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Stanford Report, May 22, 2002

Packard teams transport critically ill mothers and children


Four weeks before she was due to give birth to her second child, Patricia Banuelos was driving to a doctor's appointment when she was struck by another car. Alive when paramedics freed her from the wreckage, she died just before doctors at Salinas Valley Medical Center delivered her baby by emergency Caesarean section.

Eduardo Banuelos named his daughter Janelle Patricia, after her mother. But just after the birth, he was faced with another crisis: X-rays revealed Janelle had sustained a large skull fracture. The newborn was also having trouble breathing and needed to be placed on a ventilator.

That's when Banuelos was told his baby had to be transferred to Lucile Packard Children's Hospital with help from an expert emergency transport team.

Felix Mariposa (left) helps Brad Smith and Caroline Lamont load the isolette holding Janelle Banuelos onto an ambulance before the two-hour drive from Salinas to Packard Children's Hospital.

Not all area hospitals are authorized to keep the most critically ill or injured children or expectant mothers. Instead, they rely on Packard Children's Hospital to assume care. The hospital maintains specially trained emergency transport teams to stabilize and transfer these patients.

"It's an essential service," said David Kasting, MD, director of Salinas Valley's neonatal intensive care unit and a clinical professor of pediatrics at Stanford. "We're dependent on a prompt response by the transport team in order to get babies quickly and safely to the main ICU."

Packard has three transport teams serving the NICU, pediatric ICU and the Johnson Center for Pregnancy and Newborn Services. In the late 1970s, Stanford put together teams that initially included physicians. Having a pediatric or obstetric specialist on the road for hours at a time, however, was impractical. So, 10 years later, the medical center switched to all-nurse teams, training its most experienced nurses to intubate, place chest tubes and perform other medical procedures in the field.

Transport specialists go through three months of training before heading a team. "If we know a trained person with good judgment is on hand, it makes a huge difference," said neonatologist Ashima Madan, MD, assistant professor of pediatrics at the medical school.

Medical know-how isn't all that's needed. "A lot of critical thinking is required," said Sandy Chapman, a former transport nurse and administrative director of the Johnson Center. The nurses also must have excellent communication skills and a caring bedside manner in order to coordinate with off-site hospital personnel and deal with concerned parents.

"You've got to improvise and make decisions on the run," said Brad Smith, the nurse transport specialist who led the team sent to pick up Janelle Banuelos. "The technical stuff isn't hard once you've done the procedures a few times. The hardest stuff comes out of left field."

Handling unexpected challenges is the focus of a new training effort by the Center for Advanced Pediatric Education. The program provides transport nurses with crisis management training through intense role-playing. "We're doing realistic simulation-based training, putting people in situations that are consistent with what they face in the field," said Louis Halamek, MD, the center's director and director of the fellowship training program in neonatal-perinatal medicine.

Other area hospitals have sent their teams for training with Packard physicians and nurses. Smith and other Packard transport specialists serve as instructors. "Without a doubt, they are some of the best nurses we have," Halamek said.

Chapman noted that parents and mothers have responded well to having transports handled by nurses. Eduardo Banuelos, for example, said Smith handled the difficult situation with care, giving him the confidence he needed to entrust Janelle to Packard. "He explained everything to me. I felt I didn't have to worry."

Janelle spent six nights in the NICU where physicians closely monitored the swelling in her brain, ultimately deciding she did not need surgery. A transport team took her back to Salinas Valley Medical Center on April 23, the day her mother was buried. She went home for the first time one week later.

Anatomy of a transport

In its race to rescue a child, Packard's pulmonary center draws on innovation (2/20/02)

Lucile Packard Children's Hospital