Page 230 - 2026 SMOG

ALTITUDE PHYSIOLOGY AND PATIENT TRANSFER
• Hypoxia—Patients are at increased risk of hypoxia during transport at altitude. If transfers are
taking place in high-altitude locations, pulse oximetry should be monitored at all times, and
the medic/provider should maintain a low threshold for the use of supplemental O . At no time
2
should the patient’s O be allowed to go below 92% (commercial pulse oximeters read up to
2
3% off; therefore, a SAT of 91% may be seen in a patient who is really at 88%). Patients who
smoke or have underlying cardiopulmonary disease are at increased risk even at low altitudes.
• Dysbarism—Patients may experience discomfort due to gas expansion in air-filled body spaces
(e.g., ears, sinuses, teeth) during ascent/descent. Patients and aircrew may experience pressure
changes resulting from descent from altitude. Typically, inner ear pressure is most common—
alleviated by performing a proper Valsalva maneuver. These are typically mild during RW
transport; however, if severe, altitude should be held and attempts made to alleviate pain and/or
slow the rate of ascent/descent.
Document procedure, results, and vital signs.
Reference: CPG ID #27 (Interfacility Transfer of Patients Between Theater MTFs)

PATIENT REFUSAL
Clinical Indication
• If a patient [or person(s) responsible for a minor, refuses treatment or transport, after pre-
hospital providers have arrived on the scene, the following procedures should be carried out.
Treatment
• Complete primary assessment, obtain a set of vitals, and determine mental status
• Any injuries or illnesses found to threaten life, limb, or eyesight immediately (or can be
assumed to deteriorate en route) should be addressed and treated immediately
• Patients who prevent treatment of these injuries should be encouraged. Any doubt of capacity
should prompt treatment/transport under implied consent. Patient with decision-making
capacity refusing treatment of life-threatening injury or illness requires further clinical
judgment and consultation with the medical director prior to informed refusal
• Injuries or illnesses that do not represent imminent threats to life, limb, or eyesight (or are
considered unlikely to deteriorate en route) may be addressed in accordance with the following:
˚ Determine decision-making capacity (patient/parent)
˚ Is the patient AOx4 and understands issues with their medical condition/status? If no, treat
IAW Altered Mental Status Protocol.
• Clearly and repeatedly explain to the patient/parent the concerns and risks of refusal.
• Document all findings and discussions with the patient/parent regarding refusing treatment and/
or transportation
• Obtain a signature from a witness (crew member) and the patient/parent/parties responsible for
the patient as to refusal of care.
**NOTES: Clearly explain to Military Personnel why the treatment is needed. Notify them
that refusal of treatment may bring judicial or administrative adverse action upon them under
UCMJ.**

222 • PROCEDURES