointly share in the legal responsibility for the transport and should establish guidelines for patient care.

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    20 . What is the first step in arranging an interfacility transfer?
    A) Completed documentation
    B) Physician-to-physician communication
    C) Selection of appropriate mode of transport
    D) Stabilization of the patient to limit stressors

    THE TRANSPORT PROCESS

    After the determination has been made that a patient requires transport, there are a number of steps to be taken to ensure safe transport. The referring facility should choose the appropriate transport vehicle, ground, helicopter, or fixed wing. When a dedicated transport program is available, this decision is usually made by general agreement between the referring physician and the transport program. Air transport cannot be chosen indiscriminately; many third-party payers will only cover the cost of air transport when it is deemed medically necessary. The following is a list of steps that comprise an interfacility transfer:

    1. Physician-to-physician communication

    2. Selection of the appropriate mode of transport and personnel to accompany the patient

    3. Signed consent for transfer, signed by the patient or legal representative

    4. Stabilization of the patient to limit the stressors of transport

    5. Completed documentation

    6. Development of a plan of care to be provided in transport

    7. Communication with all involved personnel and family

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    21 . For which of the following types of patients would endotracheal intubation NOT be recommended?
    A) Those with facial burns
    B) Those with pneumothoraces
    C) Those with spinal cord injuries
    D) Those with altered levels of consciousness

    STABILIZATION FOR TRANSPORT

    Endotracheal intubation should be considered in any patient who has the potential to lose their airway due to aspiration, swelling, or edema. This may include patients with facial or neck burns, epiglottitis, facial fractures, or patients with an altered level of consciousness. Patients requiring mechanical ventilation and ventilatory support should be intubated in a controlled environment prior to departure. Examples of these patients include spinal cord injured patients, patients with chest wall injuries, or patients with other neurologic dysfunction.

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    22 . In cases of transfer for limb reimplantation, the amputated part should NOT be
    A) placed on ice.
    B) allowed to freeze.
    C) wrapped in gauze.
    D) placed or wrapped in plastic.

    STABILIZATION FOR TRANSPORT

    Patients requiring transfer for limb reimplantation require special care. The amputated part should be preserved by wrapping it in slightly moistened gauze and placing it into a plastic bag. The plastic bag should then be placed into a plastic container, such as an emesis basin or urine collection cup. This container should then be placed on ice in a cooler. The amputated part should not be allowed to freeze, as tissue destruction can occur, preventing the reimplantation.

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    23 . What is the most important consideration when deciding if a family member can accompany a patient during transport?
    A) Safety of the patient, crew, and family member
    B) Family member's risk of developing motion sickness
    C) Family member's previous flying experiences, if any
    D) Family member's inability to pay for transport to meet their loved one

    STABILIZATION FOR TRANSPORT

    A family member may wish to accompany the patient during the transport. While this may initially appear to be a good idea, the transport crew should consider a number of factors prior to giving the go-ahead for an accompanying member. First and foremost, safety should be considered. A family member should have his or her own seat and be able to be secured with approved straps in the transport vehicle. Accompaniment is almost always impossible in a helicopter. Not only is there no room in the cabin for the family, the additional weight may put the helicopter over its operating weight and balance capabilities.

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    24 . If time permits, which of the following baseline diagnostic studies should be performed prior to transport?
    A) Arterial blood gas measurement
    B) Radiographs of the spine, chest, and pelvis
    C) Measurement of hematocrit and hemoglobin
    D) All of the above

    STABILIZATION FOR TRANSPORT

    The patient's illness or injury and current status will impact which studies are performed. The patient's airway should be examined and stabilized. Chest x-rays may be obtained to rule out any pulmonary complications that can compromise the patient during transport. Arterial blood gases will detect any abnormalities in oxygenation that the patient may be experiencing. Baseline blood studies, including hematocrit, will allow for determination of the patient's hematologic status. In emergent situations, only the basic studies that affect ABC should be performed, as time permits. Studies that should be performed if time permits include:

    • Radiographs of cervical spine, chest, pelvis, and extremities that may be injured

    • Laboratory tests, including hematocrit, hemoglobin content, arterial blood gas measurements, urinalysis, toxicology screens, blood alcohol measurements, and blood typing and crossmatching

    • Electrocardiogram

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    25 . Guidelines for the management of cerebral trauma recommend maintaining the systolic blood pressure at
    A) 70 mm Hg.
    B) 80 mm Hg.
    C) 90 mm Hg.
    D) 100 mm Hg.

