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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5198_Библиотеки_им_академика_М_И_Перельмана.pdf
Transport Medicine
MichelangeloBortolin andJacopoM.Olagnero
20
Introduction
The right patient in the right place at the right time—this is a
fundamental principle to guarantee the swiftest and best
denitive treatment, as well as the best outcome for the
patient. This will ensure that a healthcare system is able to
manage patients with a high level of efciency and efcacy.
Often, in the case of a trauma, much attention is paid to the
aspects of the treatments that can be practiced in the eld, in
the emergency room, or in the operating theater; however,
this principle indirectly demonstrates and highlights the key
role of the patient’s transportation from the eld or from
another healthcare facility to the right hospital and in a specic time. And so, transportation becomes a key aspect in the
management of trauma and indispensable in maintaining the
continuity of care.
The transportation and the management of a trauma
patient in the correct diagnostic and clinical pathway involve
different aspects:
• The establishment and the importance of a Trauma
Clinical Network (TCN) between the Emergency Medical
Services (EMS), trauma hospitals of different levels, and
also rehabilitation trauma centers
• Classication of the transport: denition and difference
between direct and inter-hospital transportation, and
transportation in emergency or non-emergency situations
• Transportation of critically ill patients
M. Bortolin (*)
Disaster Medicine Fellowship at BIDMC (a teaching hospital
of Harvard Medical School), Boston, MA, USA
CRIMEDIM - Center for Research and Training in Disaster
Medicine, Humanitarian Aid, and Global Health, UPO - University
of Eastern Piedmont, Novara, Italy
J. M. Olagnero
Critical Care Nurse at Humanitas Gradenigo Hospital, Turin, Italy
Temporary Research Fellow in Nursing Science, Università di
Torino, Turin, Italy
• Means of transportation
• The trauma team in transportation
The Trauma Clinical Network (TCN)
A Clinical Network is dened as an organizational model
that ensures patient care by interconnecting via formalized
and coordinated methods, healthcare professionals, healthcare facilities, and services providing health and social health
interventions of different types and levels. This interconnection will be in compliance with continuity of care and clinical and organizational appropriateness. The Clinical Network
identies the nodes and the related connections of the network, dening the rules of operations, the monitoring system, the quality and safety requirements of the processes and
care pathways, and the roles and responsibilities of the
healthcare professionals. [1]
In the establishment of a Trauma Clinical Network (TCN),
it is crucial that overall quality is improved and that there is
a successful outcome in the supply of trauma patient care [2,
3]. The network will involve EMS, hospitals of different lev-
els, from rural or local hospitals to highly specialized hospitals (Trauma Centers, TC), and then from the hospital
discharge to the rehabilitation trauma center. Usually, the
TCN is established regionally.
The mission, stakeholders, rules, roles, responsibilities,
and Key Performance Indicator (KPI) of the TCN must be
revised systematically and improved according to evidencebased guidelines.
Classication oftheTransport
The transport can be classied as direct or inter-hospital
transport and emergency or non-emergency transport.
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_20
151
152
M. Bortolin and J. M. Olagnero
Direct Transport
Direct transport, or primary transport, is patient transportation
managed by the EMS, from the eld to the hospital, in agreement with the TCN.Direct transport is, by denition, always
carried out in an emergency situation. Direct transport involves
a eld triage and a rst assessment and stabilization of the
patient on the scene in order to proceed with the patient’s evacuation to the most suitable hospital. Assuming an accurate
eld triage and rst assessment by the EMS team on the scene,
which recognizes and initiates the initial treatment of a trauma,
the transportation of a major trauma patient directly to a TC
can consensually be considered optimal, bypassing the nearest
rural or local hospital. But this is not always possible. For
example, in rural areas, the TC is often some distance away
and an Advanced Life Support (ALS) team is not always available. Therefore, to be compliant with the golden hour, a Basic
Life Support (BLS) team is dispatched to the scene and the
patient is then transported by the BLS team to the nearest hospital, even if rural. This is to allow the initial ATLS stabilization of the patient and then, at a later stage, proceed with the
transfer to a specialized center with an ALS team [4]. This is
an example of a so-called inter- hospital transport: it is the
movement of patients from one healthcare facility to another.
