Overview of Critical Care/Specialty Care transport Mobile Intensive Care Paramedic Series

Focus Statement Focus Statement: This module will introduce the participant to the History of Critical Care Medicine, the roles and function of CCT, and basic differences between CCT and pre-hospital EMS. This lecture meets Section 1 of the Idaho EMS Critical Care Curricula Guide

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

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

Presentation Information Last revised 04/20/08 For more information contact the education department 208-287-2972

Last revised 04/20/08

For more information contact the education department

208-287-2972

Terminology CCEMTP: Critical Care Emergency Medical Transport Program Not Critical Care EMT-P SCT: Specialty Care transport AKA CCT: Critical Care transport IFT: Inter-facility Transport

CCEMTP: Critical Care Emergency Medical Transport Program

Not Critical Care EMT-P

SCT: Specialty Care transport

AKA CCT: Critical Care transport

IFT: Inter-facility Transport

Role of the Critical Care Paramedic Various Models Standard EMS with critical care role, if needed Dedicated critical care ground transport Rotor transport Fixed-wing transport

Various Models

Standard EMS with critical care role, if needed

Dedicated critical care ground transport

Rotor transport

Fixed-wing transport

Ground Transport PROS Larger patient compartment Lower cost Relative immunity to changing weather Safer Less severe environmental factors Oxygen levels Acceleration/deceleration forces Gas volume changes with altitude Cabin pressurization Humidity Noise Vibration Specialty UNITS CONS Slower response Needs a designated Driver

PROS

Larger patient compartment

Lower cost

Relative immunity to changing weather

Safer

Less severe environmental factors

Oxygen levels

Acceleration/deceleration forces

Gas volume changes with altitude

Cabin pressurization

Humidity

Noise

Vibration

Specialty UNITS

CONS

Slower response

Needs a designated Driver

Rotor Wing PROS Can land almost anywhere Scene Direct to ER/OR Quick to launch Flying Billboards CONS Least Safe Most expensive Weight Restrictions Affected by temperature Tiny Patient compartment Affected by weather Not pressurized IFR/VFR Cant Fly “above the weather” Noise and vibration

PROS

Can land almost anywhere

Scene

Direct to ER/OR

Quick to launch

Flying Billboards

CONS

Least Safe

Most expensive

Weight Restrictions

Affected by temperature

Tiny Patient compartment

Affected by weather

Not pressurized

IFR/VFR

Cant Fly “above the weather”

Noise and vibration

Fixed Wing PROS Larger patient compartment than Rotor Lower cost than Rotor Better Operating parameters than Rotor Safer than Rotor Faster than Rotor Less severe environmental factors Oxygen levels (pressurized) Humidity Noise Vibration CONS Need a runway More expensive up front? More lead time to launch

PROS

Larger patient compartment than Rotor

Lower cost than Rotor

Better Operating parameters than Rotor

Safer than Rotor

Faster than Rotor

Less severe environmental factors

Oxygen levels (pressurized)

Humidity

Noise

Vibration

CONS

Need a runway

More expensive up front?

More lead time to launch

TEAM Configuration Team configuration ( Four Common Variations) RN/ Paramedic RN/ RN Paramedic/ Paramedic RN/ RT May or may not include a third crew member (EMT) as a driver on ground operations Some specialize in the transport of patients classified as Pediatric Neonatal /Maternal Burns

Team configuration ( Four Common Variations)

RN/ Paramedic

RN/ RN

Paramedic/ Paramedic

RN/ RT

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

Some specialize in the transport of patients classified as

Pediatric

Neonatal /Maternal

Burns

TEAM CONFIGURATION THE RN/Paramedic configuration is the most common. Different view, perspectives, and training Ideally, equal responsibilities State legislation and Nursing Lobbies may affect this RN/RT more common on specialty teams and inter-hospital focused programs. Neonatal

THE RN/Paramedic configuration is the most common.