    STABILIZATION OF SPECIFIC PATIENT POPULATIONS

    Stabilization of the patient requires the use of supplemental oxygen, often at 100%. Intubation should be considered for all neurologically compromised patients, and oxygen saturations and end-tidal carbon dioxide levels should be monitored. Fluid status should be monitored to prevent dehydration. Guidelines for the management of cerebral trauma recommend maintaining the systolic blood pressure at 90 mm Hg [9]. Patients with suspected cervical spine injury should be transported on a hard backboard with spinal immobilization precautions. Positioning the patient with the head of the stretcher elevated, if tolerated, will reduce the effects of acceleration and deceleration forces. Prior to transport, pressure areas should be padded, and during transport, the patient's position should be changed within the confines of the transport vehicle. The use of cotton ear plugs can reduce extraneous noise; however, the effects of vibration are unavoidable. Neurotrauma patients receiving mannitol should have a Foley catheter placed for urine drainage and measurement of output volumes.

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    26 . During air transport, the tidal volumes on a mechanical ventilator will
    A) increase.
    B) decrease.
    C) not be affected.
    D) increase two-fold.

    STABILIZATION OF SPECIFIC PATIENT POPULATIONS

    In long transports, respiratory patients may require mechanical ventilator support. During air transport, a ventilator should be continually checked. Tidal volumes can be affected by gas expansion; commonly, the tidal volumes delivered will increase incrementally. For most patients, this increase in tidal volume is tolerable. However, there are some patients who cannot tolerate these minor changes in volume and they subsequently develop pneumothoraces. Additionally, ventilators require up to 15 liters/minute of air flow to function properly. This high flow rate rapidly depletes oxygen supplies, which, if not closely monitored, can be life-threatening to the patient.

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    27 . Which of the following types of burns requires treatment at a burn center?
    A) Chemical burns
    B) Burns involving the trunk or neck
    C) Second-degree burns in any age group
    D) Partial thickness burns over 5% of the total body surface area

    STABILIZATION OF SPECIFIC PATIENT POPULATIONS

    Burn patients require transport to a burn center whenever they have large, deep burns or burns that involve the face, hands, feet, or joints. The American College of Surgeons Committee on Trauma published classifications of patients requiring treatment at a burn center, including [11]:

    • Partial thickness burns over more than 10% of the total body surface area (TBSA)

    • Burns involving the face, hands, feet, genitalia, perineum, or major joints

    • Third-degree burns in any age group

    • Electrical burns, including lightning injuries

    • Chemical burns

    • Inhalation injuries

    • Burn injury in patients with significant pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality

    • Patients with burns and concomitant trauma when the burn injury poses the highest risk of morbidity or mortality

    • Burn injury in pediatric patients (transfer to burn center for the care of children)

    • Burn injury in patients who will require special social, emotional, and/or long-term rehabilitative intervention(s)

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    28 . Burn patients at greatest risk of significant fluid loss are those with
    A) electrical burns.
    B) inhalation injuries.
    C) partial thickness burns.
    D) burns and concomitant trauma.

    STABILIZATION OF SPECIFIC PATIENT POPULATIONS

    Hypovolemia is one of the most common problems occurring after a burn injury. Patients with partial thickness burns are at greatest risk of significant fluid loss. This loss of fluid, coupled with the dehydration that occurs in air transport, further compromises the patient's volume status. Evaporative losses are enhanced in the dry cabin environment, further increasing the patient's need for hydration. Prior to transport, a patient should be stabilized with IV fluids and all wounds should be covered with absorbent dressings. The transport team should be aware of the patient's fluid requirements. When determining how much fluid to take in transport, the patient's needs are calculated and that amount is increased again by half. A Foley catheter should be placed to monitor urine output, as this is the best indicator of the patient's response to fluid resuscitation efforts [13].

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    29 . Children are at increased risk for developing respiratory complications during transport because they
    A) have smaller vital capacities.
    B) may refuse to wear an oxygen mask.
    C) have smaller pulmonary surface area.
    D) All of the above

    STABILIZATION OF SPECIFIC PATIENT POPULATIONS

    Hypoxia develops more rapidly in the pediatric patient. Children have smaller vital capacities and a smaller surface area for gas exchange. An additional complicating factor can be that the child will refuse to utilize an oxygen mask. This potentiates the hypoxia as well as increases the risk of combativeness that is precipitated by hypoxia. If a child refuses a mask, oxygen tubing can be held in front of the child's face and oxygen blown at his oral and nasal airways.

