19
Chapter
Himanshu Khurana, Yatin Mehta
INTRODUCTION
We have come a long way from the evacuation of the
legendary injured Laxman from battle scene for treatment in
the epic Ramayana; to the massive evacuation undertaken
by the Indian forces in Uttrakhand and Jammu and Kashmir
in recent times. Many more transfers that may not form the
headline are undertaken in no less dramatic conditions
worldwide.
The safest place for a critically ill patient is in an
intensive care unit (ICU) with all monitors and invasive
lines in a controlled environment. These patients on many
occasions may need to venture out of the ICU for various
diagnostic, procedural, administrative reasons or simply for
a “second opinion”. These occasions may give rise to many
considerations as it is the time of instability or potential
instability and may affect the outcome in a compromised
patient. Better understanding and accumulation of evidence
over the years has led to significant advancement in safety
of transfer in critically ill patients.1
The standard is to provide the same level of care during
all the time patient is out of the ICU. This may need intensive
monitoring and interventions or procedures.2
HISTORY
Transport vehicles used by earlier civilizations to forcefully
transport leprosy patients out of the city limits can be
technically termed as early ambulances. The first recorded
use of ambulance was by the Spanish army for injured soldiers
Ch-19.indd 219
Transport of Critically Ill
in 1487. Dominique Jean Larry (1766–1842), Chief Physician
to Napoleon Bonaparte is credited for designing 2–4 horse-
driven cart for transport of wounded soldiers from active battle
field.3 He later used camel-driven carts for this purpose in
Egypt. Next major change came during the cholera epidemic
in London in 1832 to transport the sick. Steamboats and rail
carriages were used for the purpose during the American
Civil War. The first hospital-based ambulance service was in
Commercial Hospital, Cinncinati, Ohio 1865. In June 1887,
St Johns Ambulance Brigade was established which now has
presence in many countries, including India. Air balloons
were used to evacuate over 160 wounded during the Siege
of Paris in 1870. The first recorded ambulance flight was to
evacuate a wounded British soldier in Turkey in 45 minutes.
The same would have taken 3 days by road.
In 1969, USA implemented a research program
coordinated accident rescue endeavor, State of Mississippi
(CARESOM) to assess impact of hospital medical transport
on mortality and morbidity. It was considered a success and
established the first civilian air medical program in USA.
CLASSIFICATION OF Medical
Transportation
Transportation of critically ill patients can be broadly
divided into two subgroups:
1. Emergency on-site transfer/prehospital transport/
primary transportation.
2. Inter- and intrahospital transfer/secondary transportation.
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 220 Section 1: General Principles
Emergency on-site transfer is transfer of patient from the
site of trauma or the medical emergency by the emergency
medical system (EMS) to a medical facility. It involves
resuscitation and stabilization. Road traffic accidents,
cardiac emergencies and stroke are the major contributors
to this category.
Intrahospital transfers are within the hospital to
radiology department, operating room or other departments.
Interhospital transfers are to other hospitals for diagnostic,
procedural or social indications. These patients have usually
been in the ICU for a considerable time and require en-route
monitoring and interventions as in an ICU setting.
Many professional societies have devised consensus
guidelines on transport of critically ill patients, as by
Intensive Care Society in 2002, Society of Critical Care
(SCCM) and American College of Critical Care Medicine
(ACCCM) in 2004 and Study Group for Safety in Anesthesia
and Intensive Care (SIAATRI) in 2006 and are revised from
time to time.4-6 These give recommendations on equipment,
medications, monitoring, documentation and training of
personnel for transport of critically ill patients.
EMERGENCY ON-SITE
TRANSPORTATION/EVACUATION/
PREHOSPITAL/Primary
TRANSPORTATION
Any transportation of critical or potentially critically ill
patient before hospitalization is covered in this category.
Any emergency arising at road side or home requiring
immediate medical attention comes under this category.
