Good morning, was the night ok? What have we got today, a couple of abscesses?
Oh dear this isn’t good
Ok so yeah, we have 40 year old in resus who was at home when they became suddenly unresponsive. Brought in by ambulance. Found to be GCS of 3 on arrival. Now tubed and ventilated. Grade 7 view. Their CT head has revealed a SAH and they’ve now been accepted by neurosurgeons at ‘The Royal Hospital of Somewhere Else’ and they need to be transferred
*Downs coffee and puts sudoku away*
Right then off to Neverland we go…...ugh
Let’s face it, tackling the M25 can be a soul-destroying procedure on the best of days.
So adding an intubated, ventilated and usually unstable patient into the mix isn’t the most heavenly way to spend a Monday morning, or any morning really.
Oh! Let’s add in travel sickness to that heady cocktail too for good measure. Some of us are blessed with all the good genes…. Eye roll….wait that’ll make me sick
I cannot lie, transfers used to fill me with utter dread, but I must admit I do find them rather enjoyable now. Well let’s not get too excited. I enjoy them only if it’s not 3 in the morning when I’m about to have my lovely, freshly made cup of coffee, as I’m sure you will agree…well we are anaesthetists after all…how else am I meant to supplement my circulating volume?!
Now, in theory it doesn’t sound too bad, moving a patient from point A to point B.
Easy right? However, in order to get from point A to B we might be presented with ancient Victorian lifts - which don’t like to be moved - and I’m pretty sure are haunted (going on the noises some of them make).
Add to that fun scenario, a bed which steers like the bumper car trolley in Tesco’s (you know the one I’m talking about) and appears to have been sent from the very depths of hell to test your patience. A bed that also somehow manages to treat the tiniest pebbles on the ground as though it was overcoming Everest itself.
Oh, and then there are the lines, infusions and wires that tangle the very instant you set eyes on them, so you try and act casual when stealing glances, in order not to frighten them into chaos.
Then, somewhere beneath all of that Christmas lights mayhem – lies a jolly unstable patient. Merry Transfer to you…. whoopee.
This isn’t to startle you but to ready you, so that it doesn’t all feel so overwhelming.
It’s also an attempt to reassure you that this is in fact, utterly normal.
Rest assured, once you start getting into the flow of your role as an anaesthetist, transferring patients - be it in your own hospital or between hospitals - will become your bread and butter. You’ll soon discover all those tricky bits that accompany you on journeys, be it a quick trot around to CT or a canter up the motorway to your nearest and dearest tertiary centre, become slightly less scary each time.
I won’t lie, when you start doing transfers - you’ll start to worry about things that you didn’t even know you could worry about…pauses to think…
….“If I get stuck in this lift who is going to know?! I did send someone ahead….I think…no I definitely did, I sent them with all….the…..kit….note to self, don’t do that again...
When they do end up finding out we’re stuck in this Victorian iron prison - because I’ve been banging SOS in morse code on the lift doors - would I rather have the patient’s head closer to the doors or further away - (head always closest to the doors in my opinion, so less distance between you and exit. Also it’s easier connecting important things - like your ventilator to oxygen if your cylinder runs out).
What happens if my C circuit somehow manages to explode, has a hole in the bag, or I lose that very important white connector thingamabob…. again. Then how will I ventilate this patient?! I’m worrying because - you know - my ventilator also has somehow managed to fall off the trolley and roll down the hill we’re apparently now magically standing on in this nightmare”….
Transfers can be a scary business for even the most seasoned anaesthetists but as long as you mitigate against disaster as much as possible then you’ll be alright.
One really easy way of doing this is with any anaesthetists’ best friend…the checklist! Did I tell you anaesthetists are excellent catastrophe planners or was that not apparent in the nightmare I just illustrated?
You may have heard the old phrase
Never have those words rung truer than before moving a critically ill patient anywhere.
One of the best courses I did in CT1 was a transfer course.
It was immensely helpful and transported me (pun intended) to a degree of readiness.
It taught me, as with most things in anaesthetics, that the key to challenges is to break them down into bite sized chunks. The way we often do that is with that old gem - the A to E. It’s incredibly safe and reliable which actually makes it quite difficult to miss things.