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    30 . Which of the following conditions presents unique complications in the pediatric population?
    A) Motion sickness
    B) Gastric gas expansion
    C) Effects of acceleration/deceleration forces
    D) Predisposition to wetter mucous membranes

    STABILIZATION OF SPECIFIC PATIENT POPULATIONS

    The child's gastric cavity is relatively small; therefore, the child is more prone to complications of gastric gas expansion. Gastric and bowel function are irregular, and it may take a long period of time for food to pass into the bowel, increasing the risk of aspiration. Most pediatric nasogastric tubes available do not have a sump attached; these tubes can clog and suction is more difficult to apply. Occasionally flushing the tube with a small amount of water will assist with emptying the gastric cavity.

    Pediatric patients are mouth breathers, which predisposes them to dry mucous membranes. The dry environment in a pressurized aircraft will potentiate this problem. For example, a child with respiratory syncytial virus who has thick tenacious mucous will have increasing difficulty in clearing secretions in this type of transport. Instilling saline into the nasal and pharyngeal passages will assist in thinning the secretions and opening the airways.

    Children have a large body surface area to body mass ratio. This predisposes the child to increased evaporative heat losses and subsequent hypothermia. Transporting a child in a cool environment will enhance hypothermia development, and it is crucial that efforts are made to keep the child warm. With the large surface area of the head, placement of a stocking cap is quite successful in keeping the child warm. Rescue-type blankets can be utilized. However, with the large radiated heat loss a child produces, it is easy for the child to become overheated while wrapped in such a blanket. If a rescue blanket is used, it should be placed over the blankets that cover the child, and the edges should not be tucked in around the child.

    Children are prone to the same effects of acceleration and deceleration forces as adults. The advantage of transporting a child is that their position can be more easily changed within the confines of the transport vehicle, including elevating the head of the child during landing (deceleration) to limit these forces on intracranial pressure.

    Immobilizing the pediatric patient is often challenging, as the child may be too small to fit within the approved stretcher securing belts. Therefore, the crew members should be inventive in their immobilization of the child. Restraining devices need to be secure enough to provide for the safety of the child, while at the same time, not compromising the child's cardiovascular function. Restraining devices that are too tight across the chest of a child can hinder respiratory function and should be avoided. One method of transporting the very small child is to utilize a child's car seat. This offers two advantages. First and foremost is that the child is well secured and safe in the car seat. Secondly, most children feel comfortable in their car seat and may be more cooperative with this increased sense of security.

    Noise, vibration, and motion sickness present the same complications in the pediatric patient as are found with adults. Providing diversionary activities to a child may help remove some of these stressors. Fully explaining all noises and procedures to a child may also reduce their fear and anxiety.

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    31 . A decrease in pulmonary compliance and total lung surface area enhances the elderly patient's risk for
    A) hypoxia.
    B) hypothermia.
    C) hyperventilation.
    D) gas expansion in the pleural space.

    STABILIZATION OF SPECIFIC PATIENT POPULATIONS

    With advanced age comes an increase in underlying disease processes, which should be considered when assessing the elderly patient. A decrease in pulmonary compliance and total lung surface area enhances the risk of hypoxia. Coupled with pre-existing poor respiratory function, elderly patients need aggressive therapies to prevent the problems of hypoxia. Confusion, a sign of developing hypoxia, is often misinterpreted as senile dementia and therefore determined to be acceptable. The transport team has a short interaction with the patient and is not able to fully assess the patient's neurologic status. An accurate history regarding the patient's status from the referring hospital staff will assist the transport members in precisely assessing changes in the patient's condition.

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    32 . During aging, which of the following physiologic changes occur?
    A) Loss of subcutaneous tissue
    B) Diminished hearing and eyesight
    C) Cardiac return and output become compromised
    D) All of the above

    STABILIZATION OF SPECIFIC PATIENT POPULATIONS

    The loss of subcutaneous tissue that occurs with aging predisposes the patient to hypothermia. The patient should be kept warm with blankets, clothing, and hats. Limiting out-of-hospital time will decrease the environmental changes that a patient experiences in transport. The better stabilized the patient is prior to transport, the more efficient the transport process.

