MEDICAL TRANSPORT IN AUSTERE CIRCUMSTANCES
In austere circumstances, a functioning emergency medical system (EMS) may not exist or an existing system may not function as it should. In these circumstances, you may not be able to reach patients or they may not be able to get to you using normal methods, such as if the roads are impassible. This chapter discusses improvised methods to transport patients or medical personnel.
The first question is always whether to transport the patient. In resource-poor settings, this decision is a delicate balance between patient benefit and the appropriate use of available resources. It comes down to two vital questions: Can we transfer and should we transfer? The detailed parts of each question are listed in Table 21-1. All the parts must be answered “Yes” for a transfer to take place.
TABLE 21-1Elements of Patient Transfer Decisions |Favorite Table|Download (.pdf) TABLE 21-1 Elements of Patient Transfer Decisions
|Can We Transfer? |
|Yes ||No |
|Higher level of care (facility/equipment/skills) reasonably available (time/distance) ||No higher level of care reasonably available |
|Referral facility accepts transfer ||Referral facility refuses transfer |
|Transfer method available ||Transfer method unavailable |
|Transfer safe for personnel ||Unacceptable danger to personnel |
|Should We Transfer? |
|Yes ||No |
|Patient benefit probable ||Patient benefit uncertain |
|Patient will probably survive transfer ||Patient will probably die during transfer |
|Resources used for transfer not needed immediately by other patients and can be replaced before other patients need them ||Other current patients need the resources to be used for transfer, or resources can’t be replaced before needed by other patients |
|Patient/surrogate wants/accepts need for transfer ||Patient/surrogate does not want/accept need for transfer |
PREHOSPITAL FLUID THERAPY
Optimally, prehospital resuscitation should be goal directed, based on the presence or absence of prehospital hypotension. In severely injured blunt trauma patients without hypotension, a prehospital crystalloid volume >500 mL is associated with an increased risk of mortality and coagulopathy.1 Obtaining prehospital intravenous (IV) lines are associated with longer EMS on-scene and prehospital times; the patients with prehospital IVs do not receive blood products any faster than those without them.2
If the patient has an IV line in place, keep it flowing during transport: Either put a pressure cuff (or a blood pressure (BP) cuff or an elastic bandage) around the bag or place the bag under the patient to maintain pressure and flow. The danger of this practice is not paying attention to the now-hidden IV bag, which can result in letting the bag run dry, thus ruining the IV access port.
If the patient has an IV line but does not currently need fluids—or needs them only intermittently—use a saline lock and put the IV fluids through it in boluses, as necessary. That also works ...