Bongard Frederic , Darryl Sue. Diagnosis and Treatment Critical Care

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INTENSIVE CARE MONITORING

207

utilization may be monitored. There are insufficient out-

come data supporting routine use of indirect calorimetry,

but numerous studies have pointed out that, without direct

measurements, patients are often under- or overfed in com-

parison with their actual needs.

As indicated earlier, precise determination of dead

space:tidal volume ratio requires measurement of expired

rather than estimation. Respired gas measurements

therefore may be useful in predicting weaning from mechan-

ical ventilation or for estimating prognosis in ARDS or

COPD exacerbations.

Boullata J et al: Accurate determination of energy needs in hospi-

talized patients. J Am Diet Assoc 2007;107:393–401. [PMID:

17324656]

Davis KA et al: Nutritional gain versus financial gain: The role of

metabolic carts in the surgical ICU. J Trauma 2006;61:1436–40.

[PMID: 17159687]

Heyland DK et al: Canadian clinical practice guidelines for nutri-

tion support in mechanically ventilated, critically ill adult

patients. J Parent Ent Nutr 2003;27:355–73. [PMID: 12971736]

Petros S, Engelmann L: Enteral nutrition delivery and energy

expenditure in medical intensive care patients. Clin Nutr

2006;25:51–9. [PMID: 16216393]

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208

This chapter will describe and discuss interfacility transport

of the critically ill. As technology advances and as fiscal real-

ities increase the incentive to control health care spending,

increased regionalization will result in transport of the criti-

cally ill to the hospital that can best manage the patient.

Lessening the need for duplicate resources by regionalization

of specialized health care services may achieve optimal

patient outcomes at minimal costs. Repatriation of health

plan participants with their primary care providers has led to

a dramatic increase in interfacility transport of persons

requiring hospitalization or extended emergency evaluation.

Management of resource-intensive critical illness in spe-

cialized regional centers has been shown to improve medical

outcomes and cost-effectiveness. Most studies support the

concept that patient volume in tertiary care centers

(Table 9–1) leads to better patient outcomes because staffs

of these centers maintain high experience and proficiency

levels. With medical evidence strongly supporting regional-

ized medical specialty centers, methods for transport of

patients to these centers must be developed using practices

based on the best scientific and management evidence.

Alter DA et al: Long-term MI outcomes at hospitals with or with-

out on-site revascularization. JAMA 2001;285:2101–8. [PMID:

11311099]

Frankema SP et al: Beneficial effect of helicopter emergency med-

ical services on survival of severely injured patients. Br J Surg

2004;91:1502–6.

Clark DE et al: Evaluating an inclusive trauma system using linked

population-based data. J Trauma 2004;57:501–9. [PMID:

15454794]



Interhospital Transport

Composition of the Transport Team

Once the referring physician decides that a patient needs

a higher level of care, the mode of transport must be cho-

sen as well as the composition of the transporting crew.

For interfacility transfers, there are no standard guidelines

regarding which patients may be transferred solely with

paramedics, which require a nurse in attendance, and

which require a physician in attendance. Local regulations

may restrict the role of paramedics, who should not, for

example, give medications or manipulate unfamiliar

equipment such as ventilators unless they have docu-

mented evidence of training and competence. The scope of

such training may be limited by the paramedic licensing or

certification board.

There are no national data on overall transport volumes

or team composition within transport systems. Published

guidelines recommend that a minimum of two medically

qualified people in addition to vehicle operators accom-

pany a critically ill patient. The two medical attendant

teams usually consist of combinations of ambulance atten-

dants, emergency medical technicians (EMTs) who receive

100–300 hours of initial education, paramedics who

receive 1000–3000 hours of initial education, respiratory

therapists, critical care technicians, licensed registered

nurses, and physicians. In urban areas, ground transport is

most common; in rural areas, air transport is more often

required because of the distances and the difficulties of

road travel. In most settings, the EMT is the highest-level

care provider on the interfacility transport team, but for

critical care transports, a physician, nurse, or paramedic is

most often the highest-level provider. EMTs, paramedics,

respiratory therapists, critical care technicians, and nurses

usually have defined scopes of practice in the jurisdiction

where they are licensed. This scope of practice limits what

the individual may or may not do during the transport

process. Many critical care transport programs that have

physicians on board transport vehicles are using physi-

cians who are still in training—there is little information

about whether the level of experience of the physicians is a

factor in outcome. Many programs ascribe considerable

value to the presence of physicians; this despite the fact

that only 11% of programs fly with physicians on board.

Transport

Samuel J. Stratton, MD, MPH

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209

Appropriately educated and monitored nonphysicians can

use paralytic pharmacologic agents and perform intuba-

tion, cricothyrotomy, and tube thoracostomy safely; nurses

or respiratory therapists may be more familiar with venti-

lators than a physician.

