General Considerations

Cabin Space

Space is limited in transport vehicles. Although vehicles come in different sizes, shapes, and configurations, the available patient care area in the trans­port environment is more limited than in the hospital setting.

An important issue related to cabin space is the consideration for family members accompanying a neonate or child during transport. Parental pres­ence often is beneficial when transporting an anxious child (see Chapter 12: Family-Centered Care). In the tight confines of some vehicles, this may not be possible or recommended. Increased size, however, will increase the cost of purchase and operation as well as compromise comfort and efficiencies. For example, the larger box ambulance with a longer wheel base provides ample space; however, it often suffers the consequences of having a rougher ride for the patient and crew.

Medical Configuration

Most states have regulations that establish the minimum medical equipment required for ground transport vehicles. Some state regulations also address medical configuration, whereas the FAA regulates how built-in equipment must be installed and secured in aircraft. Adherence to local and federal regulations is required for ground and air ambulances.

Medical configuration goes beyond the location of equipment and the number and location of patient litters and seats for transport team members. Easy access to the vehicle's patient care area is critical and must be addressed. Doors must be wide enough to accommodate a transport incubator or patient litter (gurney) with all attached medical equipment. Two personnel should be able to maneuver the equipment easily into and out of the vehicle without excessive rotation or tilt from the horizontal plane. A hydraulic lift device on a ground ambulance is helpful for reducing lifting injuries. Adequate access to the patient while seat belted in place in the transport vehicle is essential, and easy access to the patient's airway and visualization of the patient's upper torso must be possible at all times.

The medical configuration must be designed with the safety of the patient and transport team in mind. Equipment should never be installed in proximity to a person's head. During a crash or severe turbulence, the head strike area must remain clear to avoid a head injury. This is true for air and ground ambulances. In addition, the transport team members, patient, and all equipment must be secured during any vehicle movement. Unsecured or improperly secured equipment may become projectiles during a crash or a sudden extreme movement of the vehicle, possibly resulting in significant injury to the transport team members, the patient, or the pilot or driver, with potentially devastating consequences. All equipment and supplies must be secured, and all responsible personnel must be properly instructed in proce­dures to secure all on board.

Because medical equipment undergoes the same stressors of transport as vehicles, patients and transport personnel (ie, vibration, gravitational forces, thermal stress), they do not have the expected lifetime usage as compared with similar equipment used in a hospital unit setting.

Oxygen and Air

All patient transport vehicles should have built-in and portable gas sources with the ability to provide oxygen in concentrations from 21% to 100%. Sufficient medical gas must be carried to meet the estimated duration of the longest anticipated trip, with a recommended reserve of approximately 2 times the trip length. Vehicles that may transport 2 patients should have separate medical gas supply systems for each patient. Portable medical gas tanks should be available to back up the built-in system and to safely accom­plish the transfer between the vehicle and facility or between vehicles.

Suction

Suction capability is essential in the transport environment. Built-in suction is generally recommended, with a portable system for backup. The suction should be regulated with a maximum of -300 mm Hg achievable as needed. As with the medical gas, vehicles that will transport 2 patients should have duplicate suction capabilities.

Medical Equipment

Most medical equipment used during transport should be portable to allow the equipment to go with the patient, bedside to bedside. This also elimi­nates the need for the primary monitors, ventilators, infusion pumps, and other devices to be built into the vehicle.

Supply Cabinets

Whenever possible, adequate cabinet space should be built into a vehicle for the storage of routine and necessary supplies during transport. Cabinets for these on-board supplies should be easily accessible to the transport team members from a seat-belted position. The cabinets should be closed and secured during transport. Interior vehicle configurations and certain equip­ment may vary; however, they are subject to safety policies mandated by local or state regulations.

Electrical Outlets, Power Inverters, and Demand Inverters

Although portable medical equipment usually is supported by battery reserve, it is often preferable to conserve battery life during transport. The transport vehicle should provide an alternating current inverter and electrical outlets in sufficient numbers for the equipment used. Many vehicles also are equipped with a “shore line,” allowing portable equipment to be plugged into outlets in the vehicle so that the batteries can charge while the air or ground ambulance is stationary between transports.

Cabin Lighting

Adequate cabin lighting, allowing continuous assessment of the patient and necessary treatment en route, is essential. The lighting should be adjustable to meet the needs of each transport situation. Patient care compartments should have illumination to 400 lux, with high-intensity directional lighting of 1000 to 1500 lux available for procedures. In addition, barriers should be available to protect the driver or pilot from the bright patient cabin light that could interfere with night vision.

