Category:Radio Medical Traffic (RMT)
- 1 Overview
- 2 RMT Process
- 3 RMT Pearls
- 4 Regular/Outpatient RMT
- 5 Urgent RMT
- 6 Emergency RMT
- 6.1 Emergency Medications Available in the Village
- 6.1.1 Epinephrine 1:1000 =1mg (1 ampule)
- 6.1.2 Diazepam (Valium) 10mg/2ml (1 auto injector)
- 6.1.3 Phenobarbital 130mg/ml (1 ampule)
- 6.1.4 Instaglucose 24 grams in a tube
- 6.1.5 Glucagon 1mg/ml (one ampule)
- 6.1.6 Ceftriaxone 1gm vials
- 6.1.7 Morphine 10mg/ml (one ampule)
- 6.1.8 Prednisone 10mg tablets
- 6.1.9 Dexamethasone 10mg/ml
- 6.1.10 Duo-nebs (ipratropium and albuterol)
- 6.1.11 Racemic Epinephrine
- 6.1 Emergency Medications Available in the Village
- 7 Emergency RMT Scenarios and Responses
- 7.1 Adrenal Crisis-Congenital Adrenal Hyperplasia (CAH)
- 7.2 Angina/MI
- 7.3 Code-Resuscitation
- 7.4 Death In the Village
- 7.5 Drowning
- 7.6 Fever in Infants less than 90 days – Unstable
- 7.7 Hypoglycemia
- 7.8 Hypothermia
- 7.9 Respiratory distress
- 7.10 Seizures
- 7.11 Sepsis
- 7.12 Stroke (CVA)
- 7.13 SVT/Arrhythmia
- 7.14 Syncope (or near-Syncope)
- 7.15 Trauma
- 8 OB Scenarios
- 9 Death
- 10 Links
Radio medical traffic (RMT) is the most difficult clinical challenges that providers face in their jobs at YKHC. There are 50 villages/SRCs in the region staffed with CHAs of varying degrees of training, limited formularies and supplies and weather and other challenges that make getting concerning patients into Bethel difficult. The SRC’s will often, but not always have a NP/PA provider available to help assess and manage patients, and the SRC formulary and supplies are more expanded but still very limited. Often patients will have to be managed for long periods of time creatively in the village with the CHA’s and midlevels while awaiting and opportunity to get a patient in if the weather is down, there are no runway lights, the medevac team is tied up or timed out ....
Routine RMT evaluation, follow up, treatment, referrals etc is a challenge with this kind of distance delivery. It is a high risk interaction. You are managing the patient second hand and depending on vitals, CHA exams and history. You will often be overwhelmed with the sheer volume of RMT and other clinical demands on your time. Be sure to not rush too much. Pay attention and address any ‘red flags’ in the patient history and exam. Take the time to look at the problem and medication lists when indicated (ie a patient with a chronic condition that requires daily meds but isn’t taking them or needs a f/u in Bethel; a patient with recurrent OM that was treated less than a month ago with Amoxicillin and therefore needs to now have Augmentin etc).
Villages are small communities. Often the patient that a CHA is caring for is a relative, friend or well known to them. This can place them in a difficult position socially and professionally. It adds a tremendous amount of stress to their job. It may be difficult for a CHA to make an OCS report (child protective services), resuscitate a loved one, and remain objective in evaluating some patients. RMT providers must remain sensitive to this challenge and assist the CHAs in any way possible.
Orientation for RMT will extend through your entire tenure at YKHC because there are so many different scenarios and new challenges that arise even daily. Work with others to figure out how best to manage RMT patients and don’t hesitate to ask for help repeatedly until you get more comfortable with different scenarios. It is better to ask and learn (remembering there is often more than one way to handle a particular situation)
In the villages, patients are taken care of by Health Aides/Practitioners, who consult with their assigned outpatient providers when patient care falls outside of their standing orders. They fax in Patient Encounter Forms that the panel provider will review and the provider will either discuss the care plan with the Health Aide via telephone or send back the RAVEN RMT form to them with the plan of care.
Every afternoon 2-4 providers from clinic will review through Message Center approximately 200 RMTs (radio medical traffic) a day for the 50 villages through the Yukon and Kusko Proxy boxes. Chronic Peds patients are sent to the Chronic Peds proxy box. Eye and Dental RMTS are sent to the respective Eye Doc and Dental proxy boxes.
