Patient Transport
Medevacs & Schedivacs
The Qikiqtani General Hospital is the referral center for 11 communities in the Qikiqtaaluk Region.
In 2010, more than 600 patients were transported via medevac from community health centers to QGH. An additional 300 were medevac’d from QGH to hospitals in Ottawa.
Dealing with remote medical emergencies and receiving consults from Community Health Nurses (CHNs) is one of the more unique features of being a family physician in Iqaluit. Many locum physicians who come to Iqaluit have not had previous experience with this type of remote medicine and can find it stressful. Please and familiarize yourself with the technical details of arranging medevacs and managing patients in the Community Health Centers.
A brief overview of medivacs and your responsibilities
The physician carrying the Community Pager (#174) is responsible for handling emergency calls from community health centers and arranging medevacs when required. The exception to this is for calls regarding obstetrical patients who are beyond 24 weeks gestation. These patients are managed by the family physician on call for obstetrics.
A medevac may be required for patients with urgent or emergent medical conditions, and for patients who cannot be reasonably or safely managed in the community. When medically appropriate, a trial of treatment should be initiated in the community to stabilize the patient so they can be managed at the Community Health Centre or brought to Iqaluit on the next scheduled flight.
The decision to medevac is made through consultation between the ED Physician and Community Health Nurse. If the Community Health Nurse feels a medevac is the only appropriate mode of travel, then, in general, a medevac should be arranged. If there develops a clear difference of opinion on the need for a medevac, the SHP at the health centre and/or Chief of Staff can be called to provide additional opinions.
It is reasonable for the physician receiving the phone call to ask for a second opinion from another nurse in the community. Many of the CHNs are experienced clinicians who have spent years working in Nunavut, while others may have more limited experience.
All incoming medevacs must be communicated with the receiving ED physician at shift change.
Arranging a Medevac
Documentation
Required information:
Full Name
Date of Birth
Health Card Number
Community of Residence
Diagnosis/Medical Problem.
To arrange a medevac, print the community pager form and provide it to the ED charge nurse.
Frequently, the Flight Paramedics/Nurses will call the ED physician for more information or attend the department to discuss the case. Providing complete information helps them to determine what supplies to bring on the plane.
The pilots will determine when and if it is safe to fly. At no time should any MD try to influence the pilot’s decision to fly, regardless of the gravity of the case.
Sending a physician on a medevac
Most medevacs do not require physician accompaniment.
A physician should accompany the medevac paramedic when there is a high likelihood of a procedure or if the ongoing patient care is out of the paramedic scope of practice. (e.g. critically ill newborn or child; critically ill adults; multi-system trauma; anticipated delivery; anticipated need for any of the following: difficult intubation, central venous access, chest tube insertion; etc.)
It is appropriate to discuss the case with the paramedic when deciding whether to send a physician. In certain situations, the paramedic’s level of experience will determine this need. The Medical Director for Keewatin Air/Nunavut Lifeline can also be contacted 24/7 if questions arise. (867-979-440-8244)
A physician experienced in obstetrics will go on medevacs requiring a physician when there is the potential for a delivery. These will be arranged through the Obstetrics MD on call.
During the day the community pager physician can go on medevacs. After hours the on-call physician will go. Sometimes it is more appropriate for the GPA/Pediatrician to go. Please use your discretion.
Medevacs to Ottawa and Winnipeg
All medevacs require a transfer note. This note must contain the receiving MD name, exact location the patient is to be dropped off, and appointment time.
Prior to arranging a medevac you must find an accepting physician at an appropriate hospital. Most frequently, patients are transferred to Ottawa. You must also document the exact location the medevac is going (i.e. the ED or the ICU in which hospital). For elective referrals to Ottawa, there is often an appointment with specified time and place and these must be documented on the referral form.
For medical, surgical, obstetrical, and pediatric patients, the Ottawa Hospitals and CHEO (Children’s Hospital of Eastern Ontario) are our main referral hospitals. There are formal agreements between Nunavut and TOH/CHEO for this, and a medical boarding home is set up in Ottawa for this purpose (‘Larga’).
If Ottawa is unable to accept the patient (e.g. no liver transplant capability, no beds, etc.), the alternate site is Winnipeg Health Sciences Centre (204-787-3661). There is also a boarding home and transportation service set up there for Nunavut patients. Edmonton could be considered as a third choice, as it has some support facilities. Other sites (Toronto and Montreal) should only be used if all of the above (in that order) are unable to accept the patient, as these sites do not have any Inuit support services.