Road traffic accidents constitute a majority of these
emergency situations. According to WHO 1.2 million people
die each year in road accidents and another 50 million
are injured.7 Data from India is equally disturbing with
500,000 road traffic accidents resulting in 130,000 deaths
and 500,000 serious injuries including limb amputations
per year. On average, 1 person dies every 4 minutes in
road accidents in India. Ambulances and prehospital
care is inadequate and ill equipped; according to a report
submitted by Ministry of Road Transport and Highways
expert committee to the Supreme Court of India in 2010. It
further observed that road traffic accident has the potential
of being the largest challenge to orderly human existence.8
In New Delhi, only 2% of road trauma victims are
transported to the medical facility by ambulances, for the
rest, private and public vehicles are used for transport.9
According to a study in England when comparing urban
and rural areas and their accessibility to ambulances, the
chances of dying from a road traffic accident were higher
in areas farther from ambulance reach. The high toll of
Ch-19.indd 220
road traffic accidents can be brought down by reducing
the response time of ambulance to victims and rapid
conveyance to hospital with resuscitation and stabilization
on the way.10
Cardiac emergencies and stroke constitute the next
most common subset of patients requiring immediate
medical attention. Non traffic accidents, industrial disasters,
homicide and suicide, and other trauma constitute the other
common emergencies.
THE GOLDEN HOUR RULE
The first 60 minutes after an emergency is sometimes
referred to as the “Golden Hour”, a window of time in which
a victim is thought to have the greatest chance of survival
if given proper medical attention. This remains the basic
practice behind EMS services worldwide and it is a common
site to see rushing ambulances to help reach victims to the
hospital. It has been challenging to prove validity of the
golden hour rule as studies have given contradictory results
across the large sample size and as randomization is not
possible. A large cohort trial of 3,656 trauma patients failed
to prove association between interval and mortality among
injured patients. According to them the scope of practice of
EMS now includes airway management and resuscitation
and much more time can be spent prehospital.11 The only
condition in which EMS response time has shown to
improve survival is nontraumatic cardiac arrest.12
AMBULANCE DESIGN STANDARDS
Road ambulance or ambulance is a specially equipped
and ergonomically designed vehicle for transportation/
emergent treatment of sick or injured people and is capable
of providing out of hospital medical care during transit/
when stationary, commensurate with its designated level
of care when appropriately staffed. Research has shown
that ambulances are more likely to be involved in vehicle
collisions resulting in injury or death of occupants. This
brought about the need for effective designing.
Ambulances can be divided into three categories
according to level of care they provide:
First Responders—Type A
They are designed to provide medical care at the site of
emergency and not to transport patients.
Patient Transport Ambulance—Type B
A vehicle that is used for making nonemergency transfers
such as scheduled visits to a physician, radiology or the
laboratory, or upon discharge from a hospital or nursing
27-06-2015 4:12:52 PM

home to a hospital or nursing home or residence. These
are stable patients who are expected to remain the same
throughout the transport and will usually not require life-
support equipment. Their purpose is simply to transport
patients between places of treatment or residence.
Basic Life Support Ambulance—Type C
Ambulance is capable of providing basic life support to the
victims.
Advanced Life Support Ambulance—Type D
Ambulance is capable of managing medical emergencies
through the use of techniques such as endotracheal
intubations, medications and IV fluids, cardiac monitoring
and therapy by a qualified person.
Ambulance Design
Essentially design and equipment of advanced life support
ambulance and basic life support ambulance is similar. The
differences are in the medical equipment and staffing.
National Institute of Standards and Technology (USA)
with inputs from various concerned professional bodies
and authorities lays down basic standards of ambulance
design. In India, Automotive Industry Standards Committee
was set up by the Ministry of Road Transport and
Highways, Government of India to lay down its own design
specifications. It came up with the National Ambulance
Code in 2013 and recommended the vehicular design and
dimension, medical equipment and equipment fixation in
the patient’s compartment.13
To term a vehicle ambulance, it should have adequate
space for a driver, two attendants, a patient, carry equipment
and medications, should provide care provider access
to patient for resuscitation and procedures, should be
constructed for maximum safety and comfort and to
avoid aggravation of patient’s condition or exposure to
complications. Vehicular design should comply with the
applicable laws on patient compartment size, color of
vehicle, signage and beacon policy laid down in the National
Ambulance Code 2013. It should also provide sufficient
electric power for equipment. The law differentiates
between an ambulance and a patient transport vehicle.
Any transport vehicle for transport of stable patients from
hospital to home or nursing home is not an emergency
vehicle and cannot use beacon and hooter.
Equipment
A list of essential equipment and medications has been
prescribed.14 (Tables 1 to 3). All equipment should be
Ch-19.indd 221
Chapter 19: Transport of Critically Ill 221
stored in overhead bins or installed and readily portable for
interchange between ambulances and hospitals. Vacuum
stabilizing mattresses (Ferno Limited, West Yorkshire, UK)
filled with small polyvinyl granule which takes shape of the
supine patient when vacuum is applied; is another desirable
equipment which minimizes patient movement, accidental
disconnection of lines and tubes and makes safe multiple
shifting between beds, possible.
