S4E7: Paediatric Retrieval Medicine - PEM bonus
We thought we’d start off the new year as we mean to go on with a paeds bonus episode on the first day of 2024! In this episode EM consultant Dr Conor Davis talks all things paediatric transfers with The Irish Paediatric Acute Transport Service (IPATS). Having completed some of his EM training as well as a fellowship in general retrieval medicine in Australia, Dr Davis is the inaugural EM consultant to work with IPATS here in Ireland.
Ever wondered how to make a referral to IPATS when working in a tertiary hospital? What is the criteria for transferring a child, when can it be done by IPATS and when should the transfer be organised by the referring hospital? What do you need to have prepared before sending a child and how should you prepare to expect the unexpected? How often are helicopter transfers utilised and how does you checklist differ when preparing the child for transfer? Leah and Dr Davis answer these questions and more… and seeing as we are thecase.report, we might have even managed to give an EM consultant their own case to tackle!
Don’t forget to check out our main Paediatric episode from December where we had a detailed case of neonatal sepsis and an extensive discussion around GBS sepsis, feeding difficulties in the neonate and what to do when the child doesn’t improve despite appropriate treatment in S4E6 in December.
As always, don’t forget to follow us on socials on instagram, twitter and facebook to keep updated with all things TCR. Coffee in hand? Right then, let’s get to it!
The Irish Paediatric Acute Transport Service (IPATS)
Who are they and what do they do
“IPATS supports the transfer of critically ill infants and children (aged 4 weeks to 16 years) from a referring hospital to the Paediatric Intensive Care Unit (PICU) in Our Lady’s Children’s Hospital Crumlin or Temple Street Children’s University Hospital.”
Over 90% of IPATS transfers are done by road, with a small percentage done by helicopter for hospitals furthest away in the country. As well as providing national transfers for critically ill infants and children, IPATS occasionally transfer children for organ transplants in the UK.
The service is currently staffed 8am-8pm 7 days a week, and it is hoped to become a 24 hour service in the future. The team typically consists of a mixture of an ICU/intensivist/ED consultant, a reg or fellow, a transfer nurse and a paramedic.
Preparing for transfer
As you will hear on numerous occasions throughout the interview, there are fantastic checklists on the IPATS website for just about any situation you can think of. The website is an invaluable resource and many of them can be applied even to transfer in an intra-hospital setting. It’s worth having a look at these before calling IPATS, as they tell you exactly the information they’ll want to know - but if it’s an urgent request you can always call and they can establish the details later.
When on the motorway travelling at 160km/hr, it is difficult to do anything, and you don’t want to have to unbuckle your seatbelt to adjust something. Preparation is key. The pre-departure checklists are an invaluable resource in preparing your patient and helps offset some of the cognitive load in high stress situations.
When to transfer by IPATS vs transfer by the hospital’s own retrieval team
As a rule of thumb, if the child is more than 1 hour away by road, and the patient has an injury requiring a time critical intervention eg a blocked VP shunt or an extradural haematoma that needs excavation, it may be more appropriate for the hospital to transfer the patient rather than via IPATS. They are always happy to discuss over the phone to ensure the best modality is chosen for the patient.
Tubes and wires
Lines can become disconnected in transfer, thus making sure all lines are secured. Dr Davis is a big fan of a Luer lock. If you don’t have access to one, make sure when connecting two ends of a tube,to also rotate them slightly as this will prevent them becoming detached in transfer.
In hospital staff often aren’t used to plugging monitors into power supplies, however this should be done in the ambulance, particularly for long transfers. Paramedics will be your best friends as they are used to negotiating multiple wires and tubes to ensure you have access to the patient and reducing the risk of a line or tube becoming dislodged during transit.
Challenging access
So the patient is on vasopressors but you only have a single line for access. Let’s take for example they are on an Adrenaline infusion. It’s critical here to remember the dead space in the extension lines - especially in small children - it can be 1.5 to 2 ml and if you have an infusion that is only running at 3-4ml/hr - it could be half an hour or 45 mins before they start receiving it. Here are some tricks Dr Davis uses to help manage this:
Attaching the infusion direct to the cannula or starting the infusion at a higher rate and watch the blood pressure closely - once he sees the bump - wind back to the target MAP.
