Aeromedicine: Packaging a Patient for Flight

Patient Preparation

Transition of Care

Packaging of a patient is the most important part of the transport of the patient.

• C- spine patients must be immobilise with head blocks or blanket roll with the correct size cervical collar and on a scoop or trauma board with the spider harness.
• Intubated patient should have the correct size ET tube with water in the cuff and properly secured.
• Naso/Orogastric tube properly secured
• A blanket or sheet is will cover the patient in total so you will scoop the patient and the sheet and “packaging” the patient in the sheet to cover him/her up totally before loading on to the aircraft stretcher.
• Ensure that the patient has bilateral IVI lines and that they run parallel to the patients left or right arms.
• The catheter must be between the legs, drained and the amount measured before the flight, the bulb must be full of water
• The underwater chest drains must be changed to Heimlich valves and catheter bags.
• Put padding under patients pressure points.
• Any fractures that has POP on must be Bi-valved and must be kept in place with crepe bandage
• Pelvic #’s must have a pelvic grip in place ensure the correct size.
• Ensure that the referring notes, x-rays, scans are in your possession before leaving the referring hospital and that your patient is properly identified.
• Head injured patient we must ensure that there is no air in the cranium because of changes in the atmospheric pressure.

Patient Preparation

A. Airway - when in doubt, intubate

1. Due to altitude physiology considerations, aggressive airway management is encouraged.
2. Feel free to call the AMS No: 08611 267 267   to discuss airway management options with the duty physicians, either prior to lift-off or while the helicopter is en route to your hospital.
3. The flight crew can also make an airway management decision upon arrival. The medical team will frequently use rapid sequence induction to facilitate immediate intubation in the patient requiring an emergent airway.

B. IVs

1. Trauma cases/bleeding problems:  all patients need 2 IVs, preferably 14-16 g. IVs, but a smaller gauge will do.  Please use blood tubing for set-up so there is no delay switching over to blood tubing before transport; add an extension set (not a t-connector) to the blood tubing.
2. Unstable, or potentially unstable cardiac/medical patients also require 2 IVs, or a twin cath, not necessarily large bore.  One iv may be capped.  Use extension sets on the iv set-up; this facilitates switching over to FFL's infusion pumps.
3. Tape, tape and more tape.

C. Tubes - Flying at an altitude will cause gas expansion, increasing the chance of vomiting (of special concern if decreased LOC) or enlargement of a pneumothorax.

1. NG tube:  will be used if the patient is vomiting or intubated.                            **remember, use an OG tube if facial fractures are present**
2. Chest tube:  will be used if a pneumothorax is present.

D. X-Rays

1. The only x-ray absolutely necessary prior to transport on trauma patients is a chest x-ray.
2. Leave the spine board in place while taking x-rays and until the flight crew has assessed the patient.
3. A c-spine x-ray is not essential on trauma patients prior to transport if the patient is kept in good spinal immobilisation.

E. Splinting

1. Particularly important for trauma patients because of the potential for c-spine injury. Keep all immobilisation in place, even if the x-rays are completed, until the flight crew has arrived and assessed the patient.  It eliminates the time taken to re-immobilise if there is a question regarding interpreting the X-rays.
2. Extremity splints:  leave on; AMS will return equipment to the hospital a.s.a.p.
3. Pad pressure point areas on all patients on a spine board.  The benefits of use of a vacuum mattresses.

F. Sedation/Restraints

1. Due to safety considerations when transporting a patient via helicopter, the flight crew will make judicious use of chemical, as well as physical restraints on all patients. 
2. Of particular concern are patients who have ingested drugs and/or alcohol, combative patients, and those who have sustained a head injury.  These patients will be physically restrained, even if they are unconscious, as they may "wake up" during the transport.
3. Anxious patients (particularly cardiac) may be sedated prior to the arrival of flight crew, if not contraindicated.

Transition of Care

A. Who's in Control?

1. The flight medical crew assumes primary responsibility for the patient's care when the referring physician clearly indicates that he/she is relinquishing this responsibility to the flight crew.  The flight crew may ask for clarification of this point through clear discussion, i.e., "would you like me to assume care for the patient at this time?"
2. Documentation of care:  verify your hospital's policies/procedures regarding proper documentation during the transfer of care. 
3. Responsibility to give/take orders:  generally, flight paramedics take orders from flight physicians or their medical control physician; referring hospital MDs give orders to referring hospital

B. Report - The flight crew may split up to obtain report from your staff, and begin their patient assessment, depending on the circumstances.

C. Assessment/Equipment Transition

1. Flight personnel work with you to simultaneously assess the patient as the monitoring/infusion equipment is switched to the transport equipment.
2. Pressure bags are placed on all free-hanging IVs.  **generally, in adult trauma patients, IR and/or NS should not be running through infusion pumps**
3. Infusion pumps:
4. Extension sets at the end of iv tubing will greatly expedite switching over to the FFL pumps.
5. With multiple drips, FFL will use a lot of labels for pumps and tubing.

D. Records                                                                                       

1. Helpful to the flight crew, but not essential, is to enclose 2 copies of the face sheet on all transfers.  If the patient is not returning to referring facility, double copies of all medical records expedites flight crew transition of care at the receiving hospital.
2. Please call the receiving facility's inpatient unit with a report so that they can prepare medication drips/ventilator/etc.

E. Family

1. Flight crew  will make every attempt to speak with family members to explain what we are doing.
2. The pilot is often the one who interacts with the family (eta, maps, concerns).
3. Family cannot fly in the helicopter.
4. The patient's valuables and clothes should remain with the family.
5. Family packet information is available from the flight crew.