Inter-hospital Transport
Emergency or Non-emergency Transportation
Direct transport is always carried out in an emergency situation, but secondary transportation can be both in an emergency or also in a non-emergency situation.
Secondary transfer becomes an emergency when the
already hospitalized patient has health and trauma-related
problems that are time-dependent, and in order to provide a
denitive treatment, the patient requires a higher level of
specialized care in a different hospital, such as TC, that for a
number of reasons could not be provided at the rst stage.
For example, it is very different managing a major trauma in
the Australian desert where distances are enormous, or on a
small island, such as Capri (Italy), or in the Alps during a
winter storm when a helicopter is not t-to-y and only BLS
teams on the ambulance are available, compared to the same
event in other places such as cities like NewYork, Tokyo, or
Paris. So, in some situations, the patient is rst transported to
a local hospital for ATLS stabilization and later, in a second
phase, to the TC.Management always aims to provide the
best care for the patient, but the ways of achieving this can
differ substantially, depending on a number of different
circumstances.
In all the other cases, when the patient’s situation is not
time-dependent but will at some point require a transfer to
other healthcare facilities, this is dened as non-emergency
transportation.
Any transfer of a patient from a hospital with a low or insufcient level of care to the nearest facility providing the highest level of specialized care and/or between two hospitals
due to the unavailability of diagnosis and treatment facilities
is called inter-hospital transport, also known as inter-facility
or secondary transfer.
Generally, the following indications are recognized for
the activation of inter-hospital transport:
• Specialized expertise unavailable
• Resources not available
• Specialized investigations not available
• Unavailability of beds
Inter-hospital patient transfer should aim at maintaining
optimal health, and the transport between hospitals must take
place when the benets for the patient outweigh the risks of
the transfer. It should be considered that the transfer of a sick
patient may induce various physiological alterations and that
this is a moment of potential serious criticality which may
adversely affect the prognosis of the patient [5, 6].
Transportation andEects ofTransportation
onaCritically Ill Patient
Transportation is a very important procedure for every
patient and particularly so for critical patients. Critically ill
patients have an increased risk of morbidity and mortality
during inter- and/or intra-hospital transportation. Beforehand,
the physician must evaluate the benets and risks involved in
transportation. But when transportation is deemed to be necessary, the healthcare professional must take every precaution against possible complications. Here, new technologies,
new devices, and new processes have an important role in
being able to minimize the risks inherent in transportation.
Pre-transport: Preparation andPlanning
The preparation and planning of inter-hospital transport are
essential and crucial for ensuring the best and safest care for
the traumatized patient, by avoiding adverse events. The rst
step is the evaluation of the patient’s clinical situation, to
understand which hospital is able to take denitive care of
the patient, which risks exist in inter-hospital transportation,
which healthcare professionals can perform the transporta-
20 Transport Medicine
Table 20.1 Eherenwerth classication
Class Clinical features
I Patient ambulates autonomously
Does not require monitoring of vital signs
Clinical stability does not depend on oxygen therapy
Must not be transferred to an Intensive Care Unit
II Patient does not ambulate
Rarely requires monitoring of vital signs
Clinical stability does not depend on oxygen therapy
Must not be transferred to an Intensive Care Unit
III A (Airways)
Presents no risk of airway obstruction,
Patient who does not need Guedel cannula or orotracheal intubation
B (Breathing)
May have mild or moderate respiratory distress
May have a respiratory rate of <36 acts / min and> 8 acts min
It may require continuous administration of O2 to obtain a SpO2 of at least> 92% (in the absence of chronic
pathologies such as COPD), but it is not in assisted ventilation
C (Circle)
May have peripheral vascular access
It is hemodynamically stable, does not present arrhythmias, does not require pharmacological support
May require continuous electrocardiographic monitoring
It doesn’t need any invasive monitoring
Does not have a temporary pacemaker
D (Disability)
May present a compromised state of consciousness (GCS>9)
May present an anatomically stable or unstable lesion of the spinal cord below T9
E (Exposure)
Any uncontrolled bleeding
IV The patient must be included in class IV if it is characterized by the need for frequent monitoring of vital signs such as
class III and if the following criteria are added:
Requires tracheal intubation
Requires ventilatory support
It needs two venous lines or CVC to keep the cardiovascular parameters stable
May present with severe respiratory distress
Impairment of the state of consciousness may be present, with GCS </= 8
May require continuous administration of articial or supportive drugs or substitute treatments without which the
patient’s hemodynamic or respiratory failure occurs
It is transferred to the general ICU.In this case, the cases of transfers between two ICUs of stabilized patients that do
not require life support treatments or continuous infusion of life-saving drugs are excluded
Presents an anatomically unstable spinal cord injury above T9
V Assigned for a patient for whom there is a high risk of mortality during transport
153
tion, and the equipment required. To do so, it is important to
pay attention to important elements such as:
• The primary traumatological condition
• Any comorbidities
• Transportation risk classication (usually with an appropriate evaluation tool)
In order to plan transport in an accurate way, there are different methods and systems to assess and classify transportation risk. An example is the Eherenwerth Classication (see
Table20.1). The Eherenwerth Classication [7] analyzes the
patient condition and potential evolutions of the clinical situation. This classication is not specic for trauma, but it is
comprehensive and broad to include any medical and surgical condition.
