Cardiogenic Shock - Diagnosis and Treatment

Chapter 18 / Transport of the Patient 293
compromise may become hypoxic when brought to altitude, leading to additional
ischemia. For example, a patient with a PaO
2
of 60 mm Hg may have an oxygen satu-
ration of 90% at sea level, but because the PaO
2
declines with altitude, oxygen satura-
tion may drop to 70% at 5,000 ft (13).
In contrast to medical helicopters, few airplanes are dedicated solely to patient
transport because of the relatively small demand. Many charter operators will recon-
figure an aircraft from other uses (such as cargo transport) when hired as an air ambu-
lance. Crews will be of varying experience. When choosing a fixed-wing air
ambulance, the physician must ensure that the aircraft is suitable for the type of trans-
port requested and that it is staffed by appropriate crew. One should look for accredi-
tation by a national agency such as the Commission on Accreditation of Medical
Transport Services.
Choosing the Method of Transport
Although a few studies have shown the safety of transporting patients with acute
ischemic coronary syndromes, none has demonstrated a beneficial effect of air trans-
port. According to a personal communication from the Association of Air Medical Ser-
vices, cardiac patients account for approximately 25% of all air medical transports in
the United States. Most of these patients have an acute ischemic coronary syndrome
and are being transferred to a facility for cardiac catheterization. To date, we know of
no data addressing the air transport of patients in cardiogenic shock. The choice of air
transport instead of ground transport involves several considerations, including the dis-
tance between facilities, options for stopping at other facilities should problems arise
during transport, total transport time, personnel availability, vehicle availability,
weather, traffic, terrain, safety, cost, and the ability of the vehicle to accommodate any
external devices.
Helicopter transportation has some advantages over ground transportation. First,
helicopter units are dedicated to interhospital transfer, and highly trained nurses are
included in the flight crew. Second, constant radio communication with a physician is
available. Third, out-of-hospital transport time is shorter, although total transfer times
are similar. Our twin-engine Bell 430 helicopters fly at an average speed of 172 mph
and serve an air mile radius of 200 nautical miles.
Limitations include aircraft noise and vibration, and safety is a major concern (14).
From 1980 to 1986, there were 66 aeromedical helicopter crashes, with 21 deaths and
16 injuries. In 1986, the accident rate for medical helicopters was 17.7/100,000 patient
transfers. This experience has led to improved guidelines for personnel and aircraft
safety standards. A summary of the types of ambulances and their advantages and dis-
advantages appears in Table 1.
CLINICAL REPORTS
Fibrinolysis
Alteplase was the first recombinant drug approved for clinical use. It was first cau-
tiously introduced into clinical practice at large medical centers. We initially demon-
strated the importance of early time to treatment with this fibrinolytic agent and the
safety of administering it in a community hospital (15). In the beginning, patients were
treated with alteplase only after interhospital transfer. Later, the drug was sent with a
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