Planes, Vans, and Automobiles: Medical Escort of the Forensic Patient

Your Mission, Should You Choose To Accept It
Patient transfers begin with a request for patient movement. This contact may be initiated by transportation staff or a facility. Data to gather immediately includes the name of the patient, nature of the illness or injury, why the need for medical escort staff, the location of the patient and intended destination, date to be moved, current treatment plan, and any follow up care needed. If the patient is incarcerated in your correctional system, print out a “snap shot” of his or her care while incarcerated, and note the demographics. If the medical record is stored at your location, it is helpful to mail it to the receiving facility prior to the patient’s arrival.

Patient Placement
Placement is determined after reviewing data submitted by the sending facility (hospital, prison, jail, or mental health facility), and in speaking with the appropriate correctional transportation staff. A good rule of thumb is to routinely request a copy of the booking sheet (if moving from jail to jail or jail to prison), a copy of the medical records, and medication administration record (MAR). A decision is made based on the patient’s needs: inpatient or infirmary care, outpatient care, mental health services, or acute offsite care. These necessities can include services as diverse as dialysis, obstetric care, cardiac surgery, and physical therapy.  The need for a major medical center to be nearby will also factor into the equation. Keeping these factors in mind will assist you in placing the patient in the appropriate facility for continued care.

Plane, Van, or Automobile?
If the transportation will be within your region, a car or van will generally suffice. You may need a van that is wheelchair accessible instead of the usual passenger van. The patient must be able to sit up and wear a safety restraint. Also keep in mind the terrain to be covered (such as desert, mountain, or the possibility of inclement weather), route to be followed (EMS accessibility, rural roads versus interstate highways), and any planned stops for a restroom break or care interventions.

Out-of-state transportation generally involves air transport, either commercial or small plane. Air transport involves both altitude and space constraint considerations. Despite cabin pressurization, the aircraft cabin environment is different from that at ground level. Commercial aircraft cabins are pressurized for 6,500 to 8,000 feet depending on the aircraft; smaller aircraft can alter their cabin pressure with a bit more leeway as needed. (Keep in mind that flying lower will generate more fuel stops, which increases barotraumas from more take offs and landings.) Due to the flight environment, there is virtually no water vapor or moisture in the air, and the partial pressure of oxygen is reduced, which can cause relative hypoxia. The reduced barometric pressure can exacerbate or create acute complications for those patients with respiratory or cardiac ailments, head injuries, and orthopedic conditions.

Contraindications for Flight
The patient must always have a physician’s approval to travel, especially by air. Escorting a forensic patient is not comparable to an aero medical transport by a professional service. There are medical contraindications to flight, especially for those not traveling by a professional air medical transport. These contraindications include recent myocardial infarction; significant surgical procedures; cerebral vascular events; head injury, including cranial and facial fractures; blood clots; being acutely ill or non ambulatory; fractures, including compartment syndrome; having a contagious illness; and anemia. Medical staff would be wise to also consider acute mental health illness and dental conditions that can be affected by barotraumas. If these conditions are present, the options are to refer them to a professional transport company, or wait until the patient is recovered sufficiently to fly or travel by ground.

Keep in mind that the elevation of limbs for casts and splints is prohibitive in commercial aircraft and challenging in smaller aircraft. Drainage bags, catheters (both should be emptied before flight), and complicated dressings are challenging in small spaces or tiny restrooms (private aircraft may not have a restroom). Decreased oxygen saturation at higher altitudes creates more cardiac workload on a patient who may already be stressed from a medical condition.

Bridging the Gap
Ensuring continuity of care is a primary concern. Gathering data from the sending facility and relaying it to the receiving facility can be challenging. Document all contact persons, dates, fax and phone numbers, and information received. After gathering a snapshot of the patient to be transferred, contact the facility that is the most appropriate for receiving the patient. If your healthcare or correctional system has an electronic health record, this makes sharing information easier. Make sure that medical records are exchanged according to HIPAA standards. Whenever possible, speak with the healthcare manager, onsite physician or psychiatrist, and nurse manager for direct patient information. A staff to staff report is encouraged, and the numbers and contact information are shared with both institutions. Upon acceptance of the patient, the planning for transport moves forward. During this entire process, communication is ongoing with transportation staff regarding the destination, patient’s needs, and information related to their safety. It is a good idea to document who accepted the patient at the facility and any reference numbers for contact during transport.