154
Table 20.2 Risk score for transport patients (RSTP)
Measurement Indicators Score
Hemodynamics Stable
Moderately stable (requires volume <15ml/min in adults)
Unstable (requires volume >15ml/min or inotropics or blood)
Arrhythmias (existing or probable) No
Yes, not serious (and AMI after 48h)
Serious (and AMI in the rst 48h)
ECG monitoring No
Yes (desirable)
Yes (essential)
Intravenous line No
Yes (desirable)
Pulmonary artery catheter
Provisional pacemaker No
Yes (not invasive). Always AMI in the rst 48h
Yes (endocavitary pacemaker)
Respiration Respiratory rate between 10 and 14breaths/min in adults
Respiratory rate between 15 and 35breaths/min in adults
Apnea <10 or >36 or irregular breathing
Airway No
Respiratory support No
Assessment GCS = 15
Prematurity Newborn >2000g
Pharmacological and/or medical device
support (current or en route) (see Appendix A)
Yes (Guedel tube)
Yes (intubation or tracheostomy)
Yes (oxygen therapy)
Yes (mechanical ventilation)
GCS 8–14
GCS <8 and/or neurological disorder
Newborn between 1200 and 2000g
Newborn <1200g
None
Group I*
Group II**
M. Bortolin and J. M. Olagnero
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
Another transportation risk classication is the Risk Score
for Transport Patients (RSTP) [8] that suggests which type of
ambulance and team is required for transportation in agreement with the patient’s clinical condition. To RSTP, the cutoff that best identies the critically ill patient and seems to be
able to better predict which patients may be susceptible to
complications during transport is RSTP ≥ 7 (see Table20.2
with appendices).
Appendix A: Medication forRisk Groups
Group I* Inotropics
Vasodilators
Antiarrhythmics
Bicarbonate
Analgesics
Antiepileptics
Steroids
Mannitol 20%
Thrombolytics
Thoracic tube
Suction
Group II** Inotropics + vasodilators
MAST
Infant incubator
General anesthetics
Uterine relaxants
Appendix B: Management ofAt-Risk Patients
Points Group Vehicle Staff
3–6 0 Conventional ambulance Technicians (EMT)
3–6 I Conventional ambulance Nurse
Over 6 II ICU ambulance Physician and nurse
The TCN is very useful in quickly identifying the receiving hospital or facility appropriate for the patient as well as
the transportation risk classication. The referring physician
will identify and contact the admitting physician at the
receiving hospital to conrm their acceptance of the patient
in transfer and to conrm, before the transfer takes place,
that the appropriate higher-level resources are available [9].
If not already established by the TCN, both physicians will
determine the accompanying personnel and the mode of
transportation appropriate for the case.
During the preparation and planning phase, the team must
check the equipment and ensure adequate supplies of the
required drugs. Often, many instruments and materials are
required during the transport of a critically ill patient to the
accepting hospital. In order to make sure that everything necessary is available and ready to use, protocols and checklists
20 Transport Medicine
155
are useful tools to mitigate any safety events. It is essential to
prepare ALS drugs for the transport, according to the most
up-to-date international guidelines, drugs to ensure correct
analgesia and sedation and infusions for volume resuscitation. To ensure the safety of the patient and the operators’
effectiveness and to avoid the necessity for dilutions during
transport, drugs in a ready-to-use formulation may be preferred. These are thermostable and therefore less subject to
environmental conditions, their effects can easily be controlled by parenteral route, and they are in single doses and
concentrations to avoid confusion for the operators who
administer them.
