1. Transferência para Tratamento Definitivo
12-1 Title Slide
Note: This interactive lecture is presented by the course director
The course director should introduce the topic and relate to the students that based on their preparation for the course, a series of questions will be asked throughout the lecture, and their active participation and responses are expected.
The first mouse click causes the “Committee on Trauma” to “type” in and the second click causes the photograph to zoom in followed by the lecture title.
Pressing the down arrow key on the computer keyboard or left-clicking on the mouse initiates the animation on the slide. For brevity in this dialogue, mouse clicking is referenced. However, either method may be used.

2. Objetivos
Identificar os doentes traumatizados que possam necessitar de transferência de uma unidade de atendimento primário para um centro de trauma
Iniciar os procedimentos necessários para transferir o doente da melhor forma possível e de maneira segura
12-2 Objectives
The course director reviews the objectives with the students as provided on the slide. Each objective appears with a mouse click, and the preceding item dims as the next one appears.

3. Questões-Chave Qual é o problema? Quem deve ser transportado?
Para onde encaminhar o doente?
Quando transferir o doente?
Como transportar o doente?
12-3 Key Questions
The course directorr reviews these questions with the students, relating that their responses are expected during the discussions. Each question appears with a mouse click, and the preceding item dims as the next one appears.
Each key question appears with a mouse click, and the preceding item dims as the next one appears.

4. Princípios de Transferência
Conhecer os recursos da instituição
Estar preparado, antecipar as necessidades do doente
Não agravar as lesões
Identificar os doentes cujas necessidades excedam os recursos da instituição
Fazer apenas os procedimentos essenciais
12-4 Transfer principles
Slides 4 and 5 pertain to transfer principles
The course director should first query the students, “What does transfer the patient mean?” The course director also may ask the students for the definition of stabilization and transfer, which should be “to cause to pass from one place to another.”
The course director then reviews with the students, the transfer principles included on slides 4 and 5.
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5. Princípios de Transferência
Estabelecer comunicação direta entre o médico que encaminha e o que receberá o doente
Transportar para o hospital apropriado mais próximo
Utilizar o meio de transporte mais adequado
12-5
(See narration for slide 12-4.)
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6. Qual é o problema? Quais são as lesões do doente?
Que outras informações da equipe pré-hospitalar são necessárias?
Que preparação deve ser feita?
Quais são as necessidades do doente? Podem ser plenamente atendidas?
12-6 What is the problem?
The course director may wish to present a patient scenario for the group to analyze or ask the students to present a patient scenario of their own. For example, “What was the last patient you had to transfer?” or “ What was the last patient that you received via interhospital transfer?”
By having prior knowledge of the specialty and geographic location of the students, the course director tailors the scenario in a manner such that the patient’s injuries exceed the capabilities of the rural/small commuity emergency department resulting in interhospital transfer, or that of the emergency department in a designated trauma center resulting in the patient’s transfer to surgery (intrahospital transfer.)
The question, “What is the problem?”, is then asked to determine the problem before the patient arrives at the initial care facility. The students should be thinking and responding in terms of what must be done to solve the problems defined in the scenario and to offer the patient an optimal outcome. These questions may help guide the discussion.
Given the history of the incident, what injuries might you anticipate?
What additional information might you want to obtain from the prehospital personnel about this patient and why?
What preparations should you make before the patient arrives?
What are the capabilities of your institution and staff members? Does the possibility exist that this patient may require transfer to another institution?
What additional questions, if any, should you ask of the prehospital care personnel?
Now that the patient has arrived, what must you do?
The course director should listen for and positively reinforce the responses that lead the group to the conclusions that the patient’s degree of injuries exceeds the capabilities of the primary receiving facility/department and its staff members. The problem is now identified and the determination should be made that the patient requires transport to another facility or to another individual’s care.
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7. Quem deve ser transportado?
Pacientes com trauma multissistêmico
Pacientes cujas necessidades excedam os recursos da instituição
Pacientes com comorbidades
12-7 Who do I transport?
The discussion now progresses to “Who do I transport?” The purpose of this phase of the discussion is to get the students to concur that transfer is required when effort constraints exist and for patients who exhibit evidence of multiple trauma, whose conditions are not stable, or whose required level of care exceeds the management and diagnostic capabilities of the local institution.
During this discussion, the students can relate patient situations that, when compared with the capabilities of the local institution, make it apparent that the patient’s degree of problems cannot be managed. To further emphasize who should be transported, time permitting, the course director could introduce injury severity scoring into the discussion by presenting the examples of trauma patients, and have the students quickly calculate the patient’s Revised Trauma Score or Pediatric Trauma Score. This also is an excellent time to bring into the discussion the fact that, even though there are patients who could be managed at the local institution, there is a limit to the number of patients who can be managed by the institutional and professional resources available.
The course director summarizes by identifying all of the different types of cases that fall into each group. The generic category of “Effort Constraints” represents rural hospitals and urban centers, and their doctors who choose not to participate in a system of care because they do not want to make the effort (private practice is too busy or no desire to treat trauma patients) or cannot make the effort (limited resources in the community or hospital).
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Extremos de idade
Doença prévia