At this time we have several long distance providers who are also doing RMT – Helen Hancken PAC in Kenai, Lois Rockcastle FNP in Eagle River, Anne Marie Narog in Kodiak and Bud Vermeire, Sze Pang.
Emergency patients who need medivac or immediate attention to Bethel are should be sent directly or forwarded to the Emergency/NW Proxy box and the appropriate ward doctor should be paged or called depending on how urgent it is.
For routine village encounters that fall outside a CHA’s standing orders, the health aide will complete a RAVEN encounter form and send it to Delta, Yukon RMT or CPP box. An assigned medical provider will then review the encounter and send back their assessment and plan.
For urgent and emergency village patients encounters, i.e. sick or critical patients who need immediate treatment or to be sent in quickly via a commercial or medevac flight, the CHA should complete and encounter RAVEN form (if time allows), send it to the inpatient medical provider RMT box and have the ward doctor paged for an urgent or emergency consult.
Occasionally the ER physician will take urgent or Emergency RMT calls if the ward doctor is too busy to answer the call or requests assistance.
All RMT providers need to review documentation paying close attention to the vitals and “Note to RMT” section. It is important to also look at "other history" as important clinical history can often be found there as well. The RMT provider will either discuss the care plan with the Health Aide via telephone and/or send back the modified RMT with the plan of care.
How to do RMT on RAVEN
- Go to Message Center (RPG Page 16)
- Go to Proxies tab on upper left– hit arrow – Select the appropriate RMT box: Yukon/Kusko/Emergency/CPP/Optometry/Dental
- Select 1st document in the list appearing on the Right side and open it.
- Read RMT- then to review orders
- Locate patient’s name in right upper corner and select the downward arrow to open the patient’s chart within orders
- Scroll on the Order’s View box (lite blue box on the left side) to see the village clinic powerplans located at the top.
- Review the Village Powerplan selected in the right window.
- If no orders added, just close the chart.
- If you check additional order boxes, sign (NOT INITIATE)
- For orders not on the powerplans, choose ADD to PHASE. Then hit sign (NOT INITIATE)
- Close the patient’s chart; MESSAGE CENTER should automatically becomes visible with the RMT document you were working on.
- Now to Modify and add addendum – right click within the body of the RMT document and chose modify.
- The area for you to add the addendum will appear at the bottom of the RMT document.
- Type in your comments.
- Now at bottom of RMT document Hit Additional Forward Action box –
- In the To: field - Select the Health aide who sent the RMT document to you (delete previous RMT health aide’s name).
- Then Click OK and Close – (DO NOT HIT NEXT)
- If a patient is needs a medication to be sent from Bethel pharmacy – Order it from the blue Plus from the left side of the screen and select mail it when ordering it. New meds can be written on either form.
Heading links to page
Common Regular RMT ‘’’??Encounters we need some info on these and how they are often handled??’’’ **LINK TO RMT SECTION – All of this is in RMT section 11/5/14
- Sick checks
- Other common sick checks?
- Medication Refills
- STD Checks
‘’’??Other types of routine RMT encounters?/’’’ Need to say what to do when an urgent RMT comes up and where to refer it to here (this would be nice to have some guidelines for these because it seems everyone does things a little differently – mostly the questions of abx for PNA in both adults and kids, when to give or not give, etc)
OB in possible labor
Other than the 3 recognized truly Orthopedic Emergencies
- compartment syndrome
- compound fracture
- knee dislocation
that should likely require both a call to ANMC Ortho + medevac activation, you can likely send an ortho patient to Bethel ER with splint-sling-ice-elevation-pain control-crutches as indicated once you establish an intact neuro-vascular exam. For some cases, like a hip fracture for example, the patient may go directly to ANMC. You might be able to save one leg of a medevac (instead of a ramp-to-ramp transfer) and send the patient directly to ANMC. To do this, get an accepting doc at ANMC and then you can have LifeMed activate the Anchorage team instead of the Bethel team.
Sick patients that probably need to come in
These patients either have a compelling initial presentation or they have worsened in village follow-up. If vitals and exam are reassuring and spO2 is not <90%, they can probably come to Bethel ER or clinic on the next commercial flight or boat-ice road vehicle. If transport is unlikely or the clinical situation does not allow it, the next decision that needs to be made in conjunction with the CHA’s comfort level and resources available as well as weather conditions, is whether a medevac or more local treatment is indicated. Sometimes weather forces decision-making.
