• Transport medicine is a challenging subspecialty of medicine that requires thoughtful and systematic planning in order to protect patients from harm.
• The out-of-hospital environment is at best unpredictable, and at worst unforgiving.
• The occupational workspace inside ambulances and aircraft impose restrictions in diagnostic and therapeutic interventions rending many routine things done in-hospital, difficult or at times impossible to do, during transport.
• When considering medical evacuation of a critically ill patient, consider the patient’s pathophysiology, duration of transport, mode of transport (e.g. ambulance, helicopter, plane, boat, etc.), weather, route, and provision of care with limited resources when preparing the patient for transfer.

• British Columbia Emergency Health Services (BCEHS) is responsible for the delivery, coordination, and governance of out-of-hospital emergency health services, and as part of this mandate provides interfaculty transport for critically ill patients throughout BC.
• Clear communication of a patient’s disease and pathophysiology will assist in allocating the most appropriate resources and transport team to meet the patient’s needs.
• Critically ill patients or those with complex medical transport considerations will be cared for by Critical Care Paramedics. Stable patients may be cared for by Primary Care Paramedics.
• Scope of practice for these paramedic levels is defined by the Emergency Medical Assistants Licensing Board – the need for medical escorts on transport will be determined by BCEHS in conjunction with the referring clinician, patient needs, and will take into consideration the paramedics’ scope of practice.
• Family escorts are considered on a case-by-case basis at the discretion of BCEHS and will take into consideration such factors as aircraft space, weight restrictions, and the clinical status of the patient.
• Logistics, planning, and medical advice can be obtained from BCEHS Patient Transfer Network personnel and BCEHS EMS Physician Online Support clinicians.
• For aeromedical evacuation, BCEHS operates numerous dedicated and ad hoc charter aircraft. In general, the helicopters will be unpressurized while the planes will pressurize in-flight.

A systems-based approach is presented below to outline transport considerations:

Central Nervous System

• Sedation goals should be considered for all patients. This may be as minimal as PRN anxiolysis to deep sedation for critically ill patients.  Consider the effects of noise, vibration, and G-forces during transport.  The Richmond Agitation and Sedation Scale is commonly used reference.
• Note: patients being transported for primary psychiatric reasons will require explicit sedation goals, strategies, and should be discussed prior to transport with BCEHS.
• For those with motion sickness consider providing PRN anti-emetic/anti-nausea medication 30-60 minutes prior to anticipated pick-up time.
• Severe Traumatic Brain Injury: see Provincial severe TBI guidelines – Traumatic Brain Injury Management
• Acute Traumatic Spinal Cord Injury: see Provincial SCI perfusion guidelines – pending.

Cardiovascular

• IV access: ensure 1-2 patent IVs are established in all acute or critically ill patients. For optimal access during transport, it is preferable to have IV in patient’s right arm if being transported by fixed-wing, or left arm if being transported by ground ambulance.
• Central venous access (preferable) or intra-osseous access are recommended if there are actual or anticipated need for vasoactive agents.
• Note: Post-insertion CXR should be performed for all lines placed above the diaphragm, especially if being transported by air.
• Arterial lines are preferable for management of patients on vasoactive agents.
• Note: please ensure all lines are well secured to prevent inadvertent displacement during transport. Suture all CVCs and arterial lines in place.
• Post-cardiac arrest care: consider targeted temperature management.

Respiratory:

• There are no predefined lower limits for oxygenation in aeromedical transport; however, given the average cabin altitude of BCEHS fixed-wing aircraft, it is recommended that critically ill patients have a minimum P_aO₂ of 80-100mmHg (if possible).
• If there is a confirmed or suspected pneumothorax, a chest tube should be placed prior to transport, especially in the setting of trauma and/or mechanically ventilated patients.
• There is no need to replace air in endotracheal cuffs with water/saline.

Gastrointestinal:

• Nasogastric tubes should be considered for any patient for whom bowel dilatation on ascent and cruising altitude may cause symptoms. This includes those with free-intraperitoneal air post-laparotomy.

Genitourinary:

• Urinary catheter should be placed in any critically ill patient or in those who cannot ambulate during a prolonged transport.

Musculoskeletal:

• Spine boards are no longer recommended for spinal immobilization or transport. Please check with BCEHS for specific questions or concerns.

Infectious Diseases:

• Advise BCEHS if any infectious disease precautions exist, in particular during pandemic season and/or if respiratory isolation precautions are in place.

Special Populations:

• Bariatrics: special bariatric stretchers are aircraft are available.
• Toxic or Poisoned Patients: BC Drug & Poison Information Centre is available 24/7.
• Major Burns Trauma: see BC Guidelines for Provincial guidelines/pre-printed orders.
• For winter season transports, consider prolonged transport times and risk of hypothermia.

BC Emergency Health Services:

• Patient Transfer Network: 604-215-5911 or Toll Free: 1-866-233-2337
• EMS Physician Online Support: 604-215-5911 or Toll Free: 1-866-233-2337

BC Drug and Information Centre:

• 604-682-5050 or Toll Free: 1-800-567-8911

1. Major Burns Trauma Clinical Practice Guidelines: www.bcguidelines.ca