It is also a good idea to avoid bringing material that is not
useful for the specic transport, as this could incur unnecessary confusion. Many unforeseen events, accidents, and
adverse events that occur during both primary and secondary medical transport are due precisely to the organization
of the aids and equipment for transport. Therefore, it is
essential that a checklist of all drugs and electromedical
devices is made before transport or at the beginning of the
service shift, both to verify the appropriate quantities and
correct functionality. Several studies report that the majority
of adverse events can be prevented simply by following
existing checklists; for example, deterioration in a patient’s
clinical conditions, equipment failures, incomplete supplies,
shortage of oxygen or batteries, and drug administration
errors or delay [6, 10].
At the end of this phase, the team leader takes charge of
the patient. The team leader must have thorough knowledge
of the trauma case, the patient’s clinical condition, and the
documentation.
In the case of secondary transport, the “scoop and run”
approach is unacceptable: the team has the time to plan in
advance and to be prepared. The team must, however, avoid
unnecessary delays.
The patient’s medical record documentation and the
investigation reports of procedures that the patient has undergone in the healthcare facility are crucial. The trauma team
leader of the transport must guarantee that the documentation follows the patient until arrival at the receiving hospital,
where the medical records of the transfer process must also
be handed over. This is important for the overall diagnostic
and clinical pathway of the patient, for audit and medicallegal purposes.
Monitoring During Transport
Accurate monitoring throughout the entire duration of the
transport is mandatory for the transfer of all critically ill
patients. The minimum standard of monitoring recommended for critical patient transfer includes respiratory rate,
heart rate, blood pressure, oxygen saturation, temperature,
continuous evaluation of the Glasgow Coma Scale (GCS),
and electrocardiogram monitoring. Additional monitoring
may be required, such as end-tidal carbon dioxide (in ventilated patients), invasive (intra-arterial) blood pressure, central venous, or intracranial pressure.
The patient must be monitored and re-evaluated for the
complete time of the transport while en route. Monitoring is
essential to verify that the patient is stable and is not deteriorating or, should this be the case, changes in clinical stability
must be promptly corrected. Furthermore, continuous monitoring is also important to reveal conditions that may have
been overlooked during the rst assessment and that may be
manifested during transport.
The End ofTransportation
Upon arrival at the receiving hospital, the healthcare team
must provide patient monitoring, assistance, and support
until the receiving physician and his team are ready to take
care of the patient. This moment will be the handover. The
transportation team that had performed the transportation
must deliver all of the medical documentation: all the medical records, the investigation reports, and the transportation
medical report. These are important for maintaining the continuity of the patient’s medical care and for medico-legal
purposes.
Eects ofTransportation onaCritically Ill
Patient
Within an accurate transport plan, the inuences of the transport itself on the traumatized patient cannot be neglected:
these are the changes that a critically ill patient could experience during transportation. Indeed, the different features of
the kinematics of the means of transport can cause changes
to the patient’s stability, to his vital parameters and even
cause damage.
Transportation could involve all the systems and all the
organs of the body. Indeed, for example, the heart rate could
be inuenced, and also arrhythmias, or changes in intracranial pressure, blood pressure, or oxygen saturation.
The team must take into account all these characteristics
in order to limit them and mitigate their consequences
where possible. Knowledge of this transport pathophysiology is essential in helping the operator both anticipate and
recognize the presence of new pathological conditions, or
their worsening, as soon as possible and to hasten their
treatment.
The characteristics of transport that can cause changes to
the clinical stability of the patient transported by any means
are essentially ve:
156
M. Bortolin and J. M. Olagnero
1. Changes in patient’s position
2. The presence of inertial forces
3. The mechanical vibrations of the vehicle
4. The noises, lights, and sirens
5. The microclimate
All these elements are found in and are common to all
means of transport, both in motor vehicles such as ambulances, and on aircraft such as helicopters and airplanes or
other rescue vehicles, such as boats. Inevitably, the proportion of these elements will vary according to the means of
transport in question. In general, since it is known that transport can cause a variation in a patient’s stability, it is advisable for the traumatized patient to be satisfactorily stabilized
before the start of transport.