These patients can usually go in to Bethel ER commercially, sometimes requiring an escort after the pain is treated neither with IM morphine or PO TC3 or Tylenol-Motrin.
Fever in Infants less than 90 days
Stable See guidelines Infants under 3 months of age with a fever of 100.4° or greater must be evaluated in Bethel for a sepsis and/or meningitis work up and treatment if indicated. Infants with fevers 100.4° or greater with a normal exam, who are clinically stable, need to be evaluated within 12 hours in Bethel. These patients can come in by commercial flight, if there is one available in less than 8-10 hours. If it is after hours the patient can be monitored closely by the family at home and be rechecked by a CHA in the morning (or sooner if worse) to make sure the patient is still stable for commercial flight in. It is best not to pretreat these infants with Ceftriaxone unless there are weather delays or the patient is getting worse. Please consult the pediatrician on call if there is any question about what to do in these challenging RMT cases.
If the patient gets worse in the village…see emergency RMT section
Need more examples of sick patients that need to come in here…
Emergency Medications Available in the Village
Epinephrine 1:1000 =1mg (1 ampule)
SQ for anaphylaxis, IV or IO for resuscitation
- Adult Dose=1 ampule
- Pediatric Dose=dilute 1:10 to get 1:10, 000 dilution and give 0.01ml/kg with a max dose of 1mg (10mls 1:10,000)
Note: In the absence of standard route of administration, epinephrine may be given IM if it does not compromise CPR. (Efficacy is unknown for this route in humans) Can be nebulized=1 vial mixed with one saline bullet for an adult or a child for respiratory distress/croup.
Diazepam (Valium) 10mg/2ml (1 auto injector)
- Adult Dose=10-15 mg rectally or IM.
- May repeat q 10-15 minutes
- Pediatric Dose=0.5mg/kg rectally or IM. Appropriate dose can be drawn out of the auto injector and into a 1 or 2 ml syringe for insertion into the rectum or to for IM administration.
- May repeat q 5-10 minutes prn
Phenobarbital 130mg/ml (1 ampule)
- Adult Dose=10-20 mg/kg IV (can be given IM if no IV available) q 20 min prn
- Pediatric Dose=20mg/kg IV (can be given IM if no IV available)
- May give another 5-10mg/kg q 15-30 min prn up to a total dose of 40mg/kg
- Pay close attention to respiratory rate if repeating phenobarb doses
Instaglucose 24 grams in a tube
Smear on mucous membranes
Glucagon 1mg/ml (one ampule)
- Adult Dose=1mg SC/IM/IV. May repeat q20 minutes
- Pediatric Dose= 0.5mg SC/IM/IV. May repeat q20 minutes
- Note: not rectally absorbed
Ceftriaxone 1gm vials
- Adult Dose=2 grams IM or IV
- Pediatric Dose = 100mg/kg IM or IV (max dose= 2grams)
Morphine 10mg/ml (one ampule)
- Adult Dose=10-30mg PO, 2.5 mg SC/IM/IV (make sure to tell health aid how many mL you want so that patient gets correct dose)
- Pediatric Dose=0.1-0.2mg/kg SC/IM/IV (max dose=15mg)
Prednisone 10mg tablets
- Adult Dose=40-60mg po
- Pediatric Dose=2mg/kg po (tablets crushed and mixed with palatable substance)
- Adult Dose=depends on condition IV/IM
- Pediatric Dose
Croup/Stridor=0.6 mg/kg IM or po Congenital Adrenal Hyperplasia Crisis= 1.5-2mg/m2 IM Calculate the dose using weight in kg: [(wtx4)+7]/(90+wt). May repeat in 24 hours (or 12 hours if patient looks bad) if not able to get to a higher level of care
Duo-nebs (ipratropium and albuterol)
- Adult Dose=1 unit dose
- Pediatric Dose=1 unit dose
- Adult Dose=1 unit dose in nebulizer (0.5ml) diluted with 2.5 mls NS bullet
- Pediatric Dose= Give nebulized racemic epinephrine: <10 kg: 0.25 mL mixed with 3 mL NS
>10 kg: 0.5 mL mixed with 3 mL NS Note: Monitor pulse during and after administration. Can use IV epinephrine solution full strength or diluted in NS as a substitute if the racemic is not available
Emergency RMT Scenarios and Responses
Adrenal Crisis-Congenital Adrenal Hyperplasia (CAH)
Acute adrenal crisis presents as vomiting, diarrhea, dehydration, hypotension and shock. Crisis can be precipitated by illness, trauma and hyperthermia. If you get a call on a pediatric patient with CAH who is in crisis, find out if the caretakers have a dose of IM Solucortef for emergencies and give this ASAP. Make arrangements for medevac.If the patient has no emergency solucortef available, you can give dexamethasone from the village formulary
See YKHC Clinical Guidelines Most clinics have AFHCAN TeleHEALTH 12-lead ECG capability available to help in the evaluation of ischemic chest pain symptoms. ECG confirmation of concerning symptoms in a middle-aged to elderly patient with cardiac risk factors might warrant medevacking such a patient to the Bethel ER for further evaluation including risk assessment for possible thrombolytics within the 12 hour treatment window. Morphine, Oxygen, Nitroglycerin and Aspirin (MONA) are all available in the village clinic if needed. If chest pain does not appear ischemic, a patient is often commercially transported to the ER in Bethel for further more likely atypical chest pain.