Other equipment on case basis may include intra-
aortic balloon pump (IABP), extracorporeal membrane
oxygenation (ECMO), ultrasound and echocardiography.
Ambulances should be fitted with oxygen cylinders to
provide continuous oxygen supply for at least one and half
times more than the anticipated travel time on maximum
flow. Smaller oxygen cylinders for transfers between
ambulances and hospital should be safely stored and also
readily accessible in case of main line failure. Essential and
life-saving medications should be adequately stored.
All equipment should be periodically checked for
integrity and calibrated as per manufacturers guidelines
and labeled prominently on the equipment. The ambulance
should also maintain a check list of inventory, next due
maintenance and expiry dates of medications to avoid
inadvertent errors.
Coordination between various agencies and
preparedness is the key to provide timely medical attention
in emergencies. Ambulances should be equipped for two-
way communication to coordinate with hospitals and
authorities for better management of victims. Strategically
placed ambulances for optimal use of resources to provide
maximum coverage to the population has been emphasized
by various health policy planners worldwide. It is also
advisable to keep EMS services adequately prepared in
hazardous industries and as part of preparedness for major
human gatherings and events.
PREHOSPITAL AIR MEDICAL
TRANSPORTATION
Around 3% of all prehospital transports of trauma patients
in USA are provided by the Helicopter Emergency Medical
Services (HEMS). This is of particular benefit in transport
from hostile terrain and far flung areas. There is evidence
that severely injured patients benefit from being directly
shifted from site of trauma to the trauma center. Other
subset with survival benefit of early transportation by
HEMS is in cardiac emergencies and stroke. There is benefit
in early institution of definitive treatment (angioplasty,
thrombolysis, etc.), limb and life-saving.15-20 The true utility
of HEMS can be tapped best if a meticulous triage of victims
is performed and the ones in whom mortality and morbidity
benefit outweighs facility overutilization undergo this trip.
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 222 Section 1: General Principles

Table 1: Essential medical equipment and other items to be placed on ambulance

Head of Group of equip- Name of items Equipment details
equipment ment
A Ventilation and 1. Transport Ventilator
airway equip- 2. Portable suction apparatus Wide-bore tubing, rigid pharyngeal curved suction tip;
ment tonsillar and flexible suction catheters, 5–14F
3. Portable and fixed oxygen equipment with key wrench Variable flow regulator
and trolley
4. Oxygen administration equipment Adequate length tubing’ mask (adult, child, and infant sizes),
transparent, nonrebreathing, venturi, and valveless; nasal
cannulae (adult, child and infant sizes)
5. Pocket mask with one-way valve
6. AMBU resuscitation bags: Adult and pediatrics Hand operated, self-re-expanding bag (adult and infant
sizes), with oxygen reservoir/accumulator, clear mask (adult,
child, infant, and neonate sizes); valve (clear, disposable,
operable in cold weather)
7. Intubation equipment Magill’s forceps, laryngoscope blades and other accessories,
endotracheal tubes and connecting tubes, etc.
8. Airways Nasopharyngeal, oropharyngeal (adult, child and infant
sizes)
9. Oxygen saturation monitor with different probes for
adult and child
B Monitoring 1. Automatic external defibrillator
and defibrillation 2. Multiparameter monitor
3. End-tidal CO2 monitor
C Infusions 1. Syringe pump
2. IV lines
D Immobilization 1. Cervical collars Rigid for children ages 2 years or older, infant, child and
devices adult sizes (small, medium, large, and other available sizes)
2. Head immobilization device (not sandbags) Firm padding or commercial device
3. Lower extremity traction devices Lower extremity, limb-support slings, padded ankle hitch,
padded pelvic support, traction strap (adult and child sizes)
4. Upper and lower extremity immobilization devices To immobilize one joint-above and joint-below fracture
(adult and child sizes), rigid-support appropriate material
(cardboard, metal, pneumatic, vacuum, wood or plastic)
5. Radio lucent backboards (long, short) and extrication Joint-above and joint-below fracture site (chin strap alone
device should not be used for head immobilization), adult and
child sizes, with padding for children, hand holds for moving
patients, short (extrication, head-to-pelvis length), long
(transport, head-to-feet), with at least 3 appropriate restraint
straps
E. Stretchers and 1. Collapsible chair-cum-trolley stretcher
splints 2. Spine board
3. Pneumatic splints
F. Communication Two-way radio communication (UHS, VHF) between EMT,
dispatcher, and medical direction (physician) or cellular
phone
G. Obstetrical Kit * 1. (Separate sterile kit) Baby receiving tray with warmer Towels, 4” × 4” dressing, umbilical tape, sterile scissors or
other cutting utensil, bulb suction, clamps for cord, sterile
gloves, blanket
2. Thermal absorbent blanket and head cover, aluminum
foil roll, or appropriate heat-reflective material (enough
to cover newborn)
3. Appropriate heat source for ambulance compartment
H. Miscellaneous 1. Sphygmomanometer (infant, pediatric and adult regular,
large and extra large)
2. Stethoscope (pediatric and adult)
3. Digital thermometer
4. Heavy duty scissors for cutting clothing, belts, and boots
5. Flashlights (2) with extra batteries and bulbs
Contd...