1. Changes in the patient’s position: During transportation
by road, such as by ambulance, the patient usually
assumes a supine position with the head facing, in most
cases, in the opposite direction of travel. This can lead to
greater sensitivity to road surface irregularities and sudden movements as well as a greater risk of motion
sickness.
Two other undesirable events that can occur in supine
transport are alterations in the microcirculation with a
reduction in tissue perfusion due to the disappearance of
ow uctuations in the capillary circulation and the alteration of the relationship between ventilation and perfusion in the most declining lung portions.
Especially in the case of steep inclines and descents,
the possibility of dislocation of the abdominal viscera
must be considered and the change in position of the
vehicle positions the patient in the Trendelenburg and
anti-Trendelenburg position. An ambulance that travels a
prolonged downhill stretch with a medium-high slope
involves the patient in an imposed Trendelenburg position, in which consequently the chest is located lower
than the abdomen; this consequently leads to an increase
in preload, ICP and PVC, as well as a reduction in the
expansion of the lung bases.
On the other hand, the road travel of a prolonged uphill
stretch with a medium-high slope means that the patient
is in an imposed anti-Trendelenburg position in which the
head is higher than the chest, and this can involve the displacement and accumulation of blood in the more caudal
areas, relative hypovolemia, reduction of cardiac output,
and therefore reduced peripheral and cerebral perfusion.
2. The presence of inertial forces occurs when the body’s
state of motion varies with the decrease or increase in
speed or change in direction of the means of transport.
These forces are exerted when the means of transport
makes sudden movements when changing gear, or in
acceleration and deceleration, braking, and steering.
These inuencing elements on transport concern not
purely transport in land vehicles such as ambulances, but
also in aircraft or boats or any other means of transportation. Inertial forces can cause the abdominal masses to
compress between themselves and against the bones and
muscles. The same forces are capable of producing displacements of the blood mass, given its liquid nature,
which characterizes an easy translocation. For example,
in a helicopter take-off, the force is applied upward and
the blood mass, accordingly, moves downward. In the
case of an ambulance, road jolts determine an inertial
force upward, while the blood mass remains in the sloping spaces; in both cases, the result is a reduction in cardiac preload. Similarly, when a vehicle brakes, the blood
mass is projected forward, in the braking direction, with
the effects depending on the duration and application of
the force; in particular, a sudden stop is capable of causing a cerebral blood overow, or, in contrast, a sudden
acceleration can induce a blood overow in the peripheral
areas of the body. Likewise, the sudden changes in direction of an aircraft vehicle such as a helicopter can induce
a centrifugal movement of the blood mass that tends to
maintain the initial direction of motion.
Inertial forces also have an effect on patients in the
case of irregularities of the road (jolts on a bumpy road)
or during the phases of loading and unloading the patient.
Other adverse effects on the body in these situations are,
for example, an increase in pain (in particular for patients
with fractures: it is particularly painful for patients with a
fracture of the pelvis), or there is the risk of aggravating
spine injuries.
3. Vibrations that can affect the transport of a victim of
trauma patient mostly originate from a disconnected road
network in the case of ambulances, while in the case of
helicopters, from the rotor, turbines, and turbulence typical of low altitude. The range of vibrations within which
biological damage typically occurs is between 4 and 12
Hz: vibrational frequencies are capable of causing resonance to internal organs. The vibrations of any means of
transport are transmitted to the patient mostly from the
support surface; therefore, in order to limit the potential
damage of these phenomena, it is necessary to stabilize at
best, also using a vacuum mattress where available. The
main adverse effects due to vibration frequencies on the
patient can be the appearance of general disturbances to
the autonomic nervous system with headache, reex
vasoconstriction induced by alterations of the hypothalamic function, worsening of aneurysm or hemorrhagic
foci in previously stabilized bleeding, mobilization of the
stumps of displaced fractures, and abdominal pain by torsion of the abdominal viscera. More in detail, some
organs and systems resonate at certain frequencies generated by vibrations: the respiratory system resonates
= ++
P P PP
=
11 2 2
PV PV
20 Transport Medicine
157
between 1 and 4 Hz potentially causing dyspnea and
chest tightness, the heart resonates between 4 and 8Hz
with the appearance of precordial pains, cardiac arrhythmias, pressure changes, and the digestive tract, depending
on the lling, resonates between 4 and 8Hz stimulating
abdominal pain and vomiting. Another phenomenon that
vibrations may generate is alterations in the signals
detected by the monitors that can record artifacts, and, in
general, can inuence all electro-medical devices and
equipment.