There are times when you will get a call from a CHA who is doing CPR on a patient in the home or in the clinic.
- Have the CHA call for more help
- Get as much information as you can about what happened.
- Find out exactly what they are doing and who is there to help them.
- Do not activate a medevac for CPR in progress unless there is a spontaneous return to circulation OR it is a pediatric patient and, in consultation with the pediatrician on call, a decision is made to medevac the patient. CPR in the field without advanced life support is almost never successful. Most CHAs know this. Do the things listed below, keeping in mind that this is generally a futile process, but very necessary for the patient’s family and the CHA.
- Airway open
- Appropriate sized BVM with a good fit and seal
- Patient on O2 with tank O2
- AED placed (even peds)
- Determine if CPR is adequate (fast, effective and can palpate a pulse) and make sure CHA/s are reassessing for this regularly.
- Get glucose and HGB
- Place IV if possible
- Get the patient’s name and DOB, so you can look up the patient’s history.
- VTC Video monitoring if able
- Get the CHA contact number/s in case you get disconnected.
- Stay calm and as reassuring as you can.
- Reassess frequently-Confirm what has been done and let them know they are doing a good job
- Take good notes with times, medications given, interventions done and responses
- Prepare the CHA’s, family and helpers (keep in mind that you are often on speaker phone) for next steps depending on how resuscitation is going.
- If a patient responds to resuscitation , a medevac needs to be activated.
- If the patient is not in the clinic, they should be taken to clinic if safe transportation is possible.
- If resuscitation appears futile (ie effective CPR for > 20 minutes) you will need to go over everything that has been done and make sure there is nothing else that you and the CHAs thinks can be done.
- Prepare the CHAs and family for calling the code.
- It may be necessary to continue CPR longer than you would normally to give the family time to gather and adjust.
- Have the lead CHA step away and talk to you privately for a moment to help them prepare for stopping CPR.
Resuscitation Medications available in the village need a link to village resuscitation medicines here
- Epinephrine 1:1000 (1 ampule vials).
- NS Fluid resuscitation
If a code is called you will need to follow the protocol for a Village Death * Link here.
- Fax Village death form to Medical Examiner office (if this was an expected death (ie. Palliative care, comfort measures), this form may have already been faxed)
- Call medical examiner’s office
- Notifly Life Alaska (number is on bulletin board on northwing)
- Call state Trooper
- Write free text note documenting events, time of death, etc. And send to Ellen Hodges and Rebecca Tunuchak.
Death In the Village
CPR should be continued as safe and able in the field or village clinic. In the latter environment, re-warming with blankets and heated IV bags for likely additional hypothermia will help the resuscitation effort. Generally, without a confirmed pulse, a medevac should not be activated with the possible exception of drowning involving hypothermia in a nearby village.
Fever in Infants less than 90 days – Unstable
See YKHC Clinical Guidelines Infants with fevers 100.4° or greater are at risk for sepsis and meningitis. Any infant with fever who appears ill ie is irritable, lethargic, tachycardic, tachypneic, vomiting or has a rash needs to be medevaced to Bethel ASAP. IM ceftriaxone at 100mg/kg should be given in the village while awaiting a medevac. A blood culture should be obtained prior to Ceftriaxone if the patient is in a SRC. Have the blood culture sent in with the patient. Please consult peds on call for any questions or assistance in managing these patients.
