Depending on your department the frequency with which you are faced with the need to transfer a critically ill intubated patient may vary but it is something we think all departments face at some point.
Common examples might be:
- The intubated major trauma patient, needing to be transferred to radiology for imaging
- The intubated post-cardiac arrest patient, needing to be transferred to an intensive care setting.
While chatting about my experiences in prehospital and retrieval medicine at Sydney HEMS, Simon and I realised that we were both in the position of having undertaken these transfers at various stages of seniority in our careers and that now, with greater experience, wisdom and hindsight (!) we have an awareness that we could have done a much better job of it, particularly when we were relatively junior.
We put together the podcast below to outline our experiences and thoughts on how we would now approach this potentially very risky clinical undertaking and we would love to hear your thoughts on what we had to say.
Below is a summary of the key points covered in this podcast, plus some additional resources we thought might be useful.
Is the patient fit for this transfer?
This is a question of balancing priorities. Often the transfer is necessary to advance the patient’s care and as such there is a degree of urgency (consider the head injured patient who might have a time-critical traumatic brain injury) but this has to be balanced with the patient’s condition. You might not be able to get the patient to a perfectly ventilated, haemodynamically stable state – but are there immediate interventions that need to be performed as part of the patient’s resuscitation, or have you stabilised the patient as much as you can with no further easy wins?
It’s a tricky one. We are pretty good at finding this balance point and arguably better than we used to be (and continuing resuscitation as we go) but it’s probably a decision to be made by a senior decision maker in the ED.
Sedation, Analgesia & Paralysis
Adequate sedation to keep someone comfortable, asleep and tolerating an ETT on an ED stretcher is not the same as the sedation required for them to tolerate a move off that stretcher, which is significantly more stimulating. Remember, if you haven’t adequately sedated/analgesed/paralysed your patient you aren’t going to know until you come to move them onto the CT scanner or ICU bed i.e. at the furthest point away from all of your ED drugs and equipment! My personal tip is to suction the ETT and the patient’s mouth before you depart on your transfer – this gives you a good indication of how the patient will respond to something quite stimulating and can guide your dosing.
Having ongoing sedation ready should be part of your pre-intubation preparation, no matter what the patient’s pre-intubation GCS was. Even if it is running at a very slow rate, please be kind to intubated patients and sedate them as deeply as you can!
Paralysis is not 100% necessary but it might make your life significantly easier – there are some patients we might not want to paralyse beyond intubation (such as those whom we want to monitor for seizure activity) so you’ll need to think about this carefully in the context of the patient in front of you. Don’t even consider additional paralysis unless the patient is deeply sedated – awareness is an awful, awful thing for patients to experience. It probably does happen in the ED and we probably don’t think about this enough.
And, of course, sedation and analgesia are not the same thing. Propofol has sedative properties but it is not an analgesic. Patients with painful conditions deserve both sedation and analgesia – consider fentanyl, alfentanil, remifentanyl infusions in addition to your sedative agent.
Any of these component agents might have cardiovascular consequences so it takes an experienced clinician to consider what you are going to use in each case. Like so many things in medicine, there’s no cookbook approach.
Family and Friends
Whilst you are preparing and organising it’s quite likely that the patient’s family and friends will be watching what you are doing and this may result in anxiety. They will often realise the urgency of transfer and the need for a definitive procedure or investigation and so you must keep them informed about what’s happening and what to expect. Be kind, thoughtful and honest with them and they will thank you for it.
Anything that can go wrong, will go wrong.
Try to rationalise the equipment you are taking with you. Start by getting rid of the non-essential stuff. Stop any unnecessary infusions (heparin infusions, the tranexamic acid – it can wait 30mins!), empty the catheter bag, spigot the NG tube.
Then consider what you do need to take – check there is enough of each drug in your sedation and analgesia infusion pumps, check there’s enough oxygen in the cylinder on the trolley.
Then simplify your space – try to ensure everything that will need to move with the patient will come with the patient. The easiest way to do that is to move everything to be contained within the trolley and the sheet the patient is lying on. Use the space between the patient’s legs – Simon calls this “making everything linear.”
Consider the ventilator you are going to use – the simpler, the better. We are both fans of the oxylog series which Simon describes as basically just “squeezing a bag”.
The most important move is at the other end of the journey.
When you are preparing the equipment and patient it’s easy to think about packaging the patient for a move out of the ED, but if that’s all you do you will be missing the most important and potentially risky part of travel. It is the move from the ED trolley onto the CT table (or bed) that is the risky move. The key then is to prep your patient up to the point of being able to move off the trolley before you leave the ED. You want to arrive at the destination with as little work to do there as possible.
All this time is well spent in minimising time outside the ED (your high risk time). You are aspiring to keep that time as short as possible by having the patient ready to simply transfer across as soon as you arrive at your destination.
You also need to think about the eventualities which might occur during the transfer.
Nat’s top three questions to ask yourself before you depart:
- What if this transfer takes longer than I thought?
- What happens if the patient suddenly becomes sicker than they are now?
- What will I do if the patient is accidentally extubated?
Hofstadter’s Law: It always takes longer than you expect, even when you take into account Hofstadter’s Law.
I like to estimate the time the transfer is likely to take, multiply by two and add a bit as a guideline for how much I need in terms of drugs and oxygen.
Before you go, it’s sensible to notify your destination that you’re about to leave. Let them know you’re setting off, how long you’ll be and how sick and/or stable the patient is (especially if they are so unwell that you really don’t want to be waiting around). They might also be able to tell you if there are changes to your route (for example, if a CT scanner is out of order and you’re actually going to be transporting to a different part of the hospital).
