MICP - Introduction into CCT


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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.

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  • MICP - Introduction into CCT

    1. 1. Overview of Critical Care/Specialty Care transport Mobile Intensive Care Paramedic Series
    2. 2. Focus Statement <ul><li>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. </li></ul><ul><li>This lecture meets Section 1 of the Idaho EMS Critical Care Curricula Guide </li></ul>
    3. 3. Presentation Information <ul><li>Last revised 04/20/08 </li></ul><ul><li>For more information contact the education department </li></ul><ul><ul><li>208-287-2972 </li></ul></ul>
    4. 4. Terminology <ul><li>CCEMTP: Critical Care Emergency Medical Transport Program </li></ul><ul><ul><li>Not Critical Care EMT-P </li></ul></ul><ul><li>SCT: Specialty Care transport </li></ul><ul><ul><li>AKA CCT: Critical Care transport </li></ul></ul><ul><li>IFT: Inter-facility Transport </li></ul>
    5. 5. Role of the Critical Care Paramedic <ul><li>Various Models </li></ul><ul><ul><li>Standard EMS with critical care role, if needed </li></ul></ul><ul><ul><li>Dedicated critical care ground transport </li></ul></ul><ul><ul><li>Rotor transport </li></ul></ul><ul><ul><li>Fixed-wing transport </li></ul></ul>
    6. 6. Ground Transport <ul><li>PROS </li></ul><ul><li>Larger patient compartment </li></ul><ul><li>Lower cost </li></ul><ul><li>Relative immunity to changing weather </li></ul><ul><li>Safer </li></ul><ul><li>Less severe environmental factors </li></ul><ul><ul><li>Oxygen levels </li></ul></ul><ul><ul><li>Acceleration/deceleration forces </li></ul></ul><ul><ul><li>Gas volume changes with altitude </li></ul></ul><ul><ul><li>Cabin pressurization </li></ul></ul><ul><ul><li>Humidity </li></ul></ul><ul><ul><li>Noise </li></ul></ul><ul><ul><li>Vibration </li></ul></ul><ul><li>Specialty UNITS </li></ul><ul><li>CONS </li></ul><ul><li>Slower response </li></ul><ul><li>Needs a designated Driver </li></ul>
    7. 8. Rotor Wing <ul><li>PROS </li></ul><ul><li>Can land almost anywhere </li></ul><ul><ul><li>Scene </li></ul></ul><ul><ul><li>Direct to ER/OR </li></ul></ul><ul><li>Quick to launch </li></ul><ul><li>Flying Billboards </li></ul><ul><li>CONS </li></ul><ul><li>Least Safe </li></ul><ul><li>Most expensive </li></ul><ul><li>Weight Restrictions </li></ul><ul><ul><li>Affected by temperature </li></ul></ul><ul><li>Tiny Patient compartment </li></ul><ul><li>Affected by weather </li></ul><ul><li>Not pressurized </li></ul><ul><li>IFR/VFR </li></ul><ul><li>Cant Fly “above the weather” </li></ul><ul><li>Noise and vibration </li></ul>
    8. 9. Fixed Wing <ul><li>PROS </li></ul><ul><li>Larger patient compartment than Rotor </li></ul><ul><li>Lower cost than Rotor </li></ul><ul><li>Better Operating parameters than Rotor </li></ul><ul><li>Safer than Rotor </li></ul><ul><li>Faster than Rotor </li></ul><ul><li>Less severe environmental factors </li></ul><ul><ul><li>Oxygen levels (pressurized) </li></ul></ul><ul><ul><li>Humidity </li></ul></ul><ul><ul><li>Noise </li></ul></ul><ul><ul><li>Vibration </li></ul></ul><ul><li>CONS </li></ul><ul><li>Need a runway </li></ul><ul><li>More expensive up front? </li></ul><ul><li>More lead time to launch </li></ul>
    9. 10. TEAM Configuration <ul><li>Team configuration ( Four Common Variations) </li></ul><ul><ul><li>RN/ Paramedic </li></ul></ul><ul><ul><li>RN/ RN </li></ul></ul><ul><ul><li>Paramedic/ Paramedic </li></ul></ul><ul><ul><li>RN/ RT </li></ul></ul><ul><ul><li>May or may not include a third crew member (EMT) as a driver on ground operations </li></ul></ul><ul><li>Some specialize in the transport of patients classified as </li></ul><ul><ul><li>Pediatric </li></ul></ul><ul><ul><li>Neonatal /Maternal </li></ul></ul><ul><ul><li>Burns </li></ul></ul>
    10. 11. TEAM CONFIGURATION <ul><li>THE RN/Paramedic configuration is the most common. </li></ul><ul><ul><li>Different view, perspectives, and training </li></ul></ul><ul><ul><li>Ideally, equal responsibilities </li></ul></ul><ul><ul><ul><li>State legislation and Nursing Lobbies may affect this </li></ul></ul></ul><ul><li>RN/RT more common on specialty teams and inter-hospital focused programs. </li></ul><ul><ul><li>Neonatal </li></ul></ul>