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 Chapter 19: Transport of Critically Ill 223

Contd...
Head of Group of equip- Name of items Equipment details
equipment ment
I. Injury prevention 1. Appropriate restraints (seat belts, air bags) for patient,
equipment crew and family members
2. Child safety restraints
3. Fire extinguisher
4. Traffic signaling devices (reflective material triangles or
other reflective, nonigniting devices)
* = OPTIONAL

Contd...
Table 2: List of consumable items S. No. Name of the Item
S. No. Name of the Item 35. Dressings: Sterile multitrauma dressings (various large and small
1. Cotton sizes)
ABDs, 10” × 12” or larger
2. Bandage (a) 15 cm (b) 10 cm (c) 6 cm
4” × 4” gauze sponges
3. Savlon Cotton rolls
4. Betadine 36. Gauze rolls sterile (various sizes)
5. Leucoplast 37. Elastic bandages nonsterile (various sizes)
6. Pain spray 38. Occlusive dressing sterile, 3” × 8” or larger
7. Mistdress spray 39. Adhesive tape: Various sizes (including 2” or 3”) Adhesive tape
8. Vinodine spray (hypoallergenic): Various sizes (including 2” or 3”)
9. Coolex spray 40. Cold packs
10. Face mask (Disposable) 41. Waste bin for sharp needles, etc.
11. Surgical gloves 42. Disposable bags for vomiting, etc.
12. LMA disposable 43. Teeth guard
13. Wide bore needles 44. Sample collection kits
14. Disposable LP needles
15. Syringes ABG ( 2 mL and 5 mL) Table 3: List of emergency drugs
16. Three-way stop clock 1. Inj. Adrenaline
17. Extension IV lines 2. Inj. Atropine
18. Disposable suction pumps 3. Inj. Calcium gluconate
19. ECG electrodes 4. Inj. Dopamine
20. Lighted stylets of different sizes 5. Inj. Dobutamine
21. Guedel’s airway 00–5,00,0,1,2,3,4,5 6. Inj. Noradrenaline
22. Nasal airways (all sizes) and catheters
7. Inj. Nitroglycerine
23. Binasal cannula, combitube, COPA
8. Inj. Sodium bicarbonate
24. Tracheostomy tube cuff and plain (all sizes)
9. Inj. Hydrocortisone
25. Mini tracheostomy kit
10. Inhaler Beclomethasone
26. Ventimask, facemask with nebulizer
11. Inhaler Salbutamol
27. Pressure infusion bags
12. Inj. Frusemide
28. Right angled swivel connector
13. Inj. Diazepam/Midazolam
29. GV paint
14. Inj. Deriphyllin
30. IV fluids
15. Inj. Phenytoin sodium
31. Microdrip-set and drip-set
16. Inj. Avil
32. Nasogastric tubes
17. Inj. Metochlopramide
33. Burn pack: Standard package, clean burn sheets (or towels for
children) 18. Inj. Ondansetrone
34. Triangular bandages ( Minimum 2 safety pins each) 19. Inj. KC1

Contd... Contd...

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 224 Section 1: General Principles
Contd...
