What I did: Pediatric Critical Care Transport 1989-1994

When I became the medical director for the pediatric critical care transfer program it was a small program serving an area approximately three times the size of the state of Vermont. Transports by ambulance could take over an hour to drive and by helicopter 45 minutes. The team consisted of one pediatric resident taking a call rotation and one transport-experienced nurse and respiratory care practitioner.



The major problem they encountered was friction in the Emergency Department (ED) when they arrived to pick up the child. The ED staff desired a rapid removal of the child and believed that their stabilization was sufficient. The transport team, experienced in working in the constrained environment of the vehicle and responsible for the extended period of time in the medically austere environment, referred to become better acquainted with the child's condition and ensure the stability would last during the transport. Also, many physicians believed it was better to transport the child rapidly using a paramedic vehicle and not have a higher level of team.

To remedy this, I drew upon my fire department Rescue Ambulance experience working in South Los Angeles. It was not uncommon to have hostile bystanders and, depending on the engine company, uncooperative firefighters to assist. I advised them to enter the ED as if it was a hostile scene.

They would enter the ED and greet the caregiving team, ask about the patient's condition, and complement them on the care rendered. Further, they would identify something specific they could complement an individual on. They were to make no comment until they had physically examined the child. (I learned this from another medic who told me to never make a diagnosis until I had taken a blood pressure reading. No matter what the patient's problem, no one would listen to me unless I had taken an action to examine the patient and a blood pressure reading was the most obvious. This was a matter of demonstrating interest in the patient's condition and building trust.)

After a few visits like this, I predicted the people would begin watching them. The team was to stand in a position that people could see what they were doing and, if the person stood by or walked close enough, they would talk openly about the actions they were taking. If anybody asked the question they would answer it simply with a very short answer and conversational tone. They were to pay close attention so they do not sound condescending.

This is exactly what happened and after about six months our relations improved dramatically. ED staff began contacting me to complement us on our team.

Then another problem arose, we were called out and we began to have more severe illness in our patients. Our transport team began to request laboratory evaluations and radiologic examinations. This not only delayed transport but also caused confusion as to who had the hospital privileges to order these studies. While the patient was in the ED under our care it was considered an admission to our hospital. However, our staff did not have the authority to order the studies. But the most serious problem was the delay in care and the question whether it was necessary.

At this point I focused on clinical evaluation at the bedside and decision-making based on response to therapy. The team had to rely on their senses and perception. Unfortunately, people are taught that their senses can fool them. I developed several lectures to demonstrate that our senses are quite sensitive and that if we are aware of how we can be full we can navigate to the environment quite successfully.

This worked quite successfully except for three deaths in a six-month period because of airway problems. We began use of a five-point respiratory exam that did not require chest x-ray studies or evaluation of the blood gas. We also focused on airway stabilization prior to moving the child. We never experienced another death during transport.