1. Pediatric Transport Medicine (MD’s perspective) Pediatric Transport Anjali Subbaswamy, MD Critical Care Medicine Children’s National Medical Center

2. Overview People Process Medical Care

3. Who and why Why – diagnostic or therapeutic - MD discomfort - parental request Who – any age, any illness - must be stable enough

4. Utility vs Futility The benefits of transport must outweigh the risks for the patient limited space, equipment, staff separation from family The risks/costs of transport must be justified

5. History First AAP guidelines 1986 Goal – to provide a safe envt btw H’s Most peds is interfacility (US) <10% of ambulance calls are pediatric 15 kids/mth

6. Lack of pediatric expertise Average EMS provider sees: 1 peds BVM case q 1.7 years 1 peds intubation q 3.3 years 1 peds IO line q 6.7 years Federal EMS-C program (1984) funds educational efforts by states

7. Turn around time Emergent – trauma - where to? Urgent – DKA - ASAP – depends on logistics Routine – for subspecialty care - 24-72 hours

8. Reimbursement Patient’s insurance Taxes Out of pocket

9. Pediatric vs Adult Different pathologies More equipment (sizes) +/- parent Early goal-directed rx vs Scoop ‘n run

10. The players Sending Person who calls 911 Referring hospital MD Referring hospital RN Pt’s legal guardian Receiving State police Local EMS Pediatric transport svc Referral hospital ER Accepting physician

11. Med Control Physician PEDS ER OR PICU Accepts pt, consults subs Sends appropriate team Directs stabilization Provides ongoing direction to transport team

12. Accepting MD responsibilities Legally – when transport team arrives on scene can be tricky (ex) Insulin not started for DKA pt Ethically – when you accept the pt on the phone

13. TEAM Composition ALS team (10%) MCP Paramedic EMT Critical CareTeam (90%) MCP RN +/- RT +/- MD Paramedic EMT

14. Case 1 – 7 yo MVA ~1 hr

15. The process OSH/EMS calls referral center Accepting physician (aMD) identified MCP directs transport team Pt arrives to ED or on unit aMD provides feedback to OSH + PMD

17. Vehicle selection Ground – space and option to stop Fixed Wing – stability in bad weather Helicopter – land at scene, speed

18. Referring hospital responsibilities Call appropriate referral center +/- transport svc Copy patients chart Obtain written consent from parents Document acceptance by referral MD Stabilize lines, tubes, splints MD gives report to transport team RN gives report to receiving RN Provide parent w/written destination

19. Case 2 Pneumonia 2 yo at OSH inpt for 3 days Nec Pna, Abx – resp distress Called for PICU admission 3 hr turnaround time Correct dx? Correct representation of resp distress?

21. WRAMC contracts with CNMC CNMC 5000 per year 20% neonatal 80% pediatric WRAMC and affiliates - 261 last year

22. Case 3 4 yo w/CNS tumor Obstructive HC, VPS, Sz d/o Make-a-wish trip to Disneyworld … Status epilepticus transferred for social reasons (home)

23. MEDICAL CARE Equipment Medications Monitoring

34. Specialized meds Come with patient (factor in travel time/delays) Pre-ordered at recv’g site if poss. chemotx, off-label meds, timed abx, metabolic cocktails, all gtts

36. Monitoring Medtronic Lifepak 12 Monitor/defibrillator 12 lead ECG NIBP Capnography 2 invasive lines Vital sign trends Bluetooth wireless POC testing

37. Case 4 2 yo s/p Fontan admitted to WRAMC for pna Required Bronch, VATS, intubation ASA 4 intubation risk L MS bronchus compression Predicted LOS 5-7 days Elective transfer to CNMC

38. Conclusion People Process Medical Care