Above all else, BEWARE LIFTS. They aren’t always avoidable – but being stuck in the confined space of a lift with a sick patient can be a nightmare!
The Suddenly Sick Patient
Think about what might happen for this individual patient – for example, if you think there might be a pneumothorax but it is currently undrained, do you have the equipment to perform a finger thoracostomy if the patient suddenly becomes difficult to ventilate with high airway pressures?
What if the patient suddenly drops their blood pressure and you are concerned about bleeding? Do you have enough blood/blood products to support them so you can get them back to the ED?
Sharing your mental model with the team is key here too – articulate your assessment and concerns, and what you are going to do if they become a reality. That time taken to get your colleagues on the same page will ensure they have your back if things go wrong and that in itself is invaluable. You could even allocate specific tasks in the event of likely deteriorations (“If the patient has a traumatic cardiac arrest, Rachel, you’ll do the left thoracostomy while I do the right one; if that doesn’t work, we’ll proceed to thoracotomy which I will perform.”)
Extubation & Ventilation
If the patient is accidentally extubated, you will need enough equipment to secure and maintain an airway. You have already done your best to prepare the patient and reduce the likelihood of this but it can still happen.
You also need to think about how you’ll ventilate the patient – more important than intubation, it’s worth taking a simple oral airway and a self-inflating bag so that if it all goes really wrong you can ventilate the patient in the simplest way possible. Remember – we all love the Water’s circuit/Mapleson C but it needs oxygen to work so it’s really totally useless if your cylinder runs empty because you’re stuck in the lift!
At Sydney HEMS we have a “drop down airway” kit we take with the patient – you can find out what’s in it here.
Most EDs will have a transfer bag you can take with you which contains much of the same sort of equipment. We strongly recommend that if you have one you’ve taken the time to open it (even if it is checked and sealed) to familiarise yourself with its contents before you need to use it in the heat of the moment. Simulation is a great way to explore this.
It’s easy to send a relatively junior doctor with the patient because they are competent at intubation – we have both done this as junior doctors and got away with it, but it really is “getting away with it”. As senior doctors we both recognise it’s far more sensible to ensure that the accompanying doctor can deal with every emergency the patient might experience (as in the section above) and that usually means they should be quite senior.
The department can’t always spare the most senior person (consultant) for the whole transfer, particularly if you work in a busy ED (who doesn’t?!) but if a senior trainee is undertaking the transfer the consultant may want to be around and follow the patient a few minutes later.
Of course as education enthusiasts we felt it important to point out that this is an ideal opportunity to complete a mini CEX on safe transfer – although this is covered in basic anaesthetic competencies these ED transfers are typically of a higher level due to the complexity of the patient.
When you get there…
We also discussed the final stage of the process: the transfer itself.
As soon we arrive at the destination I like to take up position at the head of the bed with one hand always on the ETT. That gives me valuable proprioceptive feedback leading up to and during the move so that I am acutely aware of any threats of inadvertent extubation. I don’t move from that position until we are all stepping away from the patient altogether.
I like to make sure the physical movement of the patient is the very last thing that happens – before then, you’ve switched the ventilator over to the wall oxygen supply because you don’t want to risk the transport cylinder running out.
In the movement itself I like to go to halfway first for intubated patients, to account for possible tension on the ETT or on important lines, from the ventilator tubing itself or anything else attached to the patient. Before we start I give my team a pre brief;
“I’m going to give you a READY, STEADY and we are going to move to halfway on MOVE and if I am happy I’ll count you in again for the rest of the movement. What I’d like us to do is go to halfway; if I say STOP at any point we stop exactly where we are. Everyone clear?
READY – STEADY – MOVE to halfway.” If everything is ok, I’ll immediately count in another ready-steady-move.
I’m not a fan of disconnecting from the ventilator to move (it just creates haste in my mind when I’d prefer the movement was slow and controlled but I recognise it’s not always possible to complete the move without disconnecting).
Simon’s big tip is to look at the lead lengths before you move to try to anticipate what might get caught – the EtCO2 tubing seems universally to be much shorter than everything else!
After the transfer
When the scan is completed, it’s time to do everything in reverse (but hopefully with slightly less urgency).
Once back in the ED you can move infusions back to the drip stands and untangle all of the inevitably tangled cables, then prepare for the next move – whatever that might be!
For the relatively straightforward patient who is easy to ventilate (and not inotrope dependent):
- Don’t be complacent – most of these transfers will go absolutely fine but they can also go horribly wrong! Time invested in planning and preparation is well spent to avoid or ameliorate nightmare scenarios
- Have a system
- Optimise the patient
- Package and position the patient before you leave the ED bedspace
- Think carefully about sedation, analgesia and paralysis
- Anticipate problems, particularly the longer transfer, the sicker patient, the accidental extubation – simulate these in your mind, make a plan and share the mental model with your team
- Prepare the team at your destination so they know you’re coming
- Choose the right team to go with the patient – those who can deal with the likely eventualities if things go wrong.
- Pre-departure checklist? We use this at Sydney HEMS for our prehospital cases but most of it works well for hospital transfers too – there’s a version below.
A – airway secured?
B – both lungs up? Both gases (O2, CO2) good?
C – control haemorrhage (splinting, clotting – TXA), connect blood or fluid so you can easily give a bolus
D – disability (check pupils), drugs (sedation, analgesia, paralysis)
E – equipment for emergencies
F – family briefed? “Fone” numbers (how will you get help from ED if you need to return in a hurry?)
G – general demographic details – does the patient have a nameband for CT??
H – heroic needs? Let the destination know you don’t want to be waiting in the corridor
ALSG’s Safe Transfer and Retrieval (STaR) Course
Sydney HEMS Pre-Departure Checklist