20. Inj. Lignocaine 2%
21. Inj. Amiodarone (50 mg/mL)
22. Inj. Magnesium sulfate 25% 2 mL.
23. Inj. Mannitol 20%
24. Inj. Morphine/Pethidine
25. Activated charcoal
26. Inj. Naloxone HC1
27. Inj. Fentanyl
28. Bacteriostatic water for injection
29. Inj. Sodium valporate
30. Inj. Voveran
31. Inj. Paracetamol
Pediatric trauma, decreased level of consciousness, airway
obstruction, respiratory distress, shock and significant head
injury are the clinical features that should benefit from
HEMS activation.21
This facility is still nonexistent in developing countries.
The cost of developing HEMS may seem prohibitive but
the evidence is contrary. Brund et al. created an economical
model to compare the cost of air ambulance services and
ground ambulance services. The annual budgetary cost of
ground network was estimated at $3,804,000 and helicopter
ambulance cost was estimated at $1,686,5000. Per patient
cost worked out to be $4,475 and $2,811 respectively. They
concluded that the commonly held notion that condemns
helicopters as an excessively expensive technology as
incorrect.22 As is evident when developing prehospital care
facilities, it may actually be cost beneficial to develop HEMS
than maintaining a large fleet of ground ambulances and
training a large number of personnel to man them.
INTRA- AND INTERHOSPITAL TRANSFER
Intrahospital Transfers
It is common practice to shift critical patients from ICU to
radiology department for essential imaging or image-guided
interventions.23 These may be prudent for decision making
and sometimes cannot be postponed till the time patient is
stable. Other places where transfers may be required are to
operating room and ICU of other departments. It involves
multiple shifting from bed to gantry and anther bed.
Multiple hemodynamic monitoring wires, invasive access
lines, IV tubings and infusions lines, mechanical ventilation
and associated tubings and equipment are constantly at
risk of getting disconnected and damaged. Risk of further
deterioration or development of secondary injuries during
such transfers should also be kept in mind.24
Ch-19.indd 224
If the test or intervention is unlikely to alter the
management or outcome of that patient, then the decision
should be reconsidered. With newer portable modalities,
many diagnostic tests and interventions can now be done
bedside and can be considered in unstable patients or with
conditions where shifting may be potentially complicated,
for example bedside CT scan.25,26
First indication to the risks involved in intrahospital
transport of ill patients was made in 1970 when arrhythmias
occurred in 84% patients during such transfers.27 Many
articles over the past 40 years emphasize the need for safety
and intensive monitoring during such transfers. The overall
incidence of complications and adverse events during
intrahospital transfers is between 6% and 70%. These range
from minor disconnections of ECG leads or IV tubings to
cardiac arrests.28 Major life-threatening adverse events like
disconnection of monitoring lines and ventilatory circuits;
which require interventions like fluid, vasoactive boluses
or cardiopulmonary resuscitation (CPR) is between 4% and
8.9%.29,30
Preshifting Planning and Coordination
Because the transport out of ICU has its own hazards, it
is important that it is undertaken in a planned manner.
There needs to be coordination between the present
location, receiving location and the transferring teams.
Continuity of care should be maintained at all times and
physician to physician and nurse to nurse communication
should address all aspects of patient care. It has been
recommended that a minimum of two persons accompany
the patient all the time while he/she is out of the ICU, one
nurse and a physician fully competent to handle airway and
deliver advanced cardiac resuscitation if the need arises.
The number of accompanying escorts does not affect the
occurrence of adverse events.31 The hospital should develop
a standard written procedure and policy on equipment,
accompanying personnel and procedure of such transfers to
minimize risks and develop audit for further improvement.
Equipment and Medications
Pulse oximetry, blood pressure monitoring, and cardiac
monitor/defibrillator must accompany every patient. When
available, a memory capable monitor with the capacity
for storing and reproducing patients bedside data will
allow review of data collected during the procedure and
transport. Equipment for airway management and basic
resuscitation drugs are transported with each patient in the
event of sudden cardiac arrest or arrhythmia. All ongoing
medications and IV fluids should be carried in adequate
supply. In mechanically ventilated patients, endotracheal
tube position is secured before transport, and the adequacy
of oxygenation and ventilation is confirmed.
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Interhospital Transfer
It is not feasible for all hospitals to develop and acquire all
levels of facilities. After initial stabilization and evaluation
at the first response hospital, critically ill patients may
need shifting to other locations for additional care when
facility for the same is not available at the present location.