    As the vascular system stiffens, cardiac return and output become compromised. Peripheral circulation decreases, and the ability to withstand acceleration and deceleration forces is diminished. Significant fluid shifts can compromise both cardiac and respiratory function. Additionally, the patient's protective mechanisms are less adaptive, preventing self-protection measures. Positioning the patient to diminish these effects is beneficial. The head of the stretcher should be elevated if possible, and during acceleration, the feet can be placed on pillows.

    A unique challenge in the elderly patient with pronounced curvature of the spine is immobilizing the patient on a backboard, should a spinal column injury be suspected. This increased curvature prevents the patient from being secured in a position of good cervical alignment. Additionally, this curvature increases the risk of pressure sore development in areas that are not normally at risk for this complication.

    Immobilizing the elderly patient also increases the risk of the patient developing poor venous return and edema formation. Stabilization measures can include the application of antiembolism stockings to assist with circulatory support in this patient population.

    While it may seem that diminished hearing and eyesight may be an advantage in reducing noise and vibration input, the opposite is true. A patient who cannot fully comprehend the environment will become increasingly confused and disoriented. The patient may not have heard the briefing offered by the transport crew. Elderly patients' pride may prevent them from admitting to this deficiency. Continual reorientation and explanation can help lessen this confusion.

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    33 . All of the following are considered contraindications to the transport of an obstetrical patient, EXCEPT:
    A) acute fetal distress
    B) imminent delivery
    C) toxemia of pregnancy
    D) uncontrolled maternal bleeding

    STABILIZATION OF SPECIFIC PATIENT POPULATIONS

    Transporting the high-risk obstetrical patient involves the stabilization and transport of two patients, the mother and the fetus. The sudden, precipitous delivery of the fetus is always a possibility and should be prepared for. If possible, delaying the delivery would be preferable to all individuals involved in the transport. Contraindications to transport, including acute fetal distress, uncontrolled maternal bleeding, and imminent delivery, may postpone the transport until such time that both the mother and fetus (or newborn) are stabilized.

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    34 . Which of the following causes uterine irritability?
    A) Hypoxia
    B) Supplemental oxygen
    C) Insertion of a nasogastric tube
    D) Placing patient in the left lateral decubitus position

    STABILIZATION OF SPECIFIC PATIENT POPULATIONS

    During pregnancy, increased oxygen consumption occurs, predisposing the woman to hypoxia during times of stress. Hypoxia causes uterine irritability and predisposes the patient to premature labor. For the patient being transported for premature labor, this is a significant consideration. Providing supplemental oxygen throughout the transport and positioning the patient in the left lateral decubitus position will enhance the patient's oxygenation status. If exposed to hypoxia for a short duration, the fetus will experience minimal effects. However, as maternal hypoxia increases, fetal distress will develop as evidenced by a decrease or increase in fetal heart tones.

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    35 . Which of the following piece(s) of equipment should be available during the transport of a high-risk obstetrical patient?
    A) Infant endotracheal tubes
    B) Infant laryngoscope blades
    C) Infant size intravenous catheters
    D) All of the above

    STABILIZATION OF SPECIFIC PATIENT POPULATIONS

    Delivery of an infant is also a consideration. The transport crew should have sufficient training in the delivery of an infant, as well as training in stabilization measures necessary to support the life of the child. Delivery of a child requires that the transport be diverted to a closer facility if additional stabilization measures are required for the infant. Knowledge of the resources available en route is imperative during the pretransport planning. Appropriate size equipment for airway and circulatory management should be easily accessible in the transport environment; this should include, but not be limited to, infant size laryngoscope blades, infant endotracheal tubes and suction catheters, infant intravenous catheters, and intravenous fluids used for neonates. Methods of maintaining the child's body temperature should be available, including rescue blankets and stocking hats.

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    36 . Care in transport should include, but not be limited to,
    A) vital sign assessment.
    B) airway maintenance.
    C) fluid intake and output measurements.
    D) All of the above

    DETAILS INVOLVED IN THE TRANSPORT OF PATIENTS

    To maintain patient stability, the transport crew functions under standing transport protocols as well as physician orders. The interventions that can be undertaken include, but are not limited to, airway stability, suctioning, fluid management, performing advanced life support measures, administering medications, and either chest tube or flutter valve insertion. Monitoring the patient involves the utilization of a cardiac monitor, pulse oximeter, and capnography. Doppler monitors are employed to assess pulses when auscultation is difficult. Analysis of blood results is possible utilizing transportable bedside testing devices.