Current standards for interfacility transport dictate that

the decision on transport mode and team composition is

based on individual patient requirements for minimization

of transport time and monitoring and anticipated treatment

requirements during transport. For example, a patient who

requires advanced airway monitoring and skills should be

transported in a vehicle with airway monitoring equipment,

accompanied by an individual trained and qualified in

advanced airway management.

Mode of Transport

Current options for mode of transport are the ground ambu-

lance, either a helicopter or a fixed-wing aircraft, and water-

craft. In many urban centers, all options are available, and in

rural areas—Alaska, for example—the airplane is essential.

Decisions that will influence the mode of transport (if all

options are available) include the distance and thus the dura-

tion of transport, the diagnosis and thus the complications

that may arise during transport, the level of training and

techniques the transporting personnel can provide, the

urgency of access to tertiary care, and local weather condi-

tions and geography. In general terms, ground ambulances

are more available than air vehicles; ground ambulances may

be dispatched from a local facility, although an outreach

team from the tertiary care center may be requested; mobi-

lization time of such a team and their arrival will have to be

taken into consideration (Table 9–2).

A. Ground Ambulance—Ground ambulance vehicles are

usually the most readily available and may be categorized as

vehicles for basic life support (BLS) or advanced life support

(ALS). BLS ambulances are most often staffed with two EMTs

and can provide basic first aid, monitoring of vital signs, basic

airway management and intervention, automatic external

defibrillation, monitoring of maintenance intravenous fluid

infusions, and oxygen without cardiac monitoring. ALS

ambulances are staffed with a paramedic, nurse, or physician

as the highest-level provider. ALS ambulance personnel can

provide cardiac monitoring and advanced airway manage-

ment and can deliver the drugs and intravenous fluids com-

monly used for resuscitation and stabilization of medical and

trauma patients. ALS ambulances must have the necessary

outlets for managing ventilators or balloon pumps for inter-

facility critical transfers. However, if the ambulance belongs

to the local Emergency Medical Services (EMS) jurisdiction,

the administrators may not allow the vehicle to be out of serv-

ice for a long trip to a tertiary center. In many urban areas,

ambulance companies maintain some ALS ambulances for

interfacility transports so that the primary EMS system is not

affected. Ground ambulances are limited by surface condi-

tions or traffic congestion. Equipment used to support

patients during transport should have a backup supply (ie,

batteries or extra oxygen tanks) in case of need. The U.S.

Table 9–1. Medical services most effectively delivered

in specialized referral centers.

Burn injuries

Trauma

High-risk blunt and penetrating injuries

Neurologic injuries

Vascular injuries

Complex orthopedic injuries

Pediatric-age trauma

Oro-maxillary-facial injuries

Obstetric, high-risk

Neonatal care

Pediatric critical care

Cardiac

Invasive coronary revascularization

High-risk cardiac care

Cerebrovascular (“stroke”) management

Rehabilitation, intensive

Favoring ground ambulance

Ambulance staffed by critical care team

Ambulance equipped appropriately

Patient location accessible to ground transport

Ambulance can be spared for use within the local system

Geography allows ground transport

Favoring helicopter transport

Transport distance 30–180 miles

Important to minimize transport time

Helicopter staffed by critical care team

Helicopter equipped appropriately

Patient location and receiving location accessible to helicopter

landing and takeoff

Allowable weather conditions

Patient/equipment weight allows use of available helicopter

Favoring fixed-wing aircraft

Transport distance over 100–150 miles

Important to minimize transport time

Aircraft staffed by critical care team

Aircraft equipped appropriately

Patient location and receiving location accessible to an airport

Allowable weather conditions

Patient/equipment weight allows use of available aircraft

Critical care transport available for moving patient to and from

landing sites

Table 9–2. Factors that favor a specific mode of critical

care transport.

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210

Department of Transportation (DOT) has published stan-

dards that have been adopted by most states that relate to

minimum ambulance configuration and equipment require-

ments. Communication between the ground ambulance and

the receiving facility or designated medical control center can

be a consideration during transport. The ground ambulance

is the most widely used and least expensive mode of interfa-

cility transfer. This method should be considered for trans-

port distances of 30 miles or less.

B. Helicopter—Helicopters should be considered for trans-

ports over distances of 30–150 miles. They travel at ground

speeds of 120–180 miles per hour and often are dispatched

from the receiving tertiary facility or urban area emergency

service providers. The physical location of the helicopter at

the time of dispatch is important to consider because an in-

flight round trip to transport a patient may not offer advan-

tages over a one-way trip by an available ground vehicle.