    11. 12. CERTIFICATION?? <ul><li>Certification </li></ul><ul><ul><li>Currently in state of flux </li></ul></ul><ul><ul><li>Certified Flight Paramedic (FP-C) certification </li></ul></ul><ul><ul><ul><li>Offered by Board of Critical Care Transport Paramedic Certification (BCCTPC) </li></ul></ul></ul><ul><ul><ul><li>Affiliate of the International Flight Paramedics Association (IFPA) </li></ul></ul></ul><ul><ul><li>Certified Critical Care Paramedic </li></ul></ul><ul><ul><ul><li>Certification not certified or standardized </li></ul></ul></ul><ul><ul><li>UMBC CCEMTP </li></ul></ul><ul><ul><ul><li>Most widely accepted program </li></ul></ul></ul><ul><ul><ul><li>Course completion not certification </li></ul></ul></ul>
    12. 13. Scope of Practice? <ul><li>MAY Include: </li></ul><ul><ul><li>Advanced airway techniques </li></ul></ul><ul><ul><ul><li>RSI </li></ul></ul></ul><ul><ul><ul><li>Surgical airway </li></ul></ul></ul><ul><ul><li>Ventilator management </li></ul></ul><ul><ul><li>Pulse oximetry and capnogram interpretation </li></ul></ul><ul><ul><li>Chest tube placement and monitoring </li></ul></ul><ul><ul><li>Thoracic escharotomies </li></ul></ul><ul><ul><li>Transvenous pacing </li></ul></ul><ul><ul><li>Intra-aortic balloon pump </li></ul></ul><ul><ul><li>12-Lead ECGCentral venous catheter maintenance/placement/ interpretation </li></ul></ul><ul><ul><li>Intracranial pressure monitoring </li></ul></ul><ul><ul><li>Venous cutdown </li></ul></ul><ul><ul><li>Blood/blood product administration and monitoring </li></ul></ul><ul><ul><li>Infusion pumps </li></ul></ul><ul><ul><li>Advanced pharmacological intervention </li></ul></ul>
    13. 14. Scope of Practice?? <ul><li>Lots of Talk, Lots of variability </li></ul><ul><li>No federal Minimal Standard </li></ul>
    14. 15. Certification? <ul><li>“Advanced Practice Paramedic” </li></ul><ul><ul><li>Dropped from the National Scope of Practice due to pressure from fire service and affiliated lobbies. </li></ul></ul><ul><ul><li>Has garnered new support from unlikely sources…. </li></ul></ul><ul><ul><ul><li>NAEMT </li></ul></ul></ul><ul><ul><ul><li>AEMS </li></ul></ul></ul><ul><ul><ul><li>NREMT </li></ul></ul></ul>
    15. 16. NREMT and the Future of Critical Care Paramedic <ul><li>NREMT has taken a stance for the “APP” (Advanced Practice Paramedic) in 2008. </li></ul><ul><li>“ 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.” </li></ul><ul><li>William Brown of the NREMT </li></ul>
    16. 17. Idaho and Critical Care Paramedic
    17. 18. Medical Control <ul><li>Similar to Pre-Hospital Systems, Critical Care Paramedics are directed by licensed physicians </li></ul><ul><ul><li>Care guided by protocols, standing orders </li></ul></ul><ul><li>Unlike Pre-Hospital systems, use of Specific Written , Verbal, and Telephonic Orders (On line medical Control) for specific patients are far more common </li></ul>
    18. 19. Patient Care Focus <ul><li>More continuation of level of care, less initiation of emergency care </li></ul><ul><ul><li>Unless needed! </li></ul></ul><ul><li>Comprehensive formulary </li></ul><ul><ul><li>Allows for greater continuation of care instead of improvising </li></ul></ul><ul><ul><li>May use drugs not carried/stocked </li></ul></ul><ul><ul><li>Increased responsibility </li></ul></ul><ul><li>More complex tools </li></ul><ul><ul><li>Temporary Pacers, Ventilators, Pumps </li></ul></ul>
    19. 20. Who Needs CCT/SCT?
    20. 21. Who Needs CCT/SCT? <ul><li>Patients who: </li></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>OR </li></ul></ul><ul><ul><li>Need high-level care during transport (but lack time-critical illness or injury) </li></ul></ul>
    21. 22. So why CCT Now? (Nationally) <ul><li>$$$$$$$$$$$$$$$$ </li></ul><ul><ul><li>More upfront costs, bigger long term reward </li></ul></ul><ul><ul><li>Different (better) reimbursement schedule </li></ul></ul><ul><li>Federal EMTLA and COBRA statues </li></ul><ul><ul><li>Transfer requirement with appropriate staffing </li></ul></ul><ul><li>Liability </li></ul><ul><ul><li>Sending crews without appropriate training </li></ul></ul