4. Noise is another inuencing element related to transport,
common to almost all rescue vehicles of any type, both
by land, and even more so with aircraft. Among the main
negative effects, noise favors the development of motion
sickness on the transported patient but, potentially, also
on the other team members, reducing their performance;
among the team members, noise can also make communication difcult, as well as the performance of some
medical maneuvers such as auscultation and hearing the
audible alarms of electromedical devices. Finally, sirens’
lights may cause seizures in patients with neurological
diseases: sirens and alarm lights are particularly irritating not only for the team but also for the patient.
Furthermore, an alarm light can cause signicant stress
and could be a trigger for seizures. Flickering or ashing
lights can be responsible for the onset of a tonic-clonic,
absence, or myoclonic seizure.
5. The microclimate is a nal aspect to consider in the context of the elements that inuence transport. First of all,
ambient temperature nds its optimal value around 22°C,
while brightness around 1000lm. The rst fundamental
problem with regard to temperature is to nd a temperature which permits a better enzymatic activation, which
is not inhibited by too low temperatures, that inhibit
blood coagulation. It is crucial to consider how the
microclimate can have an impact on the transportation of
the patient: several studies describe and explain how
hypothermia is the rst indirect cause of complications
during the transport of a patient. Hypothermia could promote bleeding, it has effects on the pH, increasing the
excretion of acid into the blood, and it has an inuence
on the respiratory and coagulative pattern. Therefore, in
order to avoid detrimental effects, it is necessary to
appropriately increase or decrease the temperature inside
the vehicle, cover the patient with an isothermal blanket,
and evaluate the advisability of administering heated
infusions. Moreover, even if the administration of oxygen is necessary, especially in the case of prolonged
journeys, it ideally should be humidied and warmed.
Another important factor regarding the microclimate,
typical of air transportation, is altitude: the effect of an
increase in altitude on the human body is mainly related to a
decrease in inspired oxygen levels. Indeed, according to
Dalton’s Law or the Law of Partial Pressures, stating that the
total pressure exerted by a mixture of gases is equal to the
sum of the partial pressures of the gases in the mixture, it
follows that as the altitude increases, the partial pressure of
the gases, including oxygen, is reduced.
total A B N
Law of Partial Pressures
The aircraft affected by this physical law are nonpressurized ones, including helicopters, which are widely
used in the EMS systems. However, this effect does not
apply to xed-wing aircraft having a pressurized cabin in
which the gas mixture is controlled, although, during the
ight, aircraft pressurized maintains a pressure level equivalent to that of 5000 to 8000 ft above sea level.
Another physical law that is related to air transport management is Boyle’s law which afrms that as barometric
pressure increases decreases, gas volume increases.
’Boyle s Law
The clinical implications of these altitude-related changes
in pressures are: the expansion of intracranial air can lead to
brain herniation, pneumothorax, dehiscence of surgical
wounds, expansion of intestinal and gastric air causing a
decreased capacity of the lungs, and hypoxia until respiratory failure. Trauma team can predict these changes: a better
understanding of altitude-related volume changes will help
decision-making before transportation. Therefore, it is highlighted that it is appropriate to plan a ight at lower altitudes
if one of these causes can evolve, be suspected, or conrmed
[11]. The trauma team has to consider clinical characteristics
and inight physiological stressors, prescribing specic
interventions such as a cabin altitude restriction (CAR) to
ensure patient safety and clinical stability [12].
Another implication of ight altitude for non-pressurized
aircraft to be observed concerns medical devices, especially
mechanical ventilators. In fact, not all pulmonary ventilators
are able to keep the tidal volume output constant as the altitude
and barometric pressure vary. The trauma team has to be aware
of these potential problems related to ventilator performance in
order to compensate for physical variation and ready to modify
the parameters set in order to maintain the patient’s clinical
stability [13]. Regarding instead changes in endotracheal tube
(ETT) cuff pressure during HEMS transport, there is insufcient evidence to support the hypothesis that the effects of transient increase in ETT intracuff pressure are clinically signicant
[14]. Therefore, the effects of the microclimate, and in particular of temperature and altitude, are substantial during helicopter transportation, while jet aircraft have pressurized air cabins,
also permitting a precise regulation of the temperature, not to
mention also less noise and vibration.