Helicopters usually require a warmup time of 2–3 minutes

before liftoff and—allowing for communication time—can

be launched within 5–6 minutes after the flight request is

received. Medical transport helicopters are usually staffed by

critical care (ALS) crews. Under normal weather conditions,

helicopters can fly point to point and land at accident scenes

or sending facilities; the liftoff capability depends on the type of

helicopter used. Helicopter transports are limited by adverse

weather conditions and available landing sites (often a prob-

lem in densely populated areas). Helicopters are expensive—

the capital cost is between $ 2.5 million and $ 15 million

depending on whether a single- or dual-engine model is

selected; likewise, the number of patients that can be trans-

ported is determined by aircraft selection and configuration.

Helicopters can fly from point to point under visual flight

rules (VFR). In inclement weather, several helicopter pro-

grams can fly under instrument flight rules (IFR). This, how-

ever, requires that they take off and land at an airport with

appropriate instrumentation. Helicopters cannot fly in freez-

ing rain or dense fog.

C. Fixed-Wing Aircraft—Fixed-wing aircraft should be con-

sidered for transport over distances exceeding 100–150 miles.

Fixed-wing aircraft will have IFR capability and can fly from

airport to airport, with ground transportation required at

both ends. Fixed-wing aircraft are less susceptible to adverse

weather in comparison with helicopters. Aircraft cabins nor-

mally are pressurized between 6000 and 8000 feet, and this

may have effects not only on the patient’s clinical condition

but also on apparatus such as endotracheal tubes or Swan-

Ganz catheters; in addition, ventilators may need to be recal-

ibrated. Some patients—for example, those being transferred

to hyperbaric facilities for treatment of decompression

sickness—may require pressurization at ground level. Fixed-

wing aircraft are being used more often as long distant trans-

ports across states and regions occur. Fixed-wing aircraft are

used commonly for international transports. When national

borders are crossed by transport craft, international rules and

national immigration and visa requirements must be met.

D. Watercraft—Watercraft are used rarely for interfacility

critical care transport. In special environments, such as off-

shore islands and oil platforms, watercraft do play a role in

medical transport. The use of watercraft for critical care

transport is usually in a situation where inclement weather

does not allow for helicopter transport. Because of problems

with water damage to electrical equipment and dangers of

staff electrical shock from defibrillators, the monitoring and

ALS activities that can be supported on watercraft are limited.

Liability and Legal Issues

A. Interfacility Transfer—Interfacility transport of patients

received increased legal visibility by the passage in 1986 of

COBRA 1985, Section 9121, Amendments to the Social

Security Law, and Section 1867, Special Responsibilities for

Hospitals in Emergency Cases. These rules have undergone

repeated emendation, and the regulations have been renamed

the Emergency Treatment and Active Labor Act (EMTALA),

further amending Section 1867. Briefly, these laws refer to

emergency transfers of unstable patients and were drafted to

address the problem of transfers of uninsured patients.

Indeed, the EMTALA regulations are often referred to as

“antidumping legislation.” EMTALA provides a framework

of legal liability under which the sending facility is responsi-

ble for initiating the transfer and selecting the mode of trans-

portation (including the level of expertise of transferring

personnel) and thus indirectly the equipment on the trans-

porting vehicle. The sending facility is responsible for ensur-

ing that the receiving facility has space and personnel

available for care of the patient, and the sending physician is

responsible for the risks of transfer and for deciding that the

benefits to the patient following successful transfer outweigh

the risks. A receiving facility that has specialized units such as

burn units, shock trauma units, cardiac catheterization units,

and neonatal ICUs shall not refuse to accept an appropriate

transfer if that hospital has the capability to treat the individ-

ual. This is a nondiscrimination clause and is an attempt to

prevent receiving facilities from accepting only funded

patients. All emergency critical care and transferring person-

nel should understand the implications of these statutes.

B. Confidentiality—All ambulance and transport providers

who engage in transactions that transmit protected health

information in electronic form are required to comply with

the U.S. Health Insurance Portability and Accountability Act

(HIPAA). Protected health information includes any infor-

mation identifiable to a specific person that relates to that

individual’s past, present, or future physical or mental health.

HIPAA provides criminal and civil penalties for the improper

use of protected health information, requiring that consent be

given to obtain health information and that safeguards are in

place to protect such information. Records pertaining to the

use and disclosure of protected health information must be

maintained for inspection by appropriate parties.

In addition to the legal requirements of transfer, the

transferring personnel have certain liability concerns—

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211

particularly if they perform air medical transport. The high

degree of acuteness of these patients and the potential for

adverse outcomes mandate medical malpractice coverage for

the transferring personnel; the premiums will vary according

to the staffing pattern selected. Medical directors also may

need to make certain that they are appropriately covered for

giving offline medical direction and may find that although

some of their responsibilities are covered by medical mal-

practice insurance, directors’ and officers’ insurance may be

needed to cover their management decisions.