If challenging access - try and avoid giving other medications via the line that’s being used for pressors if you can - but sometimes it may need to be used for ketamine/rocuronium/other essential drugs. In this situation, it is necessary to account for the dead space each time a different drug is given so the patient continues to get the appropriate rate of infusion. Make sure to allow for it in calculations, and if necessary, repeat step 1 above.
Ensure BP cuffs are on a different limb to the vasopressor infusion - there is a higher risk of extravasation, and adrenaline can build up and then the patient will get a surge all at once. Often a limb BP cuff is used in kids.
Too sick to transfer?
It’s a difficult decision to make between transferring a critically unwell child to a specialist centre or leaving the child where they are, surrounded by loved ones if the outcome is likely to be poor. The aim is to stabilise the patient as much as possible before starting the transfer, and consider whether it may be more appropriate for the child to stay where they are surrounded by their family and friends.
Do family members accompany the child on the transfer?
In general, intubated patients are not accompanied by family members, but it can be helpful in situations where a non-intubated child may need some comfort from a parent to calm them down in the high stress situation. For air transfers, there is usually room for the parent to travel, regardless of whether or not the child is intubated.
Difficult Airway Management in PEM
Does the patient need the tube? Well, if they are deteriorating despite other measures including high flow oxygen and NIV, then it’s worth considering intubation. In addition, if the patient is paralysed at high stimulus periods of retrieval eg. being transferred from stretcher to stretcher or into or out of the ambulance, there is less movement and thus less risk of tubing becoming disconnected.
Remember, children are not little adults, so intubating them can be very different from intubating an adult. Prehospital and emergency department intubation of children is relatively rare, so it’s all about having the right person (usually someone who is familiar with paediatric intubation), the right place, the right preparation and the right equipment.
We love a good acronym in Emergency Medicine, and it’s no different in paeds. Before starting a transfer, Dr Davis likes to run through a quick Airway, Breathing, Circulation, Disability/Drugs and Environment (ABCDE) assessment, as well as using a pre-intubation checklist from, you guessed it, the IPATS website!
NOTE: This image is for reference purposes only. Please visit the IPATS website to check out the checklists and other resources.
Ideally, the patient should be relatively stable on the ventilator before transfer if intubated, as having to make frequent changes or interventions during transfer is not ideal and may delay the patient’s arrival time. Dr Davis always has a bag valve mask and LMA at arms reach. Again, situations like the ET tube becoming dislodged in transit are best managed by prevention as detailed above, and would result in the need to pull the ambulance over to reintubate.
Expecting the unexpected
“In retrieval medicine think double of what you think you might need - and that’s double of everything. Sedation drugs, inotropes, oxygen and battery power. ”
Emergency drugs that Dr Davis likes to have available include blood, calcium, glucose, insulin and 3% saline (often now favoured over mannitol in raised ICP). Particularly in trauma patients, don’t forget that if they have had blood transfusions, they may require additional calcium, so it’s a good one to have on hand. We had a whistlestop tour of Trauma in S4E4: Road Traffic Collision, including the composition of blood and potential electrolyte abnormalities to anticipate in massive transfusion.
Look after yourself
Debrief, debrief, debrief
When we expose ourselves to a parent and child’s worst day, everyday, it can take its toll on the practitioner. Be sure to debrief after every case, and the IPATS team are always happy to debrief afterwards. It’s important to look after yourself and will actually enable you to better look after others.
Take home points for paediatric emergency transfers:
It’s much harder to work and make good decisions when you’re hangry, tired and cold, so pack up some snacks and a warm coat! Don’t forget a quick toilet dash before you set off on the transfer so you have no avoidable distractions along the way. (We covered the zero point survey in depth back in season 2 which you can check out here!)
Checklists help to alleviate the cognitive overload of difficult decisions.
Hope for the best and plan for the worst; allocate team roles before you set off.
Don’t forget to debrief, look after yourself and look after each other.
Don’t underestimate the importance of good communication within the team.
References
Critical Care & Retrieval Services for Seriously Ill Infants, Children and Adults in Ireland http://www.nasccrs.ie/
IPATS - note the Irish neonatal, child, and adult retrieval services each have individual subsections on the same website (in reference 1 above) http://www.nasccrs.ie/IPATS/