158
M. Bortolin and J. M. Olagnero
All members of the trauma team must have an overall
knowledge of all these inuencing elements on transport that
can actively contribute to a change in the clinical stability of
the patient in order to permit rapid recognition and consequently an equally rapid response to preserve the clinical
conditions of the patient transported.
Means ofTransportation
The two modes of transfer used most for medical transportation are on ground or by air. On ground is by ambulance. By
air, the transportation can be performed by rotary-wing aircraft, such as helicopters, or by xed-wing aircraft, which
include propeller-driven or jet engine powered and include
commercial ights as well as private jets set up as an Intensive
Care Unit (ICU). Helicopters are used for shorter travel distances, local or regional distances. Jet aircraft are used for
long distances, including intercontinental ights. This mode
of transportation requires more infrastructures (airports) and
a stronger logistic support. In some particular places, such as
Venice (Italy), transportation is often carried out by boat.
The choice of the means of transport must also be meticulously assessed on the basis of the following main elements:
• The nature of the trauma, the patient’s condition, and
potential evolution of the clinical situation
• The urgency of transfer
• The distances to be covered and the relative times
• Contingent availability of resources
• Environment and geomorphology
• Trafc conditions
• Weather conditions
• Transportation costs
Transport by means of an ambulance allows it to be activated even in adverse weather conditions, has lower costs
and often faster activation times, is more familiar to operators, and allows easier patient monitoring. However, when
the travel times for an ambulance are too long or the geomorphological conditions are unfavorable, transfer is preferable
by air, which has reduced transport times and does not have
the sudden linear and angular accelerations and decelerations of ground vehicles. Air travel, however, has considerable disadvantages, such as being subjected to weather
conditions and higher costs. In addition, it is important to
consider for air vehicles, in particular for helicopters, elements such as noise, lack of space and visibility, potential
various physiological phenomena related to ight, and the
difculty to perform many medical procedures, as additional
elements that can affect the transportation of the patient.
The Trauma Team inTransportation
The patient’s transfer outcomes depend on the expertise of
the healthcare personnel performing the transportation and,
in the case of direct transportation, of the EMS team performing the eld triage, rst assessment, stabilization of the
patient on the scene, and evacuation to the hospital. It is
generally recommended to have at least two healthcare professionals accompanying the patient being transferred, in
addition to the vehicle operators.
An optimal trauma team recognizes and organizes itself
both in the in-hospital and out-of-hospital settings, recognizing a trauma team leader. Competence and leadership skills
are crucial: the leader’s competence must be such as coordinating and managing the team in situations where speed,
organization, and rapid response to prevent, prepare for, or
x problems are a priority. In direct transport, the leader of
the EMS team can be an emergency physician in a FrancoGerman EMS model system, or a paramedic in an AngloAmerican EMS model system.
Differently, in inter-hospital transportation: the leader of
the trauma team can be a physician, usually an anesthesiologist, an emergency physician or surgeon, or even a criticalcare nurse, a paramedic, or EMT, in accordance with the
TCN and the transportation risk classication.
It has been identied that the quality of the transport and
reduced adverse effect of any type, medical or technical,
depend on the trained and skilled healthcare professional.
The trauma transport team should be trained to anticipate or
solve complications and provide care to the needs of the
patient.
Communication is fundamental for the team and in all
the phases of transportation. There must, therefore, be
good communication between the members of the trauma
team themselves but also between the team leader and
the other healthcare professionals who are involved in
the management of the transportation such as, for example, EMS Dispatch Center personnel, the referring hospital and physician, and the accepting hospital and
physician.
Conclusion
The transportation of the patient to the right hospital, from
the eld or from another healthcare facility, is fundamental
in guaranteeing the best denitive treatment and prognosis
for the patient. Therefore, transportation becomes a key
aspect in the management of trauma and is indispensable in
maintaining the continuity of care.