Outcome

The data that support the validity of transfer of the critically

ill emphasize five recurring themes:

1. Outcomes of the critically ill in tertiary centers are better

than outcomes in other facilities (matched for severity).

2. Transport of the critically ill does not adversely affect the

patient during transport—and therefore, by implication,

the patient receives the benefit of theme 1.

3. Transport of critically ill patients improves outcome

when compared with national norms.

4. Established systems of care (encompassing critical trans-

port as a component) have societal outcomes better than

those of comparable communities without such a system

and better than those in the same community before the

system was in place.

5. Regionalization of specialized care is cost-effective and

improves utilization of community resources.

An outcome study of all critically injured children with

respiratory failure and head trauma in Oregon for 6 months

compared mortality in 71 nontertiary and 3 tertiary facilities.

Using the pediatric risk of mortality score, the study found

that outcomes in the nontertiary facilities were lower than

those in tertiary facilities—and further, that the difference in

outcome was more pronounced the higher the expected

mortality. For the most critical group (mortality risk >30%),

the odds ratio of dying in a nontertiary versus a tertiary facil-

ity was 8:1. The study concluded that “pediatric survival

from a broad range of disorders might be improved by

regional organization of pediatric care.”

Improved outcome of the critically ill has been related to

the volume of patients. This has been shown for coronary

artery bypass surgery, trauma management, acute cardiac

disease, abdominal aortic aneurysm, and stroke. For exam-

ple, using the Trauma and Injury Severity Score (TRISS)

methodology, it has been shown that rapid transport or

transfer by helicopter of trauma patients to a specialized

trauma center resulted in a 13% reduction in mortality when

compared with the outcome expected from the benchmark

Multiple Trauma Outcome Study database. Studies demon-

strating improved outcomes of the critically ill in regional-

ized specialty centers are in strong support of critical patient

transport systems that facilitate movement of patients to

these centers.

Transfer of the critically ill has been shown to be safe in

cardiac patients, patients with respiratory distress, and pedi-

atric patients. Transfer of patients sustaining acute myocar-

dial infarction by air does not appear to be detrimental to

patient outcome. Currently, critical care regionalization is

becoming more common in developed countries throughout

the world, and interfacility critical care transport is an essen-

tial component of this move to regionalization.

Thomson DP et al: Guidelines for air medical dispatch. Prehosp

Emerg Care 2003;7:265–71.

De Wing MD et al: Cost-effective use of helicopters for the trans-

portation of patients with burn injuries. J Burn Care Rehabil

2000;21:535.

Pollack NM et al: Improved outcomes from tertiary center pedi-

atric intensive care: A statewide comparison of tertiary and

non-tertiary care facilities. Crit Care Med 1991;19:50.

Post GB: Building the Tower of Babel: Cross-border urgent med-

ical assistance in Belgium, Germany, and the Netherlands.

Prehosp Disaster Med 2004;19:235–44.

Muhm JM: Predicting arterial oxygenation at commercial aircraft

cabin altitudes. Aviat Space Environ Med 2004;75:905–12.

Thomas SH: Helicopter emergency medical services transport out-

comes literature: Annotated review of articles published

2000–2003. Prehosp Emerg Care 2004;8:322–33.



Equipment & Monitoring

Interfacility critical care transport requires continuous mon-

itoring and clinical management of the patient throughout

the transport environment. The transporting vehicle should

have the necessary power converters for all equipment that

could be needed during a transfer; in addition, much of the

equipment needs battery backup in case of electrical failure

and backup oxygen supply in case of vehicle breakdown. In

cold climates, provision must be made for maintenance of a

warm environment in case of vehicle failure. In 2004, the

American College of Critical Care Medicine, the Society of

Critical Care Medicine, and the American Association of

Critical Care Nurses published a consensus document that

details minimum equipment and medications recommended

for critical care transport units.

Airway Management

Critical care transport often involves patients who require

advanced airway management. Often patients have had an

endotracheal tube placed prior to transport, but transport

team members always must be prepared to reintubate or

establish an advanced airway should the need arise. In addi-

tion to standard endotracheal intubation equipment, a

backup system such as the laryngeal mask or pharyngotra-

cheal lumen tube should be available for those in whom

intubation cannot be accomplished. Emergency transtra-

cheal jet ventilation by means of needle cricothyrotomy and

airway tube placement by cricothyrotomy have been success-

ful in establishing a temporary airway during transport when

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performed by properly trained personnel. The effectiveness

of transtracheal jet ventilation at the higher altitudes encoun-

tered in fixed-wing aircraft is not established. In addition to

advanced airway management, ALS transport crews should

have equipment available for decompression of tension pneu-

mothorax (ie, either needle or chest tube thoracostomy).