Any seizing patient should get a glucose accucheck as soon as possible to evaluate for hypoglycemia as this is a correctable cause of seizures. Additionally, patients with a history of diabetes or patients with symptoms of AMS or acute illness including sepsis might also be tested as appropriate for low blood sugar. Instaglucose, administered via the mucous membranes, is available in the village clinic to treat this. Also be aware that carnitine palmitoyltransferase (CPT) 1 deficiency is relatively common in our population and during periods of fasting or during an illness can present as hypoglycemia.
See drowning above Correct hypothermia any way possible. If the patient fully recovers in the village clinic, transport to Bethel may not be necessary.
While assuring that the patient has sufficient supplemental O2 available in the clinic, inquire if he/she normally has Home O2, is an Expected Home Death or Palliation patient to better meet both the needs and planned desires of this patient. Once full treatment of the patient is established, at least one trial of a nebulized bronchodilator with clinical progression of treatment as is indicated. Consider PO prednisone 40-60 mg x1 for broncho-constricted adult patients. Also consider medevac if after a trial of treatment, spO2 remains <90% or moderate to severe respiratory distress persists.
- Give Two back-to-back albuterol nebs
- O2 administered –preferably with NC, but blow by ok to start with
- If patient is febrile, give Tylenol and/or Motrin
- Find out who else is helping the CHAs, where the patient is and patient’s name and DOB
- Make sure the CHA calls for at least two more people to help.
- Move patient to clinic if they are at home or another site
- Make sure bag and good fitting mask is available
- Get patient information to look up past history medications etc
- Frequent reassessment and keep good documentation of times and interventions
- If patient improves with these interventions then reassess O2 requirement, RR and WOB.
- Consider close monitoring and possibly regular flight to Bethel
- Activate medevac if not improving
- VTC video monitoring if able
- Increase nasal cannula O2 to 3-5 L as needed
- Frequent nebs or continuous Albuterol if required
- Try Atrovent nebs or racemic or nebulized epinephrine (IV solution)
- Call peds or a pediatric partner for help
- Consider prednisone 2mg/kg of crushed tablet in liquid/pudding or syrup.
Stridor at Rest
Remember Supportive Measures
- Keep child upright
- May take child outside for cool air
- Minimize invasive measures – keep child CALM!
- Do NOT give albuterol; this can worsen croup
- May give NS neb
Activate a medevac immediately if patient develops signs or symptoms of severe croup or impending airway obstruction: drooling, lethargy, tripod position, marked retractions, tachycardia, cyanosis or pallor
- Start nebulized racemic epinephrine neb
- Give Dexamethasone by least invasive method possible
- Follow stridor guidelines for ongoing management
- Stay as calm and reassuring as you can
- Get the CHA contact number/s in case you get disconnected.
- Determine if the patient is still seizing and whether the patient is in the clinic or at another site
- Get the patient’s name/DOB and last weight (for peds).
- Find out who else is helping the CHA and where the patient is
- CHA must call for more help
- Move patient to clinic if they are at home or another site AND bring all patient’s meds to the clinic
- Follow your CAB/ABCs and make sure
- They have on O2
- A bag and good fitting mask is available and
- The CHAs are ready to do CPR if needed.
- VTC Video monitoring if able
- If the patient is a known seizure patient find out if the patient has any rectal Diastat available to give. If they don’t it is good to have an Rx sent to the village by pharmacy in case of future episodes.
- Place IV if possible and give NS bolus
- Get an accucheck glucose as soon as possible (low glucose is a reversible cause of seizures)
For low blood glucose you can smear Instaglucose on mucous membranes or give glucacon SC/IM/IV link to Emergency Medications available in the village If Instaglucose or glucacon are not available you use a slurry of sugar water to coat oropharynx or give per NG (may use IV tubing as makeshift NG). The rectum does not absorb glucose well, but can be used if no other options available.