Most hospitals will have a transfer checklist and though it may seem tedious, these checklists are going to absolutely save you so use them in addition to your own. They often have a carbon copy which you keep and give another copy to the accepting hospital.
Additionally, there are often sections where you can document observations and any medications you’ve given, during the transfer. If it doesn’t, then panic pas! Just make sure you do some documenting somewhere. This can be delegated to a member of the team if you need as you often have enough on your plate.
Over time you will, no doubt, develop your own checklist which you’ll run off in your mind before heading forth, brave warrior. In the meantime, you’re more than welcome to borrow this one or keep it as long as you like.
Now, this one is a little longer than your typical A to E
It’s almost the entire alphabet in fact, so please take what you want from it. It is the product of helpful stories and lots of advice from well-travelled anaesthetists and I’m truly grateful for it, to say the least.
So, this is what I personally run through before setting off…
Airway and AAGBI monitoring
- What is your current airway and what will you do if this should this fail.
- Do you have plan A to D and have you verbalised it.
- Do you know where each part of your plan A to D is.
- Make sure you have noted where the tube is at the lips. Journeys can be bumpy and no one wants a tube shaking around and becoming dislodged. Ensure it’s well secured.
- Look at the notes to see grade of intubation.
- Full AAGBI monitoring
- Ventilator - current settings, enough battery, safely secured to bed
- If vent fails - C circuit or self-inflating bag
- Capnography - no trace wrong place and that means definitely don’t leave the place
- Have a stethoscope with you, very important bit of kit that tells you so much, plus as a wise owl once said – then no one will mistake you for a surgeon
- What’s going in, what’s coming out and how are you monitoring it
- IV access – be that big or small
- Catheter if necessary
- Drains and pipes - clamped or open?
- Blood pressure monitoring – invasive or non-invasive.
- Put lines that you need in, before leaving through those hospital doors – and know where they are so you can access them quickly if necessary.
- How are you going to manage low BP. Make sure you have your uppers with you and some fluid.
- GCS, pain and sugar.
- Sedation and pumps - with charging leads. You can plug kit in when you’re in the ambulance but again if the ambulance has to pull over and there’s a mechanical fault (it has happened) then you need to make sure you’ve got enough juice for a while until another ambulance can get to you (again this has happened). So plug in every time you have a chance.
- Pain relief - infusions/boluses
- Paralysis - if tubed and sedated (goes without saying I hope) I always give paralysis before my journeys. The last thing I need to do is tackle challenging ventilation - keep them as still as possible and let the vent do the hard work of breathing for them.
- Just like a usual theatre list, get all the drugs you might need on a journey. They should be drawn up and ready for action. Don’t forget adrenaline, this can be a real life-saver…literally!
- This is so easy to forget. You don’t necessarily have to do this yourself but it’s easy to forget to tell the next of kin that their family member has moved to London. This really doesn't go down well when they turn up to visit their family member on the ward in the morning and they’re gone, as you can well imagine.
Gunk and Gastro
- Suction – make sure to take a small catheter as well in case you need to suction down the ET tube. Actually switch it on to make sure it’s working before you leave and that there’s enough battery - can you tell I’m obsessed with batteries?
- Do they need an NG tube? Is there one in place which needs suctioning before going?
- Sickness – take some anti-sickness if you need it - I really need it. There’s no shame in it. Holding down your stomach contents whilst making the rounds in London and simultaneously trying to concentrate on suctioning the tube, is the opposite of fun.
- Blood and clotting factors to go with you if necessary.
- If you don’t use the blood it’s simply returned to the blood bank at your destination if not out for too long. You won’t feel bad about taking blood and not using it, you’ll feel terribly mad, bad and sad if you need it and didn’t have any.
- Carry and give antibiotics if due. Worsening sepsis doesn’t need to get involved on your journey thank you very much.
Just in case
- I remember this bit as my ‘Just in case’. It’s my Go Bag in other words. “Just in case then I have my transfer bag” - But essentially extra bits of essential kit - IV access, syringes, drugs, wires, leads, pumps, trachy extras if they have a trachy (remember a small face mask if you need to oxygenate through it as a last resort…
Potassium and electrolytes
- Check potassium and electrolytes and latest gas to see if there’s anything correctable. You don’t want to transfer a patient with a K of 2. Top up or start topping up before moving. It might be several hours before you can do another gas so correct what you know is an issue now. This is no less true of a trip to CT or the cath lab. A transfer is a transfer and though you could get someone to run to a close ABG machine in the hospital, if you have time it is ideal to optimise before moving.