Whether by Land, Sea, or Air…
The patient’s medical issues will dictate the equipment carried, but there are some basic items that should be carried during each trip. A rescue mask, gloves, antiseptic wipes, etc, are carried in a fanny pack or small bag. A larger, more inclusive bag may include a stethoscope, blood pressure kit, penlight, duct tape, scissors, pen/paper work, cell phone with contact numbers, and a bottle of water. Other items may be added depending on the patient’s needs. These can include a glucometer and supplies for a diabetic, with a sugar source like a tube of frosting or honey; a urinal (for small aircraft), zip ties, plastic baggies; moisture proof pads; and a pulse oximeter (borrowed from a facility). An oxygen cylinder, nasal cannula, and facemask can be borrowed for special transports as back up, making sure that the oxygen cylinder is flight certified.

An example of a patient-designed transport bag includes items needed for a patient with a fractured, wired jaw: wire cutters (sent through airport screening with transportation staff), biohazard bags, gloves, airway maintenance supplies, airsickness bags, straws, and plastic spoons. Small packets of wipes are also a good idea. These supplies can easily be incorporated into an existing transport bag.

“The Bird Is in the Air.”
When transporting a patient, a few small details should be kept in mind. How is the patient going to get from the facility or hospital bed to the plane? How are they going to get from the curb, through the terminal, to the gate, and on to the plane? You may need to rent a vehicle on arrival in order to travel to the patient’s location, and transport you and your patient from the facility to the plane, when you are traveling on commercial flights. For smaller aircraft, arrangements should be made to have transportation available at the airfield (perhaps through a local service), or have the patient delivered to the aircraft. (These arrangements are made by transportation staff with input from medical staff.) Consider requesting a van or small sports utility vehicle, as they are easier to transfer a patient into and out of, especially for a patient with restraints and in a wheelchair.

After check-in at the terminal, you will accompany your transportation staff and patient to the screening area. It is a good idea to have a small blanket to drape over the patient’s lap in order to shield the restraints from the public. Due to their law enforcement status, your group will be screened in a different area. At the gate, transportation staff will generally speak to the gate agent to explain their status, and you will board first. At the completion of the flight, you may deplane last.

“De Plane! De Plane!”
Now that your patient is settled in his seat, it is a good time to look around and see where the emergency equipment is stored and introduce yourself to the flight crew. When necessary, advise the flight attendants of any possible medical issues that may arise during the flight. On a smaller aircraft, talk with the pilots about any concerns; they are more than happy to assist. An oxygen cylinder, AED, and medical supplies are usually located in First Class and near the rear galley on commercial aircraft. The pilots on a small aircraft will show you how to exit in an emergency and where emergency equipment is located. Depending on the needs of your patient, have a plan in mind for emergencies before you leave for the airport. Do you need a snack for a diabetic patient? Medication, oxygen, or wire cutters for that wired jaw? Play with a few scenarios in your head before the day arrives to make sure you are ready to handle an event during transport. The patient will be seated next to security staff, but you will generally have line of sight.

“The Eagle Has Landed.”
After the plane has landed, contact the receiving institution with an update on the patient’s status, and an updated ETA. Upon arrival at the destination, deliver any medical records you have transported, give onsite medical staff a report, and provide contact information for the sending facility in case they have questions.

Many physicians and hospital staff are unwilling to discharge patients to a correctional environment, feeling that the patient will be returning to a cell, without medical care or medical supervision. It is up to you, the liaison, to communicate the level of care and quality of correctional healthcare given at the receiving facility. This information should include details regarding inpatient care, outpatient clinics, visiting specialists, and services provided, such as physical therapy or dialysis. As a rule, encourage a physician to physician communication prior to transport.