The transfer of the pediatric patient via Air Ambulance requires careful planning and consideration. The specialist equipment used by the transferring team will need to be adjusted according to the weight/age of the patient, as well as the skill mix of flight medical crew (Hallworth and McIntyre, 2003). A holistic approach is required to ensure the safe and successful transfer of the patient to their receiving facility.

Unlike adult transfers, staff must not only ensure the comfort and safety of the patient, but frequently the accompanying parent or guardian, who will also require support, during an often-stressful event. Thankfully the transportation of critically ill children across the UK is low, however transport teams must be ready to facilitate these transfers should the need arise, with the appropriate infrastructure in place.

This case review will analyze a recent pediatric retrieval undertaken by the specialist pediatric transfer team at Gama Aviation – Special Missions Air Ambulance. Names and locations have been adjusted for patient confidentiality.

The transfer of children is a complex process which encompasses a multitude of factors which need to be considered prior to the arrival at the referring facility

Background

A referral was received for an eight-year-old child with a femoral fracture requiring repatriation to their hometown. The injury had occurred four days prior to the referral being made. The child, who will be referred to as Jane, had sustained the injury following a fall from a significant height, whilst on holiday with her parents.

The occurrence of femoral fractures in children is not uncommon. According to Brousil and Hunter (2013) a femoral fracture is the second most common fracture seen in children, after those of the forearm. Therefore, its treatment and management are well known amongst orthopedic professionals. Jane was taken to the local hospital via an emergency ambulance. Upon receipt of strong analgesics, she was placed in a Thomas splint.

According to the Royal College of Nursing (2021) a Thomas Splint is most frequently used in conjunction with skin or skeletal traction to immobilize and position fractures of the femur. Suitable for most age groups, the Thomas Splint has a vast amount of evidence supporting its use and favorable outcomes. Jane was transferred across to the pediatric ward and the family were informed that the traction device would remain in situ for six weeks.

Mobilization

Prior to a flight schedule being logged the team make multiple phone calls to the referring hospital, undertaking a clinical assessment of the patient. A vast amount of research highlights the seriousness of femoral fractures in children, along with the associated blood loss and potential shock associated with the injury (Shah et al., 2019). As a result of this, a detailed handover with up-to-date observations was required to ensure the suitability for aeromedical transfer.

This information was further discussed amongst the Multi-Disciplinary Team (MDT) and a decision made to undertake the repatriation. It is important to note that throughout this process Jane’s parents were updated daily. Whilst this is vital for a holistic approach to nursing care, it is important to remember that parent and guardians often become experts in their child’s treatment, therefore their input is a key part of the information gathering process.

A team consisting of two pilots, a Pediatric Intensive Care Unit (PICU) doctor and a specialist pediatric nurse was activated to undertake the retrieval, all specially trained in aeromedical transportation. This specialist training is vital to the delivery of the mission, bringing clinical, logistical, and aeromedical expertise.

This collaborated style of working should be a key part of the transfer process with all air ambulance providers. Each occupation offers a different perspective on the vital elements of mission delivery. An example of this is the extensive experience of air ambulance pilots. This group of professionals take into consideration factors such as: runway length (using the full length of the runway therefore decreasing deceleration forces), the internal temperature of the aircraft, predicted turbulence and the delivery of internal power for medical equipment, to name a few.

Transfer Day

A short flight to the referring location, the team are met at the airport by a pre-arranged ambulance to escort them to the hospital. On arrival the team introduce themselves to the patient and family, taking time to get to know each other and familiarize themselves with the patient. Often, as a result of restrictive flight times, this approach is not feasible. However, when undertaking the repatriation of a child, if possible, extra time should be allowed to develop this bond, as the experience can quickly become frightening, and therefore detrimental to the child’s physical and mental health. 

A full assessment is undertaken prior to departure, including the neurovascular status of the limb. A neurovascular assessment is vital in any orthopedic transfer. The medical team will assess for pain, pulses, color, sensation, movement, warmth, capillary refill time, and swelling. The findings of this will be clearly documented in the medical notes for future assessment. A key component of the transfer, this initial analysis provides health care professionals with a baseline set of observations in which to compare, should any change occur throughout the flight. Jane, like all patients transferred via air ambulance, would be required to have regular monitoring throughout the transfer.

Specialist training is vital to the delivery of the mission, bringing clinical, logistical, and aeromedical expertise

A pain management plan was developed with the assistance of the air ambulance MDT prior to the team’s arrival, with the aim to ensure that pain and discomfort would be kept to a minimum throughout the transfer. A pediatric pain scoring system was utilized to record the effectiveness of these interventions, whilst highlighting the need for further action should this be required.  Femoral fractures can often be sore and uncomfortable, with movement exacerbating this further. Left untreated, this pain can have a detrimental effect on the child, causing undue anxiety and distress (Fisher et al., 2017). A common practice in femoral fractures is the administration of Diazepam, a benzodiazepine used to treat muscle spasms in children undergoing traction. This is requested to be administered in the morning prior to the team’s arrival. A dose of oral morphine was then administered to alleviate any discomfort. Following assessment, should it be required, the team would then opt for the administration of Ketamine, a drug commonly used in pediatrics for short and painful procedures (Dolansky et al., 2008).

Jane is carefully moved onto a pediatric vacuum mattress to assist with stability throughout the transfer. The vacuum mattress, most commonly used for spinal injuries, is ideally designed to immobilize the patient and allow for easy maneuvering. Vital when considering the transportation of children with femoral fractures. A copy of the inpatient hospital notes is taken for the receiving facility and a predeparture checklist is completed. After a small road journey back to the aircraft, Jane is met by the two pilots who both introduce themselves and undertake a briefing prior to departure. Jane is loaded into the aircraft and the flight commenced. Subjected to acceleration forces during take-off, pain is anticipated and therefore the team decide to use distraction techniques to facilitate the transfer. According to Lissauer and Carroll (2018) distraction during painful procedures is highly successful in ameliorating pain in children. Consequently, eye spy is the game of choice, and is played for the duration of the flight.

Jane’s observations are stable throughout and her pain remains minimal, requiring no further interventions. An ambulance crew await the team’s arrival and Jane is transferred to her local hospital’s children’s ward for on-going care. The relief of being home is clearly visible, with Jane being excited to see her friends, who will undoubtably be visiting for another game of eye spy.

Conclusion

The transfer of children is a complex process which encompasses a multitude of factors which need to be considered prior to the arrival at the referring facility. Transport teams should carefully plan missions, taking into consideration the physical and mental wellbeing of both the patient and escorting parents and guardians. A multidisciplinary approach is vital to safe and effective delivery.

With thanks to contributors

Dr Anami Gour

Captain Terry Knights