Adult psychiatric patients (>=18 years old) are referred to Selkirk Mental Health Centre in Winnipeg.
Pediatric psychiatric patients (<18 years old) are referred to CHEO psychiatry.
Arranging a schedevac
Schedevacs occur when you send a patient to a care center via a regular scheduled flight. For this, you need a referal and you need to ensure the following is on it:
Patient Name and Demographics. Make sure they have Nunavut Coverage or work coverage, or they are on their own for both flights and accommodation.
The name of the Hospital you are referring to. We can’t send them down not knowing where they are going.
The Department you are sending them to. If this is a direct admit, this is of particular importance. If they walk into the ER, please indicate this as well.
The name of the Receiving Physician.
The time and date they are to be seen.
6. Attach all the pertinent info to this document such as transfer notes or lab work or imaging. Nursing and clerical staff can assist.
If sending a patient to Ottawa, have this info sent to (867) 975-7195 during the week and also to OHSNI and Medical Travel on the weekends. The numbers are in your various departments, and both nursing staff and clerical staff should be able to assist with this.
Travelling Home
When you see a patient from a community, and they are medically ready to go home you must:
Sign a Medical Travel Clearance form and fax to Medical Travel Dept. (see Travel Clearance section) and
Document your diagnosis and care plan in Meditech
Email the SHP generic email to inform them the patient is returning to community and if they require follow up instructions.
Each community has a generic SHP email : shp.nameofthecommunity@gov.nu.ca (Ex. Shp.pangnirtung@gov.nu.ca).
Common Issues and Pitfalls
Weather delay is a common scenario in Nunavut. The Medevac team is responsible for keeping the ED Physician and the Health Centre informed about delays and estimated times of arrival. The ER Physician will provide phone support as needed until the medevac plane arrives.
Medical equipment in Health Centres is limited. If the need for special equipment or supplies is anticipated for the medevac, they should be brought on the flight (e.g. difficult airway kit, blood, antidotes, etc.) Most other medications and supplies are already on the medevac plane. If in question, or to be safe, discuss with the paramedics involved.
Change in patient condition can complicate the medevac. It is important for the ED Physician to have regular communication with the community health center and document updated patient status and advice given.
Infectious disease precautions are an important consideration. If communicable disease is suspected (TB, meningitis, necrotizing fasciitis, RSV) appropriate precautions (gown/gloves/mask) should be discussed with the nursing staff and in flight.
Potentially violent patients may require sedated prior to transport or be brought down with assistance of R.C.M.P.
All involuntary (patients on Form 5 or Form 1) must be brought to Iqaluit with an RCMP escort. All minors (<age 16) should be accompanied by a parent/guardian escort. Arranging the RCMP escort is the responsibility of the CHN in the community where the patient is located. If available an RCMP officer from that community will escort the patient. If the RCMP detachment in the community cannot supply and officer for the flight, an RCMP officer from Iqaluit will fly to the community to act as the escort.
Important Medical Considerations
Pneumothorax almost always requires decompression before flight. Chest tubes should be placed by a physician who can accompany the medevac.
A penetrating trauma to the chest may require a physician to place a chest tube before flight.
Consider bringing blood from the hospital lab in cases of hemorrhage.
Small bowel obstruction should be decompressed by NG tube before flight.
Peri-tonsillar cellulitis/abscess can usually be managed in the community with appropriate IV medications (e.g. clindamycin and dexamethasone). Medevac should be considered for patients who present as toxic, with respiratory distress, threatened airway compromise, or non-responders to standard treatment.
Bronchiolitis can often be managed in the community. Medevac should be considered for patients who are toxic, with respiratory distress, severe in-drawing, fatiguing respiratory status, apnea, high risk children (ex-prem, additional health problems, etc.) or persistent need for supplemental oxygen.
Limb fractures can often be splinted, treated with pain control, and transported by scheduled commercial flight. Medevac should be considered for patients with open fracture, neurovascular compromise, suspected compartment syndrome, severe displacement and high risk fractures.
Suicidal patients who are intoxicated with alcohol should be allowed to sober up, as in many cases, when sober, the suicidality resolves. Community RCMP cells can be used for observation in these instances.