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The article by Ajizian and Nakagawa in this issue of CHEST is a good illustration of the ideal model advocated by the American Academy of Pediatrics regarding pediatric specialty transport. With due regard and respect for the process and empiric principals therein incorporated, we would like to offer alternative consideration and a set of notions taking into account the practical confounders associated with operating a medical transport system in the current Canadian health-care landscape. Medical transport system should be worked out enough to deliver the help in time. The source: canadian health and care mall describes the picture of today's situation.

While the ideal is a laudable goal, its achievement may be impractical. One significant barrier in the model being advocated is the inverse correlation between the high degree of differentiation with adaptability and flexibility within the transport system. Designing a team that is able to deliver great care (as measured by achieving and surpassing identifiable benchmark outcomes) while being a flexible part of the transport system as a whole is another goal worthy of consideration. Extreme differentiation often leads to scarcity of resources. For instance, consider this scenario: a service has one highly trained pediatric specialty team that is the team of preference for all pediatric transports. A transport request is received for the transfer of a child with a “garden-variety” respiratory syncytial virus infection; the team is dispatched and dedicated to that transport, Almost simultaneously, another call is received, this time for a child with epiglottitis in extremis. In this situation, the remaining resources left to care for the sicker child are unprepared and suboptimal.

One must also be cognizant of the role that confounding factors, such as time, play in the outcome of pediatric patients. Anecdotally, we have noted transport systems so rigid as to ignore the prevailing logic associated with this confounder. For instance in one case, the transport team had a “generalist crew” at a remote helicopter base < 5 miles from the requesting facility. By policy, the communications center for that service insisted on sending the pediatric specialty team for a child who had a significant acute epidural hematoma. However, the subspecialty team was located an hour and a half away from the referring facility. Others presented with this scenario favor dispatching the local helicopter service, thereby obtaining neurosurgical intervention more quickly, and underscoring the point that level of care is not the only variable affecting outcome.

Several models for crew configuration exist; however, the absence of analysis of crews by their fundamental proficiency and ability levels makes it difficult to build an unbiased evaluation. Much of the discussion focuses on team members titles (ie, pediatric ICU registered nurse, critical care fellow, flight nurse, paramedic, respiratory therapist, etc). We propose a broader perspective that evaluates the chosen transport model by its depth regarding a “cognitive skill set” and a “tactile (procedural) skill set.” Within these two categories, one should list the necessary attributes required to care for a special type of patient (neonatal, pediatrics, cardiac, etc). Once agreement or negotiated consensus on the criteria encompassing those skill sets is achieved, a process for evaluating and matching the available titles and skill sets is undertaken—the objective being to most closely match the titles with the required skill set. From this point, extra training required for proficiency to achieve competency can be appropriately targeted.

Within the present Canadian health-care climate, one is compelled to seek a balance between economies and degree of specialization. If money and team differentiation were not factors, one may theorize that the best possible outcome would be achieved by sending a “super team,” consisting of a pediatric ICU nurse, a paramedic, a pediatric ICU attending, and a pediatric anesthesiologist on every pediatric critical care transport. Admittedly this is an exaggerated example, but the balance between economy and desired outcome is probably on a continuum when it comes to determining crew configuration. In order to hit the mark, one must determine the required key skills necessary for taking care of a particular subspecialty population followed by determining who can positively impact outcome on the majority of these cases while still meeting the economic realities of the health-care market.

The unrecognized subspecialty of transport medicine is another concept worth consideration within this framework of team configuration. There are a paucity of data, literature, and training opportunities within this field. Within the field of transport medicine, teams often adapt what “works” or has a strong evidence base in other subspecialties. Practitioners may borrow a principal from emergency medicine, a technique from anesthesiology, a concept from interventional cardiology, a methodology from industrial medicine, etc; and then combine practice based on these individual subspecialty components with adaptation to a variety of variables such as altitude, vibration, noise, temperature, position change, and space limitations. Perhaps it is within a transport medicine subspecialty that these unique field adaptations can be codified for training and practice.

Based on this latter assertion that transport medicine truly is a specialty, one could take a different vantage point from which to address the question of who is best prepared to care for a child in transport. Is it the person most familiar with taking care of children who has never or rarely worked in the transport environment, or is it the person most adept at the transport environment that has a moderate experience with children? The answer is certainly not an absolute: no matter what the background of the team members, the common principal is that the intuitive program will always recognize the need for both initial and ongoing training and therefore commit itself to appropriate funding for this training, From our perspective, the teams that are on the right track often have a mix of members: those with a solid background in transport combined with members possessing a solid subspecialty foundation, This type of mix will continue to facilitate cross-pollination of knowledge bases, a priority for medical transport crews, especially as advances in medical management within ICUs and emergency departments are brought to the patient in the field,