Guidelines reflect philosophy of respect for psychiatric patients

Issue: BCMJ, Vol. 52, No. 1, January, February 2010, page(s) 21 Point Counterpoint
Stephen Wheeler, MD

Dr Wheeler defends and explains the guidelines he says were created to give psychiatric patients the same access to care as medical patients.

I have had an opportunity to review Dr Dagg’s thoughtful response to the article published in the October 2009 issue of the BCMJ, “Criteria for sedation of psychiatric patients for air transport in British Columbia.” I feel that I have to respond to some of the points that he raised.

I will respond to his last point first, that is that the guidelines stigmatize psychiatric patients. The whole point of developing these guidelines was to accommodate psychiatric patients so they can be transported by air ambulance the same as medical patients. However, the risks associated with doing this are not negligible, therefore the need for the guidelines. 

These guidelines are an attempt for the BC Ambulance Service (BCAS) to transport psychiatric patients safely. If we cannot do this then we will not be able to transport psychiatric patients by air and we feel that this would be the ultimate stigmatization. 

I would like to point out the guidelines are not just for psychiatric patients, but are applied to medical patients who have an altered sensorium. BCAS is a world leader in its philosophy toward psychiatric pa­tient transports. I challenge Dr Dagg to find an air service that provides a better service for psychiatric patients than BCAS.

Dr Dagg’s criticism that no psychiatrists were involved in the development of these guidelines might appear to have some merit; however I would like to mention the credentials of the physicians who developed them. 

All six transport advisors who make up the provincial transport advisor team contributed to these guidelines. All six physicians are board certified emergency physicians practising at the Royal Jubilee Hospital in Victoria. The Jubilee Emergency Department has within it a psychiatric emergency facility. Up to 20% of our patients have a psychiatric condition. 

All of the transport advisors are knowledgeable and experienced in dealing with acute psychiatric conditions. The role of the transport advisor is not the same as the treating psychiatrist. Our goal is to have a stabilized patient who can be safely transported. We understand that our recommendations may not help treat the chronic psychiatric problem; we leave that to the psychiatrist and family physician. 

The transport advisors are familiar with the transport environment, having flown with the crews on multiple occasions. They understand what is required for a safe transport. Therefore they are the best suited to determine what guidelines are needed for a safe transport.

We fully understand that some pa­tients will have a prolonged sedation beyond the time it takes to transport them and that other physicians will be managing these patients during this time. However we have to balance the risks. As mentioned in the article the transport advisors call on all psychiatric transports and each case is considered individually. 

A small frail patient will receive less medication than a large agitated patient. It is impossible to know beforehand which patient will become agitated—hence the broad criteria for sedation—but the amount of sedation may be tailored to the patient.

Finally, successfully treated pa­tients do not, and should not, return home by air ambulance. Successfully treated medical patients being discharged from tertiary care centres are not transported by air ambulance unless they are being readmitted into a local hospital. 

As pointed out in the article, other methods of transport are available for these treated patients: they may go home with family either by private vehicle or commercial airline. In this regard psychiatric pa­tients are exactly the same as medical patients.

I doubt Dr Dagg and I will ever fully agree on every issue related to the air transport of psychiatric pa­tients, but the dialogue helps develop an understanding of each other’s concerns.

Dr Wheeler is the medical director of the BC Ambulance Service Air Ambulance Program.