Different view, perspectives, and training

Ideally, equal responsibilities

State legislation and Nursing Lobbies may affect this

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

Neonatal

CERTIFICATION?? Certification Currently in state of flux Certified Flight Paramedic (FP-C) certification Offered by Board of Critical Care Transport Paramedic Certification (BCCTPC) Affiliate of the International Flight Paramedics Association (IFPA) Certified Critical Care Paramedic Certification not certified or standardized UMBC CCEMTP Most widely accepted program Course completion not certification

Certification

Currently in state of flux

Certified Flight Paramedic (FP-C) certification

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

Affiliate of the International Flight Paramedics Association (IFPA)

Certified Critical Care Paramedic

Certification not certified or standardized

UMBC CCEMTP

Most widely accepted program

Course completion not certification

Scope of Practice? MAY Include: Advanced airway techniques RSI Surgical airway Ventilator management Pulse oximetry and capnogram interpretation Chest tube placement and monitoring Thoracic escharotomies Transvenous pacing Intra-aortic balloon pump 12-Lead ECGCentral venous catheter maintenance/placement/ interpretation Intracranial pressure monitoring Venous cutdown Blood/blood product administration and monitoring Infusion pumps Advanced pharmacological intervention

MAY Include:

Advanced airway techniques

RSI

Surgical airway

Ventilator management

Pulse oximetry and capnogram interpretation

Chest tube placement and monitoring

Thoracic escharotomies

Transvenous pacing

Intra-aortic balloon pump

12-Lead ECGCentral venous catheter maintenance/placement/ interpretation

Intracranial pressure monitoring

Venous cutdown

Blood/blood product administration and monitoring

Infusion pumps

Advanced pharmacological intervention

Scope of Practice?? Lots of Talk, Lots of variability No federal Minimal Standard

Lots of Talk, Lots of variability

No federal Minimal Standard

Certification? “Advanced Practice Paramedic” Dropped from the National Scope of Practice due to pressure from fire service and affiliated lobbies. Has garnered new support from unlikely sources…. NAEMT AEMS NREMT

“Advanced Practice Paramedic”

Dropped from the National Scope of Practice due to pressure from fire service and affiliated lobbies.

Has garnered new support from unlikely sources….

NAEMT

AEMS

NREMT

NREMT and the Future of Critical Care Paramedic NREMT has taken a stance for the “APP” (Advanced Practice Paramedic) in 2008. “ This level wouldn't require unique licensure. It would be a specialty certification—earned through continuing education, advanced competencies and clinical requirements. It would require paramedic experience and endorsements as part of the certification process.” William Brown of the NREMT

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

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

William Brown of the NREMT

Idaho and Critical Care Paramedic

Medical Control Similar to Pre-Hospital Systems, Critical Care Paramedics are directed by licensed physicians Care guided by protocols, standing orders Unlike Pre-Hospital systems, use of Specific Written , Verbal, and Telephonic Orders (On line medical Control) for specific patients are far more common

Similar to Pre-Hospital Systems, Critical Care Paramedics are directed by licensed physicians

Care guided by protocols, standing orders

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

Patient Care Focus More continuation of level of care, less initiation of emergency care Unless needed! Comprehensive formulary Allows for greater continuation of care instead of improvising May use drugs not carried/stocked Increased responsibility More complex tools Temporary Pacers, Ventilators, Pumps

More continuation of level of care, less initiation of emergency care

Unless needed!

Comprehensive formulary

Allows for greater continuation of care instead of improvising

May use drugs not carried/stocked

Increased responsibility

More complex tools

Temporary Pacers, Ventilators, Pumps

Who Needs CCT/SCT?

Who Needs CCT/SCT? Patients who: Have critical injuries or illnesses resulting in unstable vital signs AND need transport by transport teams with the appropriate levels of care capabilities to centers able to provide definitive care OR Need high-level care during transport (but lack time-critical illness or injury)

Patients who:

Have critical injuries or illnesses resulting in unstable vital signs AND need transport by transport teams with the appropriate levels of care capabilities to centers able to provide definitive care

OR

Need high-level care during transport (but lack time-critical illness or injury)

So why CCT Now? (Nationally) $$$$$$$$$$$$$$$$ More upfront costs, bigger long term reward Different (better) reimbursement schedule Federal EMTLA and COBRA statues Transfer requirement with appropriate staffing Liability Sending crews without appropriate training Staffing No longer cost effective to pull staff from floors.

$$$$$$$$$$$$$$$$

More upfront costs, bigger long term reward

Different (better) reimbursement schedule

Federal EMTLA and COBRA statues

Transfer requirement with appropriate staffing

Liability

Sending crews without appropriate training

Staffing

No longer cost effective to pull staff from floors.