Medications

Medication lists have been published for the management of

the obstetric patient, the neonatal patient, the pediatric

patient, and the adult patient during transport. Additional

medications may be required that depend on patient profiles,

and protocols should be prepared for the use of these med-

ications. Care must be taken to ensure that expiration dates

on medications are recognized, and guidelines should be in

place beforehand for authorization to use them. Use of criti-

cal care transport under these circumstances allows a higher

level of pharmacologic intervention—for example, many

flight programs routinely use paralytic agents to facilitate

endotracheal intubation.

The use of thrombolytic agents for acute cardiac and

stroke patients during interfacility transport is controversial.

Observational studies have shown that thrombolytic use

during transport of acute myocardial infarction patients has

acceptable risk profiles, but with cardiac catheterization

becoming a primary reason for transport, interest in trans-

port thrombolytics has decreased.

Blood Utilization

Blood product transfusion during interfacility transport is

controversial. It has been shown that in rotor-wing programs

using flight nurses, the transfusion of blood can be per-

formed safely and is feasible during transport. Use of blood

product transfusions is limited to lengthy transports during

which crystalloid infusion alone will not stabilize a patient.

Use of blood products during transport requires adherence

to strict standard blood transfusion protocols, with blood

administered by properly trained transport personnel.

Ventilators

Several types of ventilators are available for the transport

environment. The choice of ventilator will depend on the

mission profile, compatibility with sponsoring ICUs, and the

preferences of the medical director. Mechanical ventilation of

intubated patients during transport has been shown to be

optimal in comparison with manual ventilation. Food and

Drug Administration (FDA)–approved transport ventilators

have performance indexes comparable with those of ICU

ventilators. Transport ventilators must be monitored contin-

uously during transport and, because of the unique transport

environment, are subject to problems such as power failure

and disconnection. Pressure-controlled ventilators are used

most commonly during transport and in aircraft must be

adjusted to for altitude changes. Most critical care transport

programs monitor their patients continuously by oximetry

and continuous end-tidal carbon dioxide monitoring; in one

study, continuous oximetry monitoring identified clinically

unrecognized hypoxia.

Monitoring

The ECG, blood pressure, oxygen saturation, and, if neces-

sary, end-tidal carbon dioxide level, pulmonary artery pres-

sure, intraarterial pressure, and intracranial pressure should

be monitored during transport. Successful defibrillation has

been performed during flight, and use of this equipment

does not interfere with other systems on helicopters and

fixed-wing aircraft. If the patient does not have an intraarte-

rial line, occlusion oscillometry or Doppler measurement

will give a satisfactory indication of blood pressure; normal

auscultation of the blood pressure using a sphygmo-

manometer cuff is difficult in the transport environment

because ambient noise may exceed 110 dB.

Medications should be administered by infusion pump

throughout transport to ensure smooth and accurate dosing.

Many small, rugged infusion pumps are available and can be

reprogrammed rapidly to manage unstable patients. In addi-

tion, portable intraaortic balloon pumps and left ventricular

assist devices are now available commercially that weigh less

than 150 lb and can be transported on most ambulances, hel-

icopters, and airplanes.

Warren J et al: Guidelines for the inter- and intrahospital transport

of critically ill patients. Crit Care Med 2004;32:256–62.

Davey AL, Macnab AJ, Green G: Changes in P

during air med-

ical transport of children with closed head injuries. Air Med J

2001;20:27.

Sumida MP et al: Prehospital blood transfusion versus crystalloid

alone in the air medical transport of trauma patients. Air Med J

2000;19:104.



Education & Training

Crew Composition Decisions

Once the mission profile of the transport program has been

specified, decisions must be made concerning the qualifica-

tions of the personnel. The mission profile also may dictate

the qualifications of the medical director.

Physicians: On- and Offline

In addition to their duties in off-line medical control (eg,

supervising training, development of medical protocols and

standing orders, and quality assurance), physicians must be

available online 24 hours a day (by cellular phone or radio)

to help manage critical situations. Most online medical con-

trol is provided by emergency physicians. These individuals

have experience conveying instruction by radio to para-

medics, are immediately available 24 hours a day, and are

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213

familiar with radio equipment and the rules and regulations

covering their use. Occasionally, online medical direction

may be obtained through an ICU or from a neonatologist at

a tertiary care facility.

Crew Qualifications

Training modules for all transporting personnel should be

developed in such a way that it is consistent with the policies

and practices of the local emergency medical services and

critical care community. The facilities and the crew should be

subjected to ongoing curriculum development and quality

assurance by the medical director.

A. The Emergency Medical Technician—Emergency med-

ical technicians (EMTs) have completed a course of training

outlined by the DOT and are required to recertify every 2–4

years, usually by means of taking a nationally standardized

skills and knowledge test. EMTs are taught first aid and basic

rescue skills in programs composed of 100–300 contact

hours. EMTs receive training in the basic management of

trauma and medical, pediatric, obstetric, and psychiatric

emergencies. Many EMTs are proficient in the use of auto-

matic external defibrillators. EMTs know basic noninvasive

airway techniques and are often certified to monitor continu-

ous maintenance intravenous infusions. Generally, EMTs do

not have training in cardiac rhythm recognition, intravenous

access, or invasive procedures.