8. Para onde encaminhar o doente?
Para uma instituição que disponha do equipamento e dos recursos necessários
Aos cuidados de um cirurgião qualificado que seja capaz de:
Fazer os diagnósticos
Tratar as lesões encontradas
Assegurar os recursos necessários para o atendimento do doente
12-8 Where do I send the patient?
After the students have identified the type of patients to be transferred, the discussion progresses to “where” the patient should be sent, with the course director asking the aforementioned question.
During this discussion, the students may relate specific institutions, characteristics of the institution capable of managing the patient ,and the capabilities of the individual who should be caring for the patient. The course director can add emphasis here by identifying available resources and the present system of trauma care in the region where the course is being conducted, especially if the group members are all from the area.
If the students are having difficulty in determining where the patient should be transferred, the course director can query the students about what information is needed to make the decision. Their answers should lead the students to discover the significance of preplanning discussion previously and how this integrates with where the patient should be transported.
If students identify that the patient should be transported to the care of a neurosurgeon (versus only a consultant role), this is an excellent opportunity for the course director to capitalize on this suggestion. The course director should state that a patient with multiple injuries should be transferred to the care of a qualified surgeon. To add import to this concept, the course director can elaborate on a number of cases that went awry; for example, a patient who was managed by a neurosurgeon for an apparent head injury. The patient subsequently died, not from the head injury, but from a ruptured spleen.
At this point in the discussion, the students should have discovered and internalized three concepts. The course director can summarize this portion of the discussion by paraphrasing the question and students’ discoveries. The patient should be transferred to a facility that can: (1) make the diagnosis, (2) manage the patient’s injuries, and (3) make the commitment of effort and resources.
In concluding, the course director should emphasize to the students that it is important to remember the concept of interhospital versus intrahospital transfer. The patient may not require transfer to another facility, but to the care of a surgeon who directs the patient to the operating room or the intensive care unit.
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9. Quando transferir?
Depois que as lesões com risco de vida tenham sido tratadas
Depois que as lesões que podem deixar seqüelas tenham sido estabilizadas
Depois que a transferência tenha sido acertada
Antes de fazer exames ou procedimentos que não sejam essenciais no momento
Não perder tempo!
12-9 When do I transfer the patient?
The next phase of the discussion deals with the question of “When?” The purpose of this phase of the discussion is to have the students concur that the transfer process should be initiated when the determination has been made that the patient’s injuries exceed the capabilities of facility and/or personnel. Furthermore, the students should discover that the patient is transferred when the basic components of initial assessment and management (life-threatening and potential life-threatening or disabling injuries) have been accomplished. The course director can refer the students to the list of protocols outlined in Chapter 12 in their manual. The course director should emphasize that it is not appropriate to perform procedures that may result in further harm to the patient; for example, delays incurred when performing unnecessary tests or procedures that do not optimally stabilize the patient’s condition. This applies to both interhospital and intrahospital transfers.
The students need to ascertain the points listed herein that the course director can utilize to conclude the discussion on “when.”
The patient should be transferred:
After lifesaving problems are managed (ABCDEs).
After life-disabling injuries are stabilized (secondary survey, time permitting).
After the transfer is arranged.
After the patient documentation is completed.
Before performing unnecessary tests or procedures that do not contribute to optimal stabilization.
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10. Como transportar? Depende de:
Cuidados necessários durante o transporte
Destino do paciente
Recursos disponíveis
Acordos de transferência vigentes
12-10 How do I transport the patient and with whom do I communicate?
Now that the “what, who, where, and when” have been discussed, the course director can progress to the last two pertinent questions related to this discussion“How is the patient transported and with whom do I communicate about the patient transfer?”
The discussion should be aimed at having the students arrive at the conclusion that the mode and level of transportation depend on these issues:
What the patient’s problems are.
What care has already been administered to the patient.
What level of care is required en route.
Where the patient is going.
What they are used to accessing in their community.
What resources are available in the area.
What, if any, specific state policies dictate.
The existence of prearranged transfer agreements.
Once the students reach a consensus that all these factors require consideration, the course director can emphasize that this information supports the importance of their need to know the capabilities of the various facilities in the area and of any related legislation. The students’ responses may vary during the discussion, depending on the group’s homogeneity or heterogeneityby air or group (interhospital) or by gurney (intrahospital), and with basic or advanced life support measures. The students should discuss the variables and the pros and cons related to each mode and level. This is an excellent opportunity for the course director to emphasize that the level of care must not deteriorate during transport.
Questions that the course director can use to help guide this discussion are, “If the patient is transferred to another facility, how would you prepare the patient?” Or, “If the patient is transferred to the neurosurgical intensive care unit, how would you package or prepare the patient?” The students may identify a series of variables, eg, maintain the airway, stabilize fractures, send all laboratory work with the patient. The course director should make the point that, regardless of whether the patient is transferred via air or ground transportation or by gurney to another department in the receiving hospital, the only difference is distance. After making this point, the course director can maneuver the discussion by asking, “Who do you talk to and what do you say?” From their discussion, the students should agree that only through direct communication between the referring and receiving doctors can the patient’s status and need for transfer be expressed and addressed adequately. The course director concludes this segment of the discussion when the students discover that, regardless of the mode or level of patient transfer, the referring doctor’s responsibility to the patient ends when the patient’s care is relinquished to another individual.

11. ?
12-11 Questions
The course director asks for questions and then pauses, allowing the students time to form and ask their questions.

12. Resumo
Qual é o problema? Nem todos os hospitais têm condições de tratar de todos os traumatizados.
Quem deve ser transferido? Os doentes cujas necessidades excedam os recursos locais.
Para onde encaminhar o doente? Idealmente, para um centro de trauma reconhecido.
12-12 Summary
Slides pertain to the summary.
The course director summarizes the presentation by reviewing the principles of stabilizing and transporting the injured patient, and the “who, what, when, where, and how” issues. Additionally the course director should reiterate in the summary that all injured patients must be accurately assessed and resuscitated, patient transfer should be expedient, and definitive care and the transfer process should not be delayed unnecessarily.
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13. Resumo
Quando transferir o doente? Depois que as lesões com risco de vida imediato tenham sido tratadas.
Como transportar o doente? Depende da situação do doente e dos recursos disponíveis.
12-13 Summary
See narrative for slide 12.
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