Oncology and transport. Beware of the presentation and anticipate the clinical course.
These cases demonstrate a few of the presentations that may occur with new onset oncologic problems. While the transport phase of these children's care was not extraordinary, the development and management of the clinical issues might have been influenced by earlier interventions. Would the outcome of Case 1 have been different if the abnormal hematologic parameters demonstrated on the preoperative laboratory results had been further investigated? Would the institution of cerebral resuscitative measures before and during transport have offered this child a better chance of survival? Would the involvement of a specialized pediatric team earlier in the process have addressed some of those issues and would it have made a difference? Should the patient in case two have had cerebral resuscitative measures instituted at the referring hospital or during transport? In hindsight, this clearly would not have been useful or beneficial to the patient. But what if the initial CT interpretation of a brain tumor and increased intracranial pressure with ventricular ablation and midline shift had been correct? Should the transport team have suggested or instituted a different level of therapy with the information that was available at the time of transport? The patient in Case 3 had a dramatic presentation of his ALL. Were there signs and symptoms that should have alerted the referring hospital, transport command physician or transport team to the likely deterioration of that patient? If this patient had presented to a hospital a further distance away, would the impending cardiovascular collapse and respiratory failure have been anticipated or occurred during the transport? Would or should the mode of transport or team configuration have been altered? If this patient had deteriorated during the transport, would the transport team have had the skills to manage this potentially difficult airway? Should the patient in Case 4 have had antihypertensive medication started at the referring hospital or during the transport process? What are the guidelines for antihypertensive intervention in this situation? If antihypertensive therapy were instituted by the transport team, should this have affected time or mode of transport, or was it more prudent not to rock the boat by instituting interventional therapy? Is hypertension a different issue with a liver mass, as suspected at the time of referral, or with a nephrogenic tumor? These cases afford us the ability to review several presentations of oncologic emergencies. The questions above are but a few of the potential areas of discussion that can arise from these cases. We should use these cases as an opportunity to review and refresh our transport teams on the many faces of oncology and potential pitfalls in the care of those patients.