B. The Paramedic—Paramedics have completed a course

curriculum outlined by the DOT and usually are required to

pass a state licensing examination and to seek recertification

every 2 or 4 years. Most U.S. paramedics obtain initial certi-

fication by participating in a nationally recognized testing

program. In the United States, paramedic training programs

vary from 1000–3000 contact hours. Paramedics have knowl-

edge of all emergency situations, including the acute man-

agement of trauma and of cardiac arrhythmias. Under state

or regional guidelines, they usually can perform defibrilla-

tion and are able to recognize and treat lethal dysrhythmias.

They are trained in endotracheal intubation and cricothyro-

tomy, interosseous lines, needle thoracostomy, and transtho-

racic cardiac pacing, although not all of these skills are

sanctioned for performance by paramedics in all states.

Paramedic training corresponds to what is required for

Aeromedical Crew Level 2 personnel by the American

College of Surgeons.

C. The Critical Care Transport RN—A standard curriculum

and certification program for critical care nurses has been

developed by the American Association of Critical Care

Nurses. Schools for flight nursing have been developed, along

with a generally recognized curriculum. In addition to other

nursing skills, transport nurses should be trained to perform

endotracheal intubation, needle thoracostomy, and

cricothyrotomy and to insert and maintain interosseous

lines and central venous lines. They are also expected to be

familiar with the operation of transport ventilators and, if

the mission profile includes intraaortic balloon pumping, the

management of a balloon pumps (although many programs

use pump technicians for this function). They should have

knowledge of the critical care management of obstetric,

neonatal, pediatric, and burn patients as well as cardiac,

CNS, and psychiatric patient management. Transport teams

involved in aerospace medicine should have knowledge

about altitude physiology, aircraft safety, aviation communi-

cations, and emergency aeromedical procedures such as

crash response and survival. Training guidelines have been

developed and are in concert with the suggestions outlined in

the ACS publication cited below.

Adams K et al: Comparison of intubation skills between interfacil-

ity transport team members. Pediatr Emerg Care 2000;16:5.

Committee on Trauma: Resources for Optimal Care of the Injured

Patient. Chicago: American College of Surgeons, 1999.

Jones AE et al: A national survey of the air medical transport of

high-risk obstetric patients. Air Med J 2001;20:17.



Reimbursement Standards & Costs

Standards

Any medical interfacility aeroground transport vehicle will

have to be licensed by the designating agency as a transfer-

ring ambulance. Ambulance licensing varies considerably

from state to state but may depend on minimal equipment

requirements, staffing availability, staff licensing, and record

keeping. Non-public-sector aeromedical programs also are

required to comply with Federal Aviation Administration

regulations with respect to equipment, qualifications, and

hours of pilot duty. If transport vehicles cross state lines,

licensing of both staff and vehicles in neighboring states may

be required unless an interstate agreement has been reached

covering medical practice and emergency response contin-

gencies. Voluntary standards have been developed by the

Society of Aeromedical Systems, the Commission on

Accreditation of Medical Transport Systems, and the

Commission on Accreditation of Ambulance Services, and

accreditation tracks are available.

Reimbursement

For hospital-based transport teams involving ground ambu-

lances, the sponsoring facilities often support the medical

crew and contract with an ambulance company for the ambu-

lances, drivers, and in some cases the services of paramedical

personnel. Ground ambulance services may be covered by

third-party insurers. A medical necessity form is usually

required justifying the transfer before payment is made.

Helicopter programs often lease the helicopter together

with pilots, support mechanics, and a backup for service

during scheduled or unscheduled maintenance proce-

dures. Hospital support is provided by the medical crew.

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Most programs bill third-party payers for the transport serv-

ice. Both fixed-wing and helicopter rates and reimbursement

vary widely nationally, and most continue to require support

by sponsoring institutions in order to maintain financial via-

bility. Charges and reimbursements are variable—and

indeed, charge structure may vary from one program to

another because the medical costs such as crew salaries and

equipment may be part of the hospital’s or the flight pro-

gram’s cost base. Third-party payer reimbursement also

varies nationally and usually requires utilization review.

Medicare traditionally reimburses for transport only to the

closest medical facility capable of managing the patient, and

this policy may not be congruent with the emergency med-

ical services plan for the state or region. Medicare reimburse-

ment is made by a prospective payment system similar to

what is used for hospital ambulatory care billing.

Cummings G: Scene disposition and mode of transport following

rural trauma prospective cohort study comparing patient costs.