Inequitable distribution of medical facilities and family
preference play a big role in this decision. Even critically
ill patients are now being transported for long distances
and even inter continentally for further treatment. Medical
isolation and transport of Ebola virus victims from Africa to
USA recently is one such example. In England alone each
year 11,000 patients are transported between hospitals.32
No transport of critically ill patient is without risks and
thus the decision has to be made only after satisfying that
the required facility is not available at the location and
benefit of shifting for advanced treatment outweighs the
risk involved.33 Terminal end-of-life care patients may
need transfers close to their home, in some cases to other
countries, do not confirm to the above criteria.
Interhospital transport can take place by means of ground
ambulance and by air ambulance. The choice is guided by
the geographical distance between the transferee hospital
and the receiving hospital; and the swiftness needed to
transport. Ground ambulance for interhospital transport is
a cheaper mode and acceptable for relatively stable patients
who can reasonably survive the transport. Other factors like
weather, time and available resources also guide the choice.
Air transportation should be the choice when out-of-ICU time
exceed 90 minutes and distance is more than 80 km.34
Air Medical Interhospital Transportation
The use of air medical transportation has risen over the
past 2 decades. Increasing number of patients are being
transported daily in need of advanced medical attention to
higher centers worldwide. These are interhospital transfers
of critical patients using the available air infrastructure.
Most individuals with mild to moderate medical or
surgical conditions are able to travel safely in a normal
cabin seat with some assistance from the airline in the form
of wheelchair and oxygen in case of emergency.35 Some
patients need either a stretcher in a commercial scheduled
flight or a smaller dedicated chartered flight with all medical
equipment and medical staff experienced to handle the
situation. This may include continuous oxygen supply,
airway management, cardiac monitoring and interventions.
Many countries where large areas are served by a few
tertiary care centers have very efficient air evacuations, e.g.
Australia, South Africa. This facility is poorly developed in
India but its use has risen over the past decade and brought
a positive change in the medical transportation scenario.36
Ch-19.indd 225
Chapter 19: Transport of Critically Ill 225
Use of scheduled commercial airline for transportation
of critical care patients needs special mention here.
Stretcher in routine scheduled commercial airlines is
available on request to the concerned airline and is subject
to availability of required number of seats. The usual
procedure is to get approval from the airline appointed
doctor on the prescribed “Medif form” available with the
airline office at least 2–3 days in advance. Different aircrafts
will need to assemble a fixed stretcher on 6–9 folded seats
usually at the rear end of the aircraft with a curtain around it
and an oxygen cylinder under it (Fig. 1). The accompanying
staff is usually one doctor and one nurse. All equipment and
responsibility has to be borne by the accompanying doctor.
The advantage is that it is cheaper, faster and easier to use
available air infrastructure for long national, international
and intercontinental transfers. More family members can
accompany the patient in comparison to smaller chartered
flight. The disadvantage is that it needs advance notice to
the airline and most advanced life support systems are not
allowed in the commercial airliner making it unsuitable for
unstable patients.
Equipment for Air Medical Transportation
The medical equipment used for air medical transport
need to be portable, sturdy and comply with the
applicable aviation laws. It needs to be noninterfering
with radiocommunication of the airplane. All equipment
needs to be fixed in the airplane and readily detachable
for transfers. Oxygen cylinders should be nonferrous, fixed
and regulators need to be certified to work in a pressurized
environment by the competent authorities. The batteries
should be dry and nonspilling type. Oxygen supply and
battery backup should last one and half times the expected
flying time to account for delays. Use of a foldable ramp to
Fig. 1: Arrangement of stretcher in a commercial flight
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 226 Section 1: General Principles
transport the patient inside the cabin is a good practice
(Fig. 2).
Cardiovascular diseases and stroke remain the most
common cause for need of interhospital transfer. Essebag also
observed an increased frequency of medical transportation
of cardiac patients due to medical, economical and social
patterns in Canada.37 The same holds true for India.38
The main patient related concerns when air transporting
a critical patient are the low atmospheric pressure and gas
expansion effects of altitude, patient and family anxiety;
and movement related complications. Fixed wing propeller
aircrafts fly at an altitude of 15,000 to 30,000 feet. Barometric
pressure decreases from 760 mm Hg at sea level to 226
mm Hg at 30,000 feet. The aircraft cabin is pressurized
to an equivalent pressures of 5,000 to 8,000 feet which
corresponds to a PIO2 (Inspired) of 107 mm Hg.39 This PIO2
is easily tolerated by normal individuals but in critical
patients with limited reserves, it causes hyperventilation
and tachycardia with an increase in cardiac output. This
may also alter the need of vasopressors and inotropes and
can be particularly detrimental to patients with underlying
respiratory or cardiac diseases.