Lactate and Last check
- I check the current value and trend. Essentially this bit just reminds me to check the rest of the gas, which you will do anyways when checking electrolytes but it serves as a reminder so I can adjust vent settings or correct anything before leaving. If you’re dealing with a bleeding patient then don’t forget to check calcium to help with clotting.
Mobile and money
- Mobile phone - make sure you have one with a charger.
- Money - in case you get stranded somewhere - it happens sadly so be prepared and stay safe out there.
Numbers and notes
- Numbers you’ll need. Bosses, hospital you’re going to, department or ward you’re going to, bleeps, the lot
- Notes - up to date patients notes
- Oxygen cylinders – twice as much oxygen than you need. Ensure all the cylinders you’re taking are in the green. People may push you to take ones that are half full, no is the answer
Personal, People and Pathologies
- Personal - Coat, Phone, Water, Food
- Patient personal - their belongings
- People going with you – the skill set accompanying you can almost tip you into relaxation if you have an ICU nurse or ODP with you. You can almost, dare I say, breathe a sigh of relief.
- Pathology ready - for example intracranial pathologies – I’ll explain
There are certain pathologies that require certain medications or emergency drugs.
A good example of this is intracranial bleeds.
- Be sure to take 20% mannitol (the dose being 0.5g/kg IV over 20 mins) which can be given after discussing with the neurosurgical team.
- You should also take 5% hypertonic sodium and can usually give 100mls of this. These would be used in case there’s evidence of increased ICP.
Simple things can make huge differences in these patients.
- Keep the patient with their head elevated around 20 to 30 degrees.
- The tube should be secured but allow good venous drainage so avoid compressions of jugular venous drainage.
- Keep their head in the neutral position as if turned to one side, it may reduce venous drainage and increase intracranial pressure.
- Aim to maintain PaCO2 between 4 – 4.5 kPa as this will reduce cerebral vasodilation and therefore ICP.
- If there is evidence of raised ICP then lower this further will do no immediate harm but may actually do some good.
- Monitor pupils regularly so you’re really quick to notice possible increasing intracranial pressures and don’t be afraid to make early contact with neurosurgical team for advice. They are the experts, which is why you’re going to them. It also gives them advanced warning if the patient has become more unstable on transfer so they can be ready and waiting for you on arrival.
Oh and don’t forget to pee!
Seriously, a full bladder is not fun and can grab your attention more rapidly than the noise of dropping sats on a monitor. Even if you don’t think you need to, pee before you leave.
This checklist is not a rule.
Now to emphasise, this is simply a guide and absolutely not written in stone for the way you must do a transfer, especially the peeing bit. What you’ll find, with everything else in anaesthetics, is that people have their own way of doing things. So, before you start setting off on your own journeys, you’ll no doubt start collecting things you like about other colleagues’ methods.
One really important thing to be mindful of, is ensuring that you feel “ready” to leave before doing so.
Often these patients do need to get to point B with a bit of haste but that doesn’t mean you need to race out the doors and leave the safety of your home base. Always remember that whilst you’re in hospital you have everything you need like oxygen, medications, resus, endless battery life and extra hands so take time to prepare the patient properly before you set off, if time allows.
It's going to be okay.
I was so worried during my CT1 year because it wasn’t until quite late in the year that I did my first inter-hospital transfer.
A transfer is a transfer though, be it from ITU to CT, Resus to CT then ITU, Resus to Cath lab, well you get the point.
If you’re moving, it’s a transfer and the principles remain the same. In terms of inter-hospital transfers, you can shadow a senior trainee on a transfer during your novice period, if the opportunity presents itself. Seeing it in person and helping out will be incredibly valuable.
Use your team.
The paramedics are amazing and will always help or accommodate you if necessary. If, for example, you end up needing to intubate a patient en route, then asking them to pull over is clearly completely reasonable.
Calm is good but being too quiet isn’t always helpful. Speaking out loud whilst thinking and voicing concerns early, helps the team prepare for possible next steps. Making introductions and explaining roles within your team, when you first meet is a really good idea.