J Emerg Med 2000;18:349–54.



Current Controversies & Unresolved Issues

The beneficial and cost-effective use of air transport has been

and remains controversial. Studies now question the use of

more expensive air transport modalities in rural areas. Air

transport is a strong consideration for long-range (>50–60

miles [80.5–96 km]) transport. With regard to intermediate

transport distances of about 50 miles (80.5 km), data are

conflicting with regard to the benefit of air transport versus

ground transport. Recent evidence has shown no advantage

to air transport of trauma or burn patients when there is an

intermediate (80 km) or less transport distance. In urban

areas, a large number of variables determine the risks and

benefits of a particular mode of transport, and because of

population density with resulting loss of landing sites and

safety, ground transport is often preferred.

Chemical restraint for combative or agitated patients has

been reported to be appropriate, particularly during air

transport. Benzodiazepines are used most commonly. As

with opioid analgesic use, patients must be closely monitored

when chemical restraint is used.

Although critical care transport is a common practice,

truly comparative studies that address controversial practices

are not yet available. Because of the nature of transport and

the large number of variables to consider in transport

research, most of the published literature is qualitative and

descriptive. Qualitative research methods are appropriate for

addressing many of the issues of critical care transport and

should be done in conformity with proper research design

techniques.

The role of physician staffing of air transport units has

been questioned in recent literature. While physicians have a

broad skill set that may be an advantage during a long trans-

port, the opportunity and means to fully apply the physician

skill set during transport are severely limited. Further, with

advanced telemetry and telecommunications, physician

input and backup can be readily available.

Garner AA: The role of physician staffing of helicopter emergency

medical services in prehospital trauma response. Emerg Med

Australas 2004;16:318–23.

Berns KS et al: Comparison of air and ground transport of cardiac

patients. Air Med J 2001;20:33–6.

Slater H et al: Helicopter transportation of burn patients. Burns

2002;28:70–2.

Chappell VL et al: Impact of discontinuing a hospital-based air

ambulance service on trauma patient outcomes. J Trauma

2002;52:486–91.

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0010

Ethical, Legal, & Palliative/

End-of-Life Care

Considerations

Paul A. Selecky, MD

Advances in modern medicine have increased the ability of

the physician and the health care team to prolong life by

using a wide variety of life support modalities, including

medications, mechanical devices, and the transplantation of

vital organs. Despite their scientific success, these treatments

can prolong life of a quality that in many cases is not mean-

ingful or rewarding to the patient. The result has been that

the physician and the health care team sometimes must help

their patients make decisions about whether to withhold or

withdraw life support medications or mechanical devices—

and sometimes whether even to withhold basic life support

measures such as nutrition and hydration.

Life support decision making in the ICU often presents

ethical or legal dilemmas that must be resolved by staff and

patients and the patients’ families or surrogates. This chapter

will attempt to review the basic principles that form the eth-

ical framework of the modern practice of medicine. The pur-

pose of this discussion will not be to erect standards of

practice or to give legal advice but to offer a system for apply-

ing ethical principles in an effort to avoid or resolve conflicts.

These principles are also applied in the light of the health

care worker’s personal and professional values, institutional

policies and statutory mandates, and the published state-

ments of professional bodies.



Ethical Principles

The principles of medical ethics are rooted in religious and

philosophical traditions, which include the absolute values of

good and evil, right and wrong, and that human life is of infi-

nite worth and sanctity. Ethics is the system of principles by

which these beliefs govern our behavior and our interaction

with others. The application of these beliefs may therefore

change over time to adapt to the needs of society, but the

boundaries of the absolute values are maintained.

Four basic ethical principles flowing from these absolute

values strongly influence the practice of medicine, particularly

in critical care medicine. The first is beneficence, which directs

the physician and health care worker to do good, specifically by

restoring health and relieving suffering. This has been a funda-

mental goal of medical practice since the time of Hippocrates

in the fourth century

, but it is not the only goal.

The ethical companion of beneficence is nonmaleficence,

compelling health care workers first of all to do no harm

(primum non nocere). Nonmaleficence is not merely a corol-

lary of beneficence because these two principles must some-

times be in conflict. For example, it is considered ethically

justified to administer morphine to relieve pain (benefi-

cence) in the terminally ill patient even though the morphine

might increase the risk of death, an act that may violate the

principle of nonmaleficence. This has been described as the

principle of double effect, one act having two opposing effects.

The third ethical principle is autonomy, which dictates that

any competent adult patient who has been appropriately

informed has the right to accept or refuse medical treatment,

including life-sustaining measures—that is, the right of self-

determination. This does not include the right to commit sui-

cide or to require a physician to assist in suicide or perform

euthanasia. Although Oregon legalized physician-assisted sui-

cide under limited circumstances in 1997, physicians’ partici-

pation remains voluntary. The physician and the health care

team have a mandate to preserve patient autonomy, however,

by being honest and truthful in providing clinical informa-

tion to the patient in order to obtain informed consent to

treatment. Table 10–1 lists the patient’s rights adopted by the

American Hospital Association. The Joint Commission has

drawn up a similar list of patient rights.

