Transfer Training

Attended a Transfer Training course today. I know what you’re thinking, who needs training to learn how to transfer a patient? What rocket science is involved in the few seconds or minutes to transfer someone from one bed to another? Or how much of preparation and thought needs to go into transferring a patient from one hospital to another? It has to be fairly simple right? Atleast thats what I was thinking when I was applying for the course, I thought it’s going to be like a 30 minute session, Bam Bam, thanK you, Ma’am type situation. Boy was I wrong – this was an 8 hour long proceedings, and I actually learnt quite a bit. Some gems from today’s talks:

Movement effects
Movement of any sort brings with it it’s own demerits. So only move the patient if absolutely necessary. Deceleration causes gastric contents to come up; it also may cause fluid to ‘back up into the lungs’.
Acceleration causes the opposite: hypotension, decreased preload. Both may lead to heart failure

Limit affects of any sort by making sure patient is well hydrated; lift the legs up to counter hypotension(during acceleration)

Head end up (15-30 degrees), NG (during deceleration)

Consider if you need Blue light? Is it time critical? Make sure to limit sudden movements, blue light ambulances are notorious for getting into accidents (large vehicles, moving at high speeds, sometimes against traffic and/or against traffic rules)

Specially important is the need to be careful in head and spinal injury patients
Contrary to popular belief and your gut feeling, the more critical the patient, the slower the transfer needs to be. Not faster. Fast, hasty movements make for bad decisions, wrong or sharp turns (as well as deleterious effects of movements already discussed)

Static effects
Hypothermia is the most common problem
What is the first thing that happens when patients are brought in to ED? Their clothes get taken off. Coupled with cold environment, not a good combo
Children/eldery most vulnerable
Monitor patient during the transfer as well for temperature changes; aim for normothermia
HME filter is one way to counter drop in temperatures – ventilator usually gives cold, not-too-moist air going directly into the lungs, bypassing the moistening and humidifying warmth of the sinus cavities; connecting an HME filter to the ventilator circuit effectively prevents the dry cold air going in, and thereby prevents hypothermia.
Blankets and foil may be used, especially in ambulances
Pre warmed fluids may be considered
Cover open wounds/burns (cling film is best as wound is still visible for any changes, is sterile essentially and can be airtight)

Avoid vibration injury/movememt in ambulance/helicopters
Pad and protect soft tissues to avoid pressure sores, and reduce fractures where possible. Ulnar nerve is most commonly injured during transfer – bean bag padding is ideal for such transfers.
Interference can be caused with electronic monitoring by the unnecessary vibration.movement aberrations from helicopters and ambulances; dislodged/trapped leads may also be a concern.

Motion sickness may develop – stop feeding the potential transfer patient. A couple of hours of NBM won’t kill the patient, but aspirating their own vomit, or vomiting when their neck is immobilised can be quite a significant clinical concern. Consider NG (with free drainage) and sitting upright. Avoid rear-facing seats for transferring teams. Do not read/documentation, as can make things worse. Be prepared. Take antiemetics.

Communication
Sirens/alarms make communication difficult. Make sure you can always hear alarms. And, we all are guilty of doing this, but NEVER ignore alarms.

Immobilisation
Need to ensure patient can undergo immobilisation. Make sure patient can actually physically lie flat for CT scans, etc (e.g. may get short of breath if massively obese or really bad CHF)
Consider sedation (and airway protective measures) if absolutely necessary to scan and lie flat.
Make sure you have everything you need before you leave. And before you need it. Always be prepared for every eventuality, every foreseeable complication.

Lying supine can also have other deletrious effects on even patient who can lie flat – secretions can accumulate, reflux might be an issue, V/Q mismatch occurs, inability to cough when lying flat, strapping someone down for a scan may itself cause restriction of lung movements in an otherwise comfortable-in-lying-flat patient.

NOBODY GETS BETTER DURING A TRANSFER! They may get worse, so only transfer if absolutely imperative.

Special considerations?
Trauma
general information about the Trauma network
ED pitstops – their pitfalls

Head/spinal injuries – RTC, falls, sports, assaults, self harm (gunshots), and non-traumatic
Motor aspect of GCS is more important than anything else in the GCS
Immobilise with correctly fitted collars
Aim for Normal pO2
Normal pCO2 is now the new teaching, as low PCO2 (which was previously the guidelines) causes cerebral vasoconstriction, reducing blood flow, and ischemia is a far worse complication than brain swelling, atleast in the initial phase of the post-injury timeframe.
aim for a MAP of 90 (this is ideal for cerebral perfusion pressures to be optimum)
Normoglycemia
Normothermia
Head up, minimize movements
Urgent Neurosurgical care
Maintain parameters at all times, even if the transfer is for short periods
Monitor pupil size, GCS, Heart rate/rhythm strip, blood pressure, pCO2, resp rate during transfer
Immobilisation and transfer methods were also touched upon, various methods to transfer patients, scoops, trolleys, mattresses, sliding sheets, boards etc
Consider Spinal shock if triad of hypotension+poikilothermia+bradycardia
Avoid fluiding with large volumes if unresponsive to fluids, consider escalating to vasopressors.
Will improve on own if spinal shock
Autonomic dysreflexia – injury above T6 (headache, flushing/sweating above level of injury, urinary retention)

Paeds

Rarely transferred. Only ever in cases of trauma/head injury
CATS
WETFLAG
Broselow tape bag
Vecuronium/pancuronium, fentanyl, ketamine (children) combo in children safe.effective cocktail

Balloon pumps- weigh 70 kg, slows movement, runs off battery

 

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