Golden Hours in Safer Hands

Sai Lakshmi

Emergency Care Technician, Ambulance and Emergency Services, Kauvery Hospital, Chennai, India

Ambulance services play an important role in the healthcare system when it comes to handling any accidents or acute illnesses outside the hospitals. The emergency medical services team are the true first responders to any situation be it an accident, an assault, an industrial injury, an acute cardiac event, acutely worsening neurological event, an attempted suicide, or any other medical or surgical emergency that occurs outside the hospital premises. The patients are frequently transported by ambulance to the hospital’s emergency departments (EDs). Only on arrival at the ED, the responsibility for the patient’s further care is transferred from the emergency medical technician (EMTs) to ED staff.

The intra and inter-hospital patient transfers are an important aspect of patient care, to improve the quality of patient care delivered to the sick patient during movement from one place to another. The main objective during such transfers is maintaining the continuity of medical care, always anticipating the possibility of unexpected complications, and being prepared for the same.

As the transfer of a sick patient may be fraught with various physiological and pathological alterations that may adversely affect the prognosis of the patient, it should be conducted systematically, and according to the evidence-based guidelines.

The key elements of safe transfer involve:

1) The decision to transfer – whether high risk or low risk transfer

2) Pre- transfer preparation – with equipment and monitors

3) Pre- transfer stabilization – with prehospital initiation of treatment based on primary assessment of the patient’s condition as done by the EMTs and most importantly,

4) Communication with ED team at hospital, at all times, by keeping them in loop for necessary intervention to address any adverse changes in the patient’s condition during the journey.

Getting ready for the transfer:

By choosing:

1) The appropriate mode of transfer (i.e.) land or air transport

2) Using advanced life support or basic life support ambulance

3) Appropriately skilled personal accompanying the patient, and

4) Ensuring that the necessary equipment for monitoring through the journey are available.

The keys to a successful transfer include:

1) Adequate communication from time to time regarding the patient’s condition to the family

2) Adequate documentation of patient’s condition through the journey, and

3) Structured handing over of the patient at the receiving facility.

These key elements should be followed in each transfer to prevent any adverse events which may severely affect the patient’s prognosis.

Process in ambulance activation:

Step 1: Prehospital intimation

Prehospital care is provided by emergency medical services (EMS) responders, who are the initiators of health care at the scene. The EMS personnel often are the first to recognize the nature of a disaster or disease and this system is usually activated by a call for help from a patient/anxious attender/bystander. They can immediately evaluate the situation and determine the need for resources, and an ambulance despatch is initiated. Once, the emergency medical services (PARAMEDICS) receive a call, he/she must collect the appropriate information about the patient which includes the patient’s name, age, location of pick up, contact number, and chief complaints in brief.

Step 2: Ambulance despatch

After obtaining the details, the despatch of the ambulance with paramedic occurs within 5 min from the despatch centre.

Step 3: Arrival at the pick- up location of the patient

Once at the location-quick assessment of the patient’s vitals with simultaneously obtaining a brief but relevant history from the patient or from patient attender; the patient is triaged into a category of illness based on the overall condition of the patient.

Step 4: Intimation of patient’s condition to ED consultant

The patient’s condition is clearly explained to the emergence doctors on shift and based on their analysis, initiation of necessary treatment occurs at the pick- up location. On minimally stabilizing the patient, the patient is shifted to the hospital via the ambulance for further management.

Step 5: Obtaining high risk consent

If the patient is unstable, after explaining the nature of illness and the risks involved during transfer of the patient to the patient or the attender, a high -risk consent for transfer is obtained from the patient or the attender.

Step 6: Handing over of the patient

Once the patient reaches the destination of the hospital, the patient is transferred under the care of the emergency physician and the nursing team.

A poorly organized and hastily done patient transfer can significantly contribute to increasing morbidity and mortality.

I would like to share about once such difficult, and very challenging, inter hospital transfer of a patient from Chengalpattu CMCH to Kauvery hospital, Chennai.

On a busy day, we had all gathered for handing over from one shift to the next shift of paramedics, when we got a call from patient’s attender regarding a 33-years-aged gentleman who had met with a road traffic accident (pedestrian vs lorry). The patient had a history of loss of consciousness, ear bleed and nose bleed. He was immediately shifted to Chengalpattu CMCH by bystanders, where he was intubated, and in view of pneumothorax, received an intercostal drain in-situ, Then the attendee requested to transfer the patient for further care from CMCH to Kauvery Hospital Chennai. At CMCH, one of our senior paramedic’s got a clear and detailed history from the patient’s attender and the other paramedic assessed the patient’s condition-poly trauma with severe traumatic brain injury with subarachnoid hemorrhage, right temporal bone fracture, left pneumothorax s/p intercostal drain and this status was informed to the emergency physician at Kauvery hospital Chennai. The doctor was instructed to obtain high-risk consent from the patient’s attender as the patient was intubated. After obtaining consent, we connected the patient to the portable ventilator and started shifting from the hospital cot to the ambulance stretcher. Suddenly the patient developed desaturation, to an oxygen level of 60%. So, the senior paramedic disconnected resumed, and start to bag the patient, and gradually the patient’s oxygen saturation increased to 96%. Subsequently, he was shifted from the 3rd floor to the ground floor and shifted to the ambulance. And we started our journey to Chennai. Every 10 min, the vitals were closely monitored, and after one and half hours of travel, we finally sighed relief as we safely transferred the patient into the emergency department who then subsequently got admitted to the intensive care unit for further management.