The fourth ethical principle is justice, dictating that indi-

viduals be treated fairly in relation to other patients and the

overall distribution of medical resources. When medical

resources are limited, this principle states that treatment

should be administered to patients who are most likely to

benefit from them. The overriding consideration for the

physician is an obligation to care for the individual patient at

hand. Thus ethicists have argued that physicians involve

themselves in the process of providing medical care to society

CHAPTER 10

in general but not use arguments about limited resources in

making decisions about an individual patient.



Conflicts Between Ethical Principles

The practice of medicine often generates conflicts among

these fundamental principles. Efforts have been made to pri-

oritize them, often putting autonomy first as the most

important ethical guideline, but the matter is controversial.

Nonetheless, the physician and health care team are required

to address any conflicts among these principles in the light of

the circumstances presented in each individual case.

Patient autonomy must be preserved, but the physician

sometimes may find that the patient’s wishes are in conflict

with the physician’s own professional, personal, or religious

values. In these situations, the patient’s wishes take prece-

dence while the physician attempts to transfer the responsi-

bility for the patient’s care to another physician.

Medical Futility

A conflict also may arise if the physician feels that the ther-

apy requested by the patient is medically futile—particularly

if it is a life support measure. A method of treatment is

judged to be futile if reason and experience indicate that it

would be highly unlikely to result in meaningful survival.

One need not conclude that success of the treatment is

impossible—it is enough to decide that a good result would

be highly unlikely; for example, one proposed working def-

inition of futility is no successful outcomes in the last 100

reported or observed attempts of that treatment. The physi-

cian is best qualified to judge whether the treatment is med-

ically futile, but only the patient can decide whether

continued survival would be personally acceptable. An

example might be the decision whether or not to initiate

ventilatory support for a patient with severe progressive

chronic lung disease. Ideally, the treatment goals of the

physician and the patient should be identical and consensu-

ally derived.

The current consensus among ethicists holds that the

physician has no ethical obligation to provide life-sustaining

treatment he or she considers to be futile but does have the

responsibility to inform the patient of the reasons for that

opinion. If the patient requests the treatment nonetheless,

the physician is required to take measures necessary to trans-

fer the patient’s care to another physician or institution that

would follow the patient’s wishes. At the same time, all other

care that is both medically indicated and agreed to by the

patient must be continued.



Ethical Decision Making

Assessing Decision-Making Capacity

Medical decisions made in the ICU are governed by the prin-

ciple of patient autonomy, but the patient’s illness may have

significantly diminished his or her decision-making capacity.

This capacity is generally defined as the patient’s ability to

(1) receive and understand pertinent information, (2) reflect

on this information in an appropriate way, and (3) communicate

decisions and desires to the caregivers.

Surrogate Decision Makers

When this decision-making capacity is diminished or lost, a

surrogate decision maker can be sought. Ideally, this will be

an individual previously so designated by the patient in a

written advance directive. Alternatively, it may be an appro-

priate family member in an order of authority and responsi-

bility identified by local institutional or legal guidelines. A

common hierarchy progresses from the patient’s spouse to an

adult child, then to a parent, then to an adult sibling, and

then to a grandparent. Rarely, a court-appointed individual

(conservator) undertakes this role.

In the absence of specific decisions about health care pre-

viously made by the patient, the surrogate is obliged to act in

the patient’s best interests, weighing the potential benefits

and burdens of treatment—that is, applying the concept of

proportionality. The surrogate ideally therefore should be

someone who (1) is willing to accept these duties, (2) under-

stands and accepts the personal values of the patient, (3) has

no major emotional opposition to fulfilling the role, and (4) has

no conflict of interest.

For circumstances when an appropriate surrogate decision

maker cannot be identified (eg,“patient John Doe”), the health

care institution should have a mechanism in place for naming

someone to act in the patient’s best interests. Such a mecha-

nism should be governed by factors such as local medical prac-

tice, legal precedents, and institutional policies. Consultation

might be sought from an appropriate resource, such as a

bioethicist or a hospital health care ethics committee.

Table 10–1. A patient’s bill of rights.

The patient has a right to—

Considerate and respectful care

Information about diagnosis, treatment, and prognosis

Make decisions about treatment

Have an advance directive

Consideration of privacy

Expect confidentiality

Review medical records

Request medical services

Be informed about health care business practices

Consent or decline to participate in research

Expect reasonable continuity of care

Be informed of hospital policies on patient care, including resources

for conflict resolution

With permission from the American Hospital Association.

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