- Confirm what has been done and let health aides know they are doing a good job
- If seizure does not resolve or is prolonged, get help for yourself and get a medevac activated ASAP
- Before giving or stopping anti-seizure medications, determine if the patient is still seizing. This can be very subtle at times and VTC is helpful. The CHA may no longer see tonic-clonic movements, but the patient may still be stiff, have fine tremors or eye deviation, poor O2 sats etc.
- Have a health aide get Diazepam and Phenobarbital out of the village clinic lock box and ready for administering.
- If a patient has seized for more than 5-10 minutes, be prepared to start with either the patient’s rectal diastat prescription or village diazepam IM or rectal. The longer a patient seizes the harder it is to break the seizure.
- Before giving diazepam, make sure the CHA has obtained a good fitting bag and mask and is ready to provide assisted ventilation with bag-mask-valve device to support the patient if the patient becomes apneic. Diazepam can be repeated as often as every 10-15 minutes…waiting a little longer is often better as you must weigh the risk of apnea in the village against prolonged seizure activity.
- Your inpatient pharmacist is available in house or on call for assistance if needed.
- Take notes with times, medications given, interventions done and responses
- Reassess frequently.
- Get VTC set up for video monitoring if possible
- The second line medication will be phenobarbital IV or IM. For adults, the dose of IM phenobarb may exhaust the entire village supply.
See YKHC Clinical Guidelines If likely signs and symptoms of acute sepsis are present, IV fluids and available antibiotics should be initiated while activating an urgent medevac for transport to the ER in Bethel.
See YKHC Clinical Guidelines and Inpatient/Common Adult Admissions/Cerebrovascular Accident (CVA) (do we have guidelines for suspected stroke in the village? These would be really helpful because this comes up a lot) Consider an urgent medevac if a patient with acute stroke symptoms presents to a village clinic where there might be enough time from onset of symptoms to completion of a Head CT in the ER in Bethel to be within the 4.5 (or 3) hour limit to consider thrombolytics following evaluation with risk assessment. Otherwise commercial transport with an escort to the ER might be a more appropriate option in an otherwise stable patient with neurologic deficiency consistent with an acute or subacute process. While awaiting transport in the village clinic, supplemental O2 and IV fluids may be appropriate but not aspirin until a hemorrhagic process in the brain can be ruled out in the ER.
A pulse rate of >150/minute is usually consistent with this diagnosis but an AFHCAN TeleHEALTH 12-lead ECG is helpful for confirmation. In the village clinic,
- carotid artery massage
- Valsalva maneuver
- dive reflex (face in basin of ice water)
can all be attempted while evaluating the patient with CHA. If the above converts the arrhythmia, commercial transport to the Bethel ER is appropriate for further evaluation. If symptoms persist, activating a medevac is appropriate to bring this patient to the ER in Bethel, likely already chemically cardioverted by the medevac crew with adenosine.
Syncope (or near-Syncope)
Generally, this history is concerning and the patient is best sent to the ER in Bethel or an evaluation. In the clinic POC blood sugar and Hgb as well as an AFHCAN TeleHEALTH 12-lead ECG might all be helpful in this evaluation.
Follow ATLS with attention to ABCs as well as c-collar and back-boarding while transporting as indicated by history or severity of trauma. The “golden hour” should be considered and activating a village medevac from Anchorage (or ramp transfer in Bethel to Anchorage) with ANMC Surgery consultation may be the best plan for an acute and compelling major trauma. LifeMED can coordinate this type of medevac. Consultation with another YK physician, especially the ER attending can be helpful in decision-making.
Link to OB/OB Triage/Preterm & Term Bleeding Evaluation Assess amount of hemorrhage by “pad” count and POC Hgb and transport commercial to Bethel OB Triage (if EGA > 20 weeks, otherwise to the ER) if vital signs stable and hemorrhaging allows. Consider IV fluids as needed.
If a POC HGB and vital signs are stable this patient may go to the ER in Bethel on the next available flight. She should be warned that she may in be in Bethel for at least 2-3 days as part of the evaluation. There is also a risk she may bleed to death if she remains in the village.
[Link to OB-Newborn/OB Special Circumstances/Labor in the Village]] If a (non-preterm) delivery is imminent in the village, encouraging the CHA to marshal resources in the clinic area for delivery is important including finding the most experienced (even former) CHA or traditional mid-wife. If the term laboring mother is unstable (or didn’t sign a BIB agreement) then activating a medevac to bring the patient to Bethel OB Triage is appropriate.