    Vital sign assessment should be completed at frequent intervals to allow for early detection of patient deterioration. The patient's level of consciousness should be frequently monitored; hypoxia is a common cause of neurologic decline. Fluid intake and output should be frequently checked, as gas expansion occurring in air transport can cause changes in the fluid infusion rates.

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    37 . In choosing equipment to utilize in the transport environment, which of the following factors should be considered?
    A) Weight
    B) Ability to be safely secured
    C) Protection from electromagnetic interference
    D) All of the above

    DETAILS INVOLVED IN THE TRANSPORT OF PATIENTS

    Statutory law regulates the equipment required in ground transports. In many states these statutes also regulate the operation of air ambulances. The minimum equipment needed for maintaining the stability of the ill or injured patient is listed in Table 3. Additional items can and should be included as the patient's condition and needs dictate. Equipment utilized in the transport environment should meet specific criteria, including but not limited to being: lightweight; portable; easy to secure; easy to clean; able to be utilized with battery backup; able to be used both in and outside the transport vehicle; and able to withstand the stressors of altitude and movement.

    Medical crew members should be familiar with the operation of the equipment in the transport vehicle, as well as be able to repair the equipment should it fail. The crew members should ensure that an adequate supply of disposable equipment is available to last for the length of the transport, with consideration of possible delays that may extend the projected transport time.

    All equipment utilized in the transport environment should be easily secured. Equipment packs made of soft material are generally utilized for disposable equipment. If the equipment requires a power source, a backup battery source should be available if the power fails. The team could utilize hand-powered devices, such as resuscitation bags for ventilating the patient, if a ventilator failure were to occur. All equipment should be protected from electromagnetic interference. If not, radio transmissions may render the equipment nonfunctional.

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    38 . A safe landing zone for a helicopter should measure at least
    A) 50 by 50 feet.
    B) 75 by 75 feet.
    C) 150 by 150 feet.
    D) 200 by 200 feet.

    PRINCIPLES OF TRANSPORT

    Helicopter transports create a large amount of interest. Many people assemble to watch a helicopter take off and land. These bystanders should be kept away from danger. A safe landing zone should be established in a clearing that measures at least 75 feet by 75 feet, although most pilots prefer a landing area of a minimum of 100 feet by 100 feet. The landing surface should be solid; sand and gravel should be avoided. The slope of the landing site should be no greater than 8 degrees, otherwise the tail rotor is at risk of contacting the ground. All wires, trees, and other possible hazards should be marked and verbally described to the pilot. Smoke flares are used to assist the pilot in locating the landing zone, but it is imperative that these be removed prior to the helicopter's approach as they may obscure the landing zone and can be blown away, possibly causing a fire. All loose items should be removed from or secured to the landing zone.

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    39 . When a helicopter is approaching a landing zone, the patient and crew members should be at least
    A) 100 feet from the landing site.
    B) 250 feet from the landing site.
    C) 500 feet from the landing site.
    D) out of sight of the landing site.

    PRINCIPLES OF TRANSPORT

    When the helicopter is making its final approach, the patient, ground crew, and bystanders should be at least 500 feet from the site and should be directed to turn their backs to the helicopter. This is the hardest rule for bystanders to comply with; they came to watch and they will watch. The rotor wash, created by the rotating blades, causes swirling dust and gravel, posing a hazard to all individuals. Landing in the snow poses a real hazard, as the rotor wash produces a momentary whiteout condition. Additional hazards are created when the rotor wash blows loose items up and around. This can include stethoscopes hanging around a team member's neck, sheets covering the patient, or transport forms.

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    40 . When providing care for a patient, the crew members must act within
    A) safe and reasonable actions.
    B) the guidelines mandated by the state.
    C) the guidelines developed by the medical control officer.
    D) Both B and C

    MEDICAL-LEGAL ISSUES

    Regardless of the environment, when an individual is employed and on duty, he or she has a responsibility to provide health care within the limits of their licensure. Nursing practice acts and emergency medical system guidelines outline the responsibilities of nurses, paramedics, and emergency medical care technicians. When transporting patients, these transport crew members should function within the guidelines of their state administrative codes, as well as within the protocols for care as outlined by the medical control officer.

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