20 Transport Medicine
Key Points
• “The right patient, in the right place, at the right
time.”
• Transportation becomes a key aspect in the management of trauma, indispensable in maintaining
the continuity of care, to guarantee the best prognosis for the patient, and to assure a high level of efciency and efcacy of a healthcare system.
• The transportation and the management of a trauma
patient in the correct diagnostic and clinical pathway involve different aspects: the establishment of
a Trauma Clinical Network (TCN), the effects of
transportation on a critically ill patient, the means
of transportation, the place and the weather, and the
trauma team during the transportation.
The type and clinical condition of the patient, the TCN, the
team, the variety of characteristics typical of the operational
territory, from a geographical and environmental point of
view, the weather, and the type of vehicle used (ambulance,
helicopter, boat, plane) are crucial elements to consider for a
patient’s transportation.
***
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Trauma Team Structure
andOrganization
EricWalser, PaulT.Engels, J.DamianPaton-Gay,
HomerC.Tien, andPatrickB.Murphy
21
Introduction
The American College of Surgeons (ACS) and its Committee
on Trauma (COT) have developed the Advanced Trauma
Life Support (ATLS) program to guide healthcare professionals in the care of the injured patient [1]. The ATLS program provides a safe, reliable method for immediate
management of the severely injured patient. Tasks are performed in sequence, in a programmatically dened order of
priority. While the ATLS program provides the backbone of
trauma resuscitation, it is important to remember it was conceived and has been developed for individuals working in a
setting with limited resources, including limited healthcare
personnel.
Ideally trauma care should be a team sport [2]. It is well
established that care of the severely injured trauma patient is
best accomplished by an organized team [3, 4] that may consist of physicians, nurses, and allied health personnel [5]. A
team approach can greatly improve the efciency and efcacy of resuscitation, as tasks can be performed in parallel,
as opposed to in sequence.
In 1976, the American College of Surgeons Committee on
Trauma published the rst resource guide for care of the
injured patient that described the concept of trauma care in a
team setting [6]. The document has evolved signicantly, as
has the “Trauma Team.” A modern denition of a Trauma
Team is a group of doctors, nurses, and support staff whose
primary responsibility is to receive and care for severely
injured trauma patients in a comprehensive and multidisciplinary manner. This includes personnel removed from the
initial patient encounter, including registry staff, quality
improvement nurses, and intensive care unit staff. The
Trauma Team is an integral part of any Trauma System.
Resuscitation by a specic group of healthcare professionals,
with clearly dened roles, led by an experienced Trauma
Team Leader (TTL), has been demonstrated to improve
patient care and outcomes [7–12] and forms the backbone of
care in major trauma centers [5, 13].
Teamwork is recognized as an essential component in
ensuring the best outcomes in patient safety and is encouraged to achieve optimal performance [14]. Despite the
protocol- driven nature of ATLS, [1] human factors may
affect team structure [15], leadership, communication, [16]
and effectiveness [17]. As outlined in Section 1, nontechnical skills, or Crisis Resource Management (CRM)
skills, are increasingly recognized as being invaluable components for optimal team function [18], and the deliberate
teaching of CRM skills has been shown to improve team performance. [19] Trauma team training programs have been
shown to improve team knowledge and performance in a
multitude of settings ranging from US civilian trauma centers [20], to developing countries [21–23], and the military.
[24] The most recent edition of ATLS clearly recognizes the
importance of the Trauma Team and its function—and the
E. Walser
Department of Surgery & Division of Critical Care Medicine,
Western University, London, ON, Canada
e-mail: eric.walser@lhsc.on.ca
P. T. Engels
Department of Surgery, Faculty of Health Sciences, McMaster
University, Hamilton, ON, Canada
e-mail: engelsp@mcmaster.ca
J. D. Paton-Gay
Department of Surgery, Faculty of Medicine and Dentistry,
University of Alberta, Edmonton, AB, Canada
e-mail: patongay@ualberta.ca
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_21
H. C. Tien
Division of General Surgery, University of Toronto,
Toronto, ON, Canada
e-mail: homer.tien@sunnybrook.ca
P. B. Murphy (*)
Department of Surgery, Division of Trauma and Acute Care
Surgery, Medical College of Wisconsin, Wisconsin, WI, USA
e-mail: pmurphy@mcw.edu
161