Pediatric emergency medicine trisk 83

FIGURE 11.8 An example of “Welcome Pamphlet” given to families of transport patients of
The Children’s Hospital of Philadelphia. (Used with permission, © The Children’s Hospital of
Philadelphia, Philadelphia, PA.)

Regardless of their degree of involvement, physicians should be aware of the
air medical transport resources and capacities in their region. Two basic types of
air transport exist: RW helicopter and FW aircraft. RW aircraft are common in
both rural and urban EMS systems, are typically hospital based, and usually carry
a nurse, respiratory therapist, or physician as one (or more) of their crew
members, while some services have a paramedic (EMT-P) as a primary crew
member. The unique capabilities of rapid, direct scene response give the RW craft
a distinct advantage over FW aircraft and ground units in some cases. Helicopter
EMS (HEMS) have allowed for the provision of ALS services to larger rural
areas incapable of sustaining independent ALS units, and have provided access to
tertiary care centers for patients in regions without such centers. In both rural and
crowded metro and suburban areas, RW aircraft offers the benefit of time saved in
transit—a significant benefit in cases such as trauma and surgical emergencies.
However, recent research has suggested that direct air transport from an accident
scene to a trauma center for pediatric patients may not improve survival when
compared with local hospital stabilization prior to air transfer. Moreover,
Engbrecht et al. noted that interfacility transport of patients by RW aircraft was
generally not predictive of need for acute intervention in their study population,


but recognized a subgroup where rapid transport was useful (epidural hematomas,
vascular compromise/open fractures, and penetrating neck/trunk injuries).
Safety of the transport personnel must also be a priority. Avoiding the use of
RW transport in bad weather is a good example of a safety decision in the
transport environment. Improvements in HEMS safety profiles were recognized
when pilots were isolated from specific patient care information for transport
requests. Instead of being informed that a critically ill child might die without

their intervention, pilots now should make “go” or “no go” decisions based solely
on weather, flight personnel, and equipment issues. If an appropriate “no go”
decision is made, this should not be questioned or countermanded by medical or
administrative personnel. If a “no go” decision is made based on weather
considerations, another mode of transport or other patient care options must be
considered. Competition between transport programs or aeromedical providers
can be a safety hazard. In efforts to gain a competitive advantage, programs (or
specific personnel) may be willing to consider circumventing weather and safety
rules. Optimal policies for safety-conscious systems include when a transport is
denied by one air service for weather-related issues, those same transports are not
offered to another air service unless it is located in a different environment that
may not be subject to the same weather issues.
Unfortunately, the HEMS industry has seen periodic increased accident and
fatality rates. Compared to ground ambulance transport (15 million annual patient
exposures), the fatal accident rate is greater for helicopter transport by
approximately 13.5 times, however in the last three decades the accident rate in
HEMS has declined by 71%. In 2006, the National Transportation Safety Board
(NTSB) critically reviewed 55 HEMS accidents and found that over half of the
fatalities could have been prevented with systematic corrective actions. This
review resulted in safety initiative recommendations, which are outlined in the
NTSB publication, Special Investigative Report on Emergency Medical Services
Operations, available at www.ntsb.gov . The following recurring safety issues
were noted: (i) Less stringent requirements for EMS operations conducted
without patients on board, (ii) lack of aviation flight risk-evaluation programs for
EMS operations, (iii) lack of consistent, comprehensive flight dispatch
procedures for EMS operations, and (iv) no requirements to use technologies such
as terrain awareness and warning systems (TAWS) to enhance EMS flight safety.
Interventions by the FAA have resulted in safety improvements, including
certification of night vision goggles (NVG) for helicopter use. Other
recommendations include TAWS, more stringent flight operation requirements,

improved preflight risk management and hazard identification, and mitigation


programs with formalized dispatch procedures to include up-to-date weather
information and assistance in flight risk-assessment decisions. Although there is
not a singular intervention or assessment tool that will guarantee risk-free air
transport, accreditation by the CAMTS demonstrates adherence to the safety
standards proposed for the air medical transport industry.

Vehicle Safety
Accidents involving ground ambulances are tragically common. In these
accidents, the rear compartment of the vehicle is an extremely dangerous place.
Every patient must be safely restrained in the vehicle with shoulder and body
straps, in a position that minimizes further injury and protects the airway;
however, this can pose a significant challenge with pediatric patients. Current
guidelines for the safe transport of children in ground ambulances have been
published by the National Highway and Traffic Safety Administration
( ).
Every ambulance should have the capacity to secure a child or infant safely. If
the patient is an infant and his or her medical condition permits, the use of an
approved child safety seat (CSS) should be encouraged in a forward facing seat
without an airbag. However, these are not available in most ambulances and do
not allow for ease of continuous monitoring. In some ambulances, there is a seat
in the rear of the vehicle that can be opened into a CSS that may be appropriate.
For infants and small children who are to be secured on the ambulance cot, there
are techniques that can be used to make this practice as safe as possible to reduce
the chance of another injury if the vehicle is involved in an accident either using a
commercial car seat in accordance with manufacturer guidelines or a commercial
device approved for medical transport ( Fig. 11.9 ). New products are available,
many of which have been crash tested to establish their safety capabilities, that

can safely secure a child to the ambulance cot, such as a restraint developed by
Ferno (Wilmington, Ohio) ( ). These
devices can be used for children too large to fit in a CSS or as an alternative to a
CSS.
The transport provider must take great care to ensure that the patient is
properly attached to the cot, and that the child’s head, torso, and pelvis are
appropriately secured to prevent injury in an accident. It is important to keep in
mind that many of these products may not have established crashworthiness, and
the degree of protection they provide is unclear. The family’s own car seat, if able
to be secured properly in the ambulance, may be an excellent choice for
noncritically ill patients without special needs. This also encourages a safe


discharge home from the hospital, by already having the child’s safety seat
available. Most critically ill patients are not appropriate candidates to be
transported in a car seat.

FIGURE 11.9 A, B: Diagram of a car seat attached to an ambulance cot. A: Recommended
method for restraining children up to about 18 kg who can tolerate a semiupright seated
position, showing belt attachment to the cot and routing through the convertible child restraint.
B: Recommended method for restraining infants who cannot tolerate a semiupright seated
position, showing belt attachment to the cot and routing through the car bed loops. (From Bull
MJ, Weber K, Talty J, et al. Crash protection for children in ambulances, recommendations and
procedures. In: Proceedings of the 45th Annual Association for the Advancement of Automotive
Medicine . 2001:353–367. Reprinted with permission from the Association for the
Advancement of Automotive Medicine.)

Transport providers and passengers must also be properly restrained in the
ambulance. Sixty percent of the fatalities in a study of ambulance crashes were
ambulance personnel who were unrestrained in the patient compartment.

Additionally, all monitoring equipment must be secured to the frame of the
ambulance, because even a low-speed collision can turn loose objects into fatal
missiles for a child, provider, and/or passenger. It is unacceptable to transport a