Thoughts on Professionalism

In Hospital Culture Must be able to adapt to hospital environment Remember that you represent the entire prehospital profession “ You never get a second chance to make a first impression” Use common sense and respect when interacting with hospital staff, patients, and their families Be nonjudgmental when completing assessment and care Ask before using hospital equipment, viewing patient charts Thank transferring facility staff, and offer feedback

Must be able to adapt to hospital environment

Remember that you represent the entire prehospital profession

“ You never get a second chance to make a first impression”

Use common sense and respect when interacting with hospital staff, patients, and their families

Be nonjudgmental when completing assessment and care

Ask before using hospital equipment, viewing patient charts

Thank transferring facility staff, and offer feedback

Culture “ Scene Calls with Walls” Use common sense and respect when interacting with hospital staff, patients, and their families Be nonjudgmental when completing assessment and care Be prepared for staffing and equipment differences than what we normally use

“ Scene Calls with Walls”

Use common sense and respect when interacting with hospital staff, patients, and their families

Be nonjudgmental when completing assessment and care

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

Remember: No matter how different or poor the care, patient care will NOT be served by pissing off the staff! If they are pissed off, they wont call you for the next patient, who might need you help even more!

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

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

Professional Attributes Professional Put patient care first Practice skills to the point of mastery Understand the importance of rapid response Take continuing medical education seriously Set high standards for self, crew, agency, and system Review own performance critically Check equipment before it’s needed 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

Professional

Put patient care first

Practice skills to the point of mastery

Understand the importance of rapid response

Take continuing medical education seriously

Set high standards for self, crew, agency, and system

Review own performance critically

Check equipment before it’s needed

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 Care Paramedics Knowledge is power Critical care paramedics should know the entities opposing their presence in CCT Understanding opposing forces better prepares critical care paramedics to interface with those forces at work Helps to bridge the divide between health care team members Role of critical care paramedic in hospital is not to replace other health care team members Goals are integration and enhancement

Knowledge is power

Critical care paramedics should know the entities opposing their presence in CCT

Understanding opposing forces better prepares critical care paramedics to interface with those forces at work

Helps to bridge the divide between health care team members

Role of critical care paramedic in hospital is not to replace other health care team members

Goals are integration and enhancement

Nursing’s Longstanding Issues with Critical Care transport Medics Perspective “ Get er done” mentality Broad scope seems to be a good fit. Areas of Expertise Nursing’s perspective Holistic mentality Critical care paramedic is unlicensed provider concerned with skill provision, allegedly lacks breadth of knowledge offered in nursing school Sedom distinguishes between an EMT, a paramedic, and a Critical Care Paramedic. This is reinforced by nursing labor organizations fearing loss of nursing jobs. RECOMMENDATION: Walk softly, do the job!

Medics Perspective

“ Get er done” mentality

Broad scope seems to be a good fit. Areas of Expertise

Nursing’s perspective

Holistic mentality

Critical care paramedic is unlicensed provider concerned with skill provision, allegedly lacks breadth of knowledge offered in nursing school

Sedom distinguishes between an EMT, a paramedic, and a Critical Care Paramedic.

This is reinforced by nursing labor organizations fearing loss of nursing jobs.

RECOMMENDATION: Walk softly, do the job!

Remember: When crisis strikes, we don’t “rise to the occasion”, we “sink to the level of our training”. From “On Combat” Lt Col David Grossman (ret)

National Association of Critical Care Paramedics (NACCP) International Flight Paramedics Association (IFPA) National Flight Paramedics Association (NFPA) National Association of EMS Physicians (NAEMSP) National Association of EMTs (NAEMTs) Society of Critical Care Medicine (SCCM) Professional Organizations

National Association of Critical Care Paramedics (NACCP)

International Flight Paramedics Association (IFPA)

National Flight Paramedics Association (NFPA)

National Association of EMS Physicians (NAEMSP)

National Association of EMTs (NAEMTs)

Society of Critical Care Medicine (SCCM)

Remember….. You must always strive to earn your status as a health care professional!