Chapter 18 / Transport of the Patient 291
fluids, and perform endotracheal intubation. Of note, they receive little training in the
use of invasive monitoring devices, mechanical ventilation, and the titration of drugs in
patients with changing hemodynamic parameters.
Prehospital Versus Interhospital Care
Federal patient transfer laws (commonly referred to as “COBRA laws” after the
Consolidated Omnibus Budget Reconciliation Act that established them), dictate that
during the interhospital transfer of a patient, the responsibility for that patient’s care
rests with the sending physician until the patient is turned over to another physician or
arrives at the receiving hospital. Therefore, the decision on how to send a patient has
important medical and legal implications.
Emergency medical technician training at all levels is geared mostly toward the provi-
sion of prehospital care, not interhospital transfers. As a result, a locally based ambulance
service may not be appropriate to transport an unstable or potentially unstable cardiac
patient. In an effort to overcome this, a staff member from the referring facility (usually a
nurse or, less commonly, a physician) may be recruited to accompany the patient to avoid
a diminution in the level of care. This can be problematic in that these personnel are usu-
ally unfamiliar with the intricacies of transport medicine. They are not used to caring for
patients in an unstable environment where noise, vibration, and tight working conditions
limit the ability to identify and manage changes in a patient’s condition. They may be
unfamiliar with the operation of the equipment on the ambulance. Moreover, their
absence will impair the performance of their assigned hospital duties.
In response to the growing need for interhospital transfers, the past several years
have seen the development and marketing of “Mobile Intensive Care Units” by many
ambulance providers. Importantly, the training, experience level, and licensure of the
caregivers on these units have not yet been standardized in most states. Staffing can
range from basic EMTs to nurses and, in some locales, to physicians. Thus, it is impor-
tant that the sending physician be aware of the capabilities of the transportation service
prior to agreeing to the transport of the patient.
Fortunately, most tertiary facilities have some type of specialty transport team avail-
able for this situation. These teams are usually based at the receiving facility, so the
patient must wait for the team to arrive. Although time is lost in waiting, there are
advantages to this type of transport. The teams usually have personnel dedicated to the
transport of critically ill patients. They have the necessary training and expertise to sta-
bilize the patient before and during the transport, and they are prepared to recognize
and attend to any problems that arise en route. The sending physician must decide if the
benefit of waiting for the expertise of a specialized transport team outweighs the risk of
sending the patient with potentially underqualified personnel.
AMBULANCE TRANSPORT MODES
Ground Ambulance
Motorized vehicles were first used to transport patients in the early 1900s. Since that
time, EMS ground vehicles have evolved from hearselike vehicles (many ambulance
companies originated as a division of funeral homes) to the current modular-type vehi-
cle in common use today. The federal government has developed minimal equipment
lists for ambulances, based on the level of care provided by the EMTs on board. State
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