“This patient is desaturating and their GCS is dropping, I think with might need to intubate them”
Ironically, the transfers that have become scarier, are those where the patients are not intubated. I know that sounds ridiculous, but you spend the entire journey wondering when you’ll end up having to pull over onto the side of the road for a quick M20 RSI….gulp.
- Going over a plan A to D is useful in your head and with your team so if this does happen, you’re at least as game ready as possible.
- Verbalising early is important and safe.
One last thing.
Now, one last thing you can do before heading off, either around the corner or around the country, is to discuss plans with your seniors. It’s really good practice at any stage of training because verbalising certain plans is never really a bad thing.
Unfortunately, we can’t always plan for everything which sends shivers down many an anaesthetist's spine.
If you find yourself unsure, always go back to your A to E assessment and call your senior or consultant early to discuss concerns. Put them on speaker so you can action their advice simultaneously. It also means that your team can hear too and start handing you things without you having to repeat what was just said to you. Never be afraid to call for advice. I think it’s pretty hard to fault someone for being too safe.
We’re so fortunate now that our seniors are often very accessible, unlike the questionable “good old days”, so even though they may not be with you on the journey, they’re as good as, with your phone. Before any transfer I do my consultants have always said to call if I need. They’re also usually good at checking you’ve arrived back safely too.
“We’re just coming up to the A&E entrance now”
So, you’ve reached safety ground and are back in a hospital. Holds back tears of joy. Though it might not be your usual haunt, the walls are a different colour and theatres are strangely in the basement rather than on the third floor, it will feel nothing short of home, with unlimited (well sort of) oxygen in walls, medications, resus, batteries, more hands and a whole team/speciality waiting just for you.
“The eagle has landed, I repeat…the eagle has landed”
It might now have clicked that you have quite a bit to hand over. The eagle has now got lots of explaining to do…oh boy. One thing which is not easy, is that you might have only known this patient for a relatively short period of time before setting off. Make sure you get a thorough history when receiving your handover because it doesn’t look too great if you turn up to handover yourself, only to be clueless about what brought them into hospital in the first place. I find a classic SBAR does the trick for the story and background bit and an A to E is a great way to hand over the current situation with the patient. If all else fails just read the discharge paperwork with lots and lots of confidence and then proceed to an A to E afterwards.
“We’ve been called away to another emergency so unfortunately we can’t take you back”
The last words you want to hear. Now you might be on the clock or just desperate to get back at this point but make sure you get yourself a warm drink and a well-earned biscuit…or two or three if you can. At the very least something for the journey. One thing is certain, I don’t think I’ve ever enjoyed a cup of tea as much as the one I had after my first transfer. If you do find yourself heading back by alternative means, please let someone know how you’re getting back and stay safe! Your hospital should send a taxi to bring you back and I would verbalise a plan before you leave as to how you’re getting back. I know it’s another thing to add to the list but being stranded at the end of a transfer is not terribly fun, especially if it’s the middle of the night. Have a plan for your safe return.
Transfers are such a rewarding part of the job.
And though it has its scary moments, there is absolutely no doubt about that you’ll learn so much on those trips and hopefully feel a bit more confident after each of them.
If something goes wrong.
Lastly, it’s important to remember that occasionally it doesn’t matter how well you’re prepared, patients are sometimes just really really sick. There are some pathologies which have prompted the transfer in the first place and are very hard or impossible to treat in the hospital you’re leaving from, let alone in the back of an ambulance - an aortic dissection being a prime example.
So, if things don’t go to plan on your journey then it’s important that you don’t hold on to that worry all alone.
Make sure you speak to a senior or someone you trust and have a debrief, just like you would in hospital. It does not make you a bad anaesthetist, you’re only human and you’re trying the best you can. Feel free to voice concerns because it might be that next time there’s something you could do differently or more often than not, someone might say, I would have done the same thing and you did the best you could. Often people are just very grateful it wasn’t them.
Stress is not the most fun thing, I think we can all agree on that and transfers will give you your fair share of it to start out with. This will never go completely and actually you don’t want it to because being slightly more alert during journeys increases awareness and vigilance…some good old fashioned anxiety adrenaline…classic. Hopefully however, in time, you’ll also find them a rather enjoyable part of the job and this can be achieved with being as prepared as possible, having your trusty checklist and phoning for help when needed.
Good luck and Godspeed.