Other effect of decreased atmospheric pressure is
on gas expansion. All potential body spaces, especially
middle ear, bowel and pathological body spaces like
pneumoperitoneum, pneumocranium, pneumothorax
are at risk of expansion at high altitudes especially during
rapid changes during rapid ascent, i.e. take off and descent,
i.e. landing. Mechanical ventilation and maintenance of
adequate oxygenation may be difficult in some patients.
Most common nonserious complications are
disconnections of ECG lead, IV tubing and ventilator circuit.
Fig. 2: Use of foldable ramp to load the stretcher on to the
chartered flight through the cargo door
Ch-19.indd 226
Serious complications are cardiac arrest, arrhythmias and
accidental extubation. Overall serious complication rate of
5–6% is comparable to ground transport. It can be inferred
that air transportation carries no more risk than ground
transportation.38
Ground transportation may seem cheaper than air
transportation on case basis. Some emergencies are
potentially life- or limb- threatening and require urgent
care and speedy transport to an advanced care center. This
has been made possible only by air medical transportation
with proven survival benefits..40 -42
It can be said that only two clinical situations justify
choice of air over ground interhospital transportation of sick
patients. Firstly nonavailability of the required diagnostic
and therapeutic facility at present facility and secondly
when factors such as time and distance render ground
transportation nonfeasible.43
Over the past decade many factors have contributed
to the increase in interhospital air medical transport in
India. There is an easier availability of small aircrafts for
civil use that can be customized as ambulances (Fig. 3) and
almost all districts in India have access to either a civilian
or military airstrip which can be used for air ambulance
services on request to competent authorities.44 There is an
inequitable distribution of tertiary care hospitals in India.
Furthermore access to internet has made it easy to locate
and communicate with specialty centers worldwide.38
Even after all the above catalysts, the limiting factor
in a speedy air transport of critical patients has been the
preparation time required for the customization of the
aircraft, and shortage of specialized equipment like IABP
and ECMO and trained personnel.38
There has been an increase in our understanding and
accumulation of evidence on safety during transport of
critically ill patients during the past few decades. Transport
of critically ill is now recognized as an integral part of the
healthcare system and all concerned including the medical
fraternity, road and air traffic authorities, airlines and
the government agencies are working toward a seamless
and safe transfer of patients across boundaries. Statistics
Fig. 3: Line diagram of customized arrangement in fixed wing
chartered aircraft for medical transport
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has shown the importance of effective management of
transportation of critically ill patients in the national health.
Ministry of Health and Family Welfare, Government of India
accepted that prior to 2005, proper ambulance service
was nonexistent in India and now supports over 20,000
ambulances nationwide under various schemes.45 National
Highway Authority of India in 2014 issued guidelines for
providing equipped, manned and GPS enabled ambulances
to provide speedy medical attention to the ever increasing
toll on its national highways.46
MEDICOLEGAL ASPECT
In the United States, federal and state laws govern patient
transfers. The Emergency Medical Treatment and Active
Labor Act (EMTALA) laws detail the legal responsibilities of
the transferring and receiving facilities and practitioners.47,48
It state that financially motivated transfers are illegal and
both the referring institution and the individual practitioner
can be held responsible for it. It also prohibits financial
limitations while transferring and accepting victims for
emergency treatment.
Current regulations and good medical practice require
that a competent patient, guardian, or the legal guardian of a
minor, incompetent or incapacitated patient gives informed
consent before any transfer. The informed consent process
should be documented in the medical record and discussion
of the risks and benefits should be complete and in the
language understood by the consent giver. A signed consent
should be obtained. If circumstance do not allow for the
informed consent process (e.g. life-threatening emergency),
then both the indications for transfer and the reason for not
obtaining consent are to be documented in the medical
record. Consent should be obtained at the first opportunity.
All handover between physicians and nurses should be
documented to maintain continuity of care at all times.
As is evident, the condition of transported critically ill
patients is same as in any other critical area of the hospital
and thus requires monitoring and interventions in a
totally different environment.49 This requires specialized
equipment and trained staff. At present, there is no EMS
training facility in India.50 Norton pointed out that there
is need for medical transport curriculum for emergency
medical residents.51 We feel there is need of a structured
accreditation policy and training program to bring safety
and accountability to the mushrooming ambulance
business worldwide.
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