Overview of Critical Overview of Critical Care/Specialty Care transport Care/Specialty Care transport

Mobile Intensive Care Paramedic Mobile Intensive Care Paramedic SeriesSeries

Focus StatementFocus Statement

• Focus Statement: This module will Focus Statement: This module will introduce the participant to the History of introduce the participant to the History of Critical Care Medicine, the roles and Critical Care Medicine, the roles and function of CCT, and basic differences function of CCT, and basic differences between CCT and pre-hospital EMS. between CCT and pre-hospital EMS.

• This lecture meets Section 1 of the This lecture meets Section 1 of the Idaho Idaho EMS Critical Care Curricula GuideEMS Critical Care Curricula Guide

Presentation InformationPresentation Information

• Last revised 04/20/08Last revised 04/20/08

• For more information contact the For more information contact the education department education department – 208-287-2972208-287-2972

TerminologyTerminology

• CCEMTP: Critical Care Emergency CCEMTP: Critical Care Emergency Medical Transport Program Medical Transport Program – Not Critical Care EMT-PNot Critical Care EMT-P

• SCT: Specialty Care transportSCT: Specialty Care transport– AKA CCT: Critical Care transportAKA CCT: Critical Care transport

• IFT: Inter-facility TransportIFT: Inter-facility Transport

Role of the Critical Care Role of the Critical Care ParamedicParamedic

• Various ModelsVarious Models– Standard EMS with critical care role, if Standard EMS with critical care role, if

neededneeded– Dedicated critical care ground transportDedicated critical care ground transport– Rotor transportRotor transport– Fixed-wing transportFixed-wing transport

Ground TransportGround Transport

PROSPROS• Larger patient compartmentLarger patient compartment• Lower costLower cost• Relative immunity to changing Relative immunity to changing

weatherweather• SaferSafer• Less severe environmental factorsLess severe environmental factors

– Oxygen levelsOxygen levels– Acceleration/deceleration forcesAcceleration/deceleration forces– Gas volume changes with altitudeGas volume changes with altitude– Cabin pressurizationCabin pressurization– HumidityHumidity– NoiseNoise– VibrationVibration

• Specialty UNITSSpecialty UNITS

CONSCONS• Slower responseSlower response• Needs a designated DriverNeeds a designated Driver

Rotor WingRotor Wing

PROSPROS• Can land almost Can land almost

anywhereanywhere– SceneScene– Direct to ER/ORDirect to ER/OR

• Quick to launchQuick to launch• Flying BillboardsFlying Billboards

CONSCONS• Least SafeLeast Safe• Most expensiveMost expensive• Weight RestrictionsWeight Restrictions

– Affected by temperatureAffected by temperature• Tiny Patient compartmentTiny Patient compartment• Affected by weatherAffected by weather• Not pressurizedNot pressurized• IFR/VFRIFR/VFR• Cant Fly “above the Cant Fly “above the

weather”weather”• Noise and vibrationNoise and vibration

Fixed WingFixed Wing

PROSPROS• Larger patient compartment Larger patient compartment

than Rotorthan Rotor• Lower cost than RotorLower cost than Rotor• Better Operating parameters Better Operating parameters

than Rotorthan Rotor• Safer than RotorSafer than Rotor• Faster than RotorFaster than Rotor• Less severe environmental Less severe environmental

factorsfactors– Oxygen levels (pressurized)Oxygen levels (pressurized)– HumidityHumidity– NoiseNoise– VibrationVibration

CONSCONS• Need a runwayNeed a runway• More expensive up front?More expensive up front?• More lead time to launchMore lead time to launch

TEAM ConfigurationTEAM Configuration

• Team configuration (Team configuration (Four Common Variations)Four Common Variations)– RN/ ParamedicRN/ Paramedic

– RN/ RNRN/ RN

– Paramedic/ ParamedicParamedic/ Paramedic

– RN/ RT RN/ RT

– May or may not include a third crew member (EMT) as a May or may not include a third crew member (EMT) as a driver on ground operationsdriver on ground operations

• Some specialize in the transport of patients classified as Some specialize in the transport of patients classified as

– PediatricPediatric

– Neonatal /MaternalNeonatal /Maternal

– BurnsBurns

TEAM CONFIGURATIONTEAM CONFIGURATION

• THE RN/Paramedic configuration is the THE RN/Paramedic configuration is the most common.most common.– Different view, perspectives, and trainingDifferent view, perspectives, and training– Ideally, equal responsibilities Ideally, equal responsibilities

• State legislation and Nursing Lobbies may affect State legislation and Nursing Lobbies may affect thisthis

• RN/RT more common on specialty teams RN/RT more common on specialty teams and inter-hospital focused programs. and inter-hospital focused programs. – NeonatalNeonatal

CERTIFICATION??CERTIFICATION??