Climate Control

Patient transport has the potential to expose the vehicle, patient, and trans­port team members to significant temperature variation, which may result in clinical and operational complications.

Neonatal and pediatric patients have large surface/mass ratios and, therefore, can become hypothermic or hyperthermic rapidly. For the trans­port team members, marked deviation from the normal comfort zone may result in impaired performance. Therefore, the environment of the patient cabin should be easily controlled and monitored.

The 9th Edition Accreditation Standards of the Commission on Accreditation of Medical Transport Systems (CAMTS) stipulate that the interior of an ambulance or aircraft must be climate controlled to prevent adverse effects on patients and transport personnel on board. A thermometer must be mounted inside the cabin to measure and document cabin tempera­tures every 15 minutes during the patient leg of the transport. Transport pro­grams are now required to have written policies that address measures to be taken to avoid adverse effects of temperature extremes. Furthermore, cabin temperatures 95°F will require transport programs to record these events and undergo a quality-management process to evaluate the measures taken to avoid the adverse effects and what outcomes resulted.

Communications Equipment

Every transport vehicle should be equipped with adequate communica­tion equipment. At a minimum, the transport team members in the vehicle should be able to contact the communications center or base of operations and medical control. In addition, aircraft crew members must be able to talk to the FAA control tower personnel and personnel in other aircraft. Cellular phones are, however, prohibited by the FAA and the Federal Communications Commission in airborne aircraft because of potential interference of aircraft navigational aids, especially those on the ground that send radio signals to planes to help pilots stay on course. Satellite phones, however, are FAA approved, do not interfere with avionic equip­ment, and have an extensive coverage area that is larger than most com­mercial cellular systems.

It is advantageous to have multiple communication modalities in ambulances. In ground ambulances, cellular phone technology is permit­ted. Ground ambulances are often equipped with 2-way radios having very high frequency (VHF) and/or ultrahigh frequency (UHF) capabilities. Therefore, the transport team can contact its base hospital, medical con­trol, or the receiving hospital via the dispatcher of the ambulance vendor. Similar methods can be used with aircraft pilots communicating with their dispatcher or air traffic control. Helmets outfitted with avionics can be used by helicopter transport personnel who can communicate with the pilot, who, in turn, can transfer information to an appropriate recipient. Ideally, specific medical information is relayed directly to the intended recipients and not through a nonmedical intermediary. Communication can also be achieved by other modes such as alphanumeric paging, fax machines, and computer­based programs (ie, wireless Internet).

Speed

In a time-critical situation or when out-of-hospital time must be kept to a minimum, the speed of the transport vehicle may be important. Ground ambulances may be limited to the legal speed limit, and there is little differ­ence between the different types of ambulances with regard to capabilities for speed. The speeds for helicopters and airplanes, however, vary by make and model. Helicopters can fly between 100 and 180 mph, and airplane speeds range between 120 and 450 mph, depending on the manufacturer and model of the aircraft.

Range

The range of a vehicle is defined commonly as the total distance it can travel without refueling. Ground ambulances and helicopters often have a func­tional range between 0 and 150 miles (although it can be farther), whereas airplanes and jets commonly used for medical transport may have a range up to 2000 miles.

Service Area

There is a direct correlation between the anticipated service area of a trans­port program and the range and speed for the chosen vehicle. Beyond dis­tances of 100 miles, a ground ambulance may become inefficient, costly to operate, and time-consuming. Programs with helicopters generally operate within a radius up to 150 miles from the base of operations, although this may be expanded in some programs with refueling or long-range capa­bilities, whereas programs with airplanes may be regional, cross-country, or international.

Costs

Financial considerations are addressed in Chapter 15; however, a few points deserve emphasis in this chapter. The cost varies greatly based on the type of vehicle chosen and whether the vehicle is dedicated to patient transport and/ or to only 1 transport team. The helicopter is the most expensive (cost per mile) vehicle for transportation from the operational standpoint and with regard to patient charges. Airplane transport also may be costly but becomes more economical for greater distances.

It also is likely that a dedicated vehicle will be more expensive than a vehicle that can be used on an as-needed basis. A dedicated vehicle may or may not be feasible for a particular transport service. If it is impractical for a neonatal-pediatric transport team to have its own dedicated vehicle, involvement of other transport teams to share the vehicle and the high costs involved in its operation and upkeep may be necessary. If a dedicated vehicle cannot be justified, it is recommended that the team select one or more vehicle operators who can provide the appropriate vehicle(s) for use within an established timeframe.