• CertificationCertification– Currently in state of fluxCurrently in state of flux– Certified Flight Paramedic (FP-C) certificationCertified Flight Paramedic (FP-C) certification

• Offered by Board of Critical Care Transport Paramedic Offered by Board of Critical Care Transport Paramedic Certification (BCCTPC)Certification (BCCTPC)

• Affiliate of the International Flight Paramedics Association Affiliate of the International Flight Paramedics Association (IFPA)(IFPA)

– Certified Critical Care ParamedicCertified Critical Care Paramedic• Certification not certified or standardizedCertification not certified or standardized

– UMBC CCEMTPUMBC CCEMTP• Most widely accepted programMost widely accepted program• Course completion not certificationCourse completion not certification

Scope of Practice?Scope of Practice?

• MAYMAY Include: Include:– Advanced airway Advanced airway

techniquestechniques• RSIRSI

• Surgical airwaySurgical airway

– Ventilator managementVentilator management– Pulse oximetry and Pulse oximetry and

capnogram interpretationcapnogram interpretation

– Chest tube placement and Chest tube placement and monitoringmonitoring

– Thoracic escharotomiesThoracic escharotomies– Transvenous pacingTransvenous pacing

– Intra-aortic balloon pumpIntra-aortic balloon pump– 12-Lead ECGCentral venous 12-Lead ECGCentral venous

catheter catheter maintenance/placement/maintenance/placement/interpretationinterpretation

– Intracranial pressure Intracranial pressure monitoringmonitoring

– Venous cutdownVenous cutdown– Blood/blood product Blood/blood product

administration and monitoringadministration and monitoring– Infusion pumpsInfusion pumps– Advanced pharmacological Advanced pharmacological

interventionintervention

Scope of Practice??Scope of Practice??

• Lots of Talk, Lots of variabilityLots of Talk, Lots of variability

• No federal Minimal StandardNo federal Minimal Standard

Certification?Certification?

• ““Advanced Practice Paramedic”Advanced Practice Paramedic”– Dropped from the National Scope of Practice Dropped from the National Scope of Practice

due to pressure from fire service and affiliated due to pressure from fire service and affiliated lobbies.lobbies.

– Has garnered new support from unlikely Has garnered new support from unlikely sources….sources….• NAEMTNAEMT• AEMSAEMS• NREMTNREMT

NREMT and the Future of Critical NREMT and the Future of Critical Care ParamedicCare Paramedic

• NREMT has taken a stance for the “APP” NREMT has taken a stance for the “APP” (Advanced Practice Paramedic) in 2008. (Advanced Practice Paramedic) in 2008.

• ““This level wouldn't require unique licensure. It This level wouldn't require unique licensure. It would be a specialty certification—earned would be a specialty certification—earned through continuing education, advanced through continuing education, advanced competencies and clinical requirements. It would competencies and clinical requirements. It would require paramedic experience and require paramedic experience and endorsements as part of the certification endorsements as part of the certification process.”process.”

• William Brown of the NREMTWilliam Brown of the NREMT

Idaho and Critical Care Idaho and Critical Care ParamedicParamedic

Medical ControlMedical Control

• Similar to Pre-Hospital Systems, Critical Similar to Pre-Hospital Systems, Critical Care Paramedics are directed by licensed Care Paramedics are directed by licensed physiciansphysicians– Care guided by protocols, standing ordersCare guided by protocols, standing orders

• Unlike Pre-Hospital systems, use of Unlike Pre-Hospital systems, use of Specific Written , Verbal, and Telephonic Specific Written , Verbal, and Telephonic Orders (On line medical Control) for Orders (On line medical Control) for specific patients are far more commonspecific patients are far more common

Patient Care FocusPatient Care Focus

• More continuation of level of More continuation of level of care, less initiation of emergency care, less initiation of emergency carecare– Unless needed!Unless needed!

• Comprehensive formularyComprehensive formulary– Allows for greater continuation of Allows for greater continuation of

care instead of improvisingcare instead of improvising– May use drugs not carried/stockedMay use drugs not carried/stocked– Increased responsibilityIncreased responsibility

• More complex toolsMore complex tools– Temporary Pacers, Ventilators, Temporary Pacers, Ventilators,

PumpsPumps

Who Needs CCT/SCT?Who Needs CCT/SCT?

Who Needs CCT/SCT?Who Needs CCT/SCT?

• Patients who:Patients who:– Have critical injuries or illnesses resulting in Have critical injuries or illnesses resulting in

unstable vital signs AND need transport by unstable vital signs AND need transport by transport teams with the appropriate levels of transport teams with the appropriate levels of care capabilities to centers able to provide care capabilities to centers able to provide definitive caredefinitive care

OROR– Need high-level care during transport (but Need high-level care during transport (but

lack time-critical illness or injury)lack time-critical illness or injury)

So why CCT Now? (Nationally)So why CCT Now? (Nationally)

• $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$– More upfront costs, bigger long term rewardMore upfront costs, bigger long term reward– Different (better) reimbursement scheduleDifferent (better) reimbursement schedule

• Federal EMTLA and COBRA statuesFederal EMTLA and COBRA statues– Transfer requirement with appropriate staffingTransfer requirement with appropriate staffing

• LiabilityLiability– Sending crews without appropriate trainingSending crews without appropriate training

• StaffingStaffing– No longer cost effective to pull staff from floors. No longer cost effective to pull staff from floors.

Thoughts on ProfessionalismThoughts on Professionalism

In Hospital Culture In Hospital Culture

• Must be able to adapt to hospital environmentMust be able to adapt to hospital environment– Remember that you represent the entire prehospital Remember that you represent the entire prehospital

professionprofession– ““You never get a second chance to make a first You never get a second chance to make a first

impression”impression”– Use common sense and respect when interacting with Use common sense and respect when interacting with

hospital staff, patients, and their familieshospital staff, patients, and their families– Be nonjudgmental when completing assessment and Be nonjudgmental when completing assessment and

carecare– Ask before using hospital equipment, viewing patient Ask before using hospital equipment, viewing patient

chartscharts– Thank transferring facility staff, and offer feedbackThank transferring facility staff, and offer feedback

CultureCulture

• ““Scene Calls with Walls”Scene Calls with Walls”– Use common sense and respect when Use common sense and respect when

interacting with hospital staff, patients, and interacting with hospital staff, patients, and their familiestheir families

– Be nonjudgmental when completing Be nonjudgmental when completing assessment and careassessment and care

• Be prepared for staffing and equipment Be prepared for staffing and equipment differences than what we normally usedifferences than what we normally use

Remember:Remember:

• No matter how different or poor the care, No matter how different or poor the care, patient care will NOT be served by pissing patient care will NOT be served by pissing off the staff!off the staff!

• If they are pissed off, they wont call you for If they are pissed off, they wont call you for the next patient, who might need you help the next patient, who might need you help even more!even more!

Professional AttributesProfessional AttributesProfessionalProfessional– Put patient care firstPut patient care first– Practice skills to the point of Practice skills to the point of

masterymastery– Understand the importance of Understand the importance of

rapid responserapid response– Take continuing medical Take continuing medical

education seriouslyeducation seriously– Set high standards for self, Set high standards for self,

crew, agency, and systemcrew, agency, and system– Review own performance Review own performance

criticallycritically– Check equipment before it’s Check equipment before it’s

neededneeded

Nonprofessional– Put ego first– See no reason to improve– Get to a scene when

convenient– Feel no need for continued

education– Aim for minimum standards– Protect self, hide inadequacies,

blame others– Hope that equipment will work

when needed

Political Influence on Critical Political Influence on Critical Care ParamedicsCare Paramedics

• Knowledge is powerKnowledge is power• Critical care paramedics should know the entities Critical care paramedics should know the entities

opposing their presence in CCTopposing their presence in CCT– Understanding opposing forces better prepares critical Understanding opposing forces better prepares critical

care paramedics to interface with those forces at workcare paramedics to interface with those forces at work– Helps to bridge the divide between health care team Helps to bridge the divide between health care team

membersmembers

• Role of critical care paramedic in hospital is not Role of critical care paramedic in hospital is not to replace other health care team membersto replace other health care team members– Goals are integration and enhancementGoals are integration and enhancement

Nursing’s Longstanding Issues Nursing’s Longstanding Issues with Critical Care transportwith Critical Care transport

• Medics PerspectiveMedics Perspective– ““Get er done” mentalityGet er done” mentality– Broad scope seems to be a good fit. Areas of ExpertiseBroad scope seems to be a good fit. Areas of Expertise

• Nursing’s perspectiveNursing’s perspective– Holistic mentalityHolistic mentality– Critical care paramedic is unlicensed provider concerned Critical care paramedic is unlicensed provider concerned

with skill provision, allegedly lacks breadth of knowledge with skill provision, allegedly lacks breadth of knowledge offered in nursing schooloffered in nursing school• Sedom distinguishes between an EMT, a paramedic, Sedom distinguishes between an EMT, a paramedic,

and a Critical Care Paramedic.and a Critical Care Paramedic.– This is reinforced by nursing labor organizations fearing This is reinforced by nursing labor organizations fearing

loss of nursing jobs. loss of nursing jobs. • RECOMMENDATION: Walk softly, do the job!RECOMMENDATION: Walk softly, do the job!

Remember:Remember:When crisis strikes, we don’t “rise When crisis strikes, we don’t “rise to the occasion”, we “sink to the to the occasion”, we “sink to the

level of our training”. level of our training”.

From “On Combat”From “On Combat”Lt Col David Grossman (ret)Lt Col David Grossman (ret)

• National Association of Critical Care National Association of Critical Care Paramedics (NACCP)Paramedics (NACCP)

• International Flight Paramedics Association International Flight Paramedics Association (IFPA)(IFPA)

• National Flight Paramedics Association National Flight Paramedics Association (NFPA)(NFPA)

• National Association of EMS Physicians National Association of EMS Physicians (NAEMSP)(NAEMSP)

• National Association of EMTs (NAEMTs)National Association of EMTs (NAEMTs)• Society of Critical Care Medicine (SCCM)Society of Critical Care Medicine (SCCM)

Professional OrganizationsProfessional Organizations

Remember…..

You must

always

strive to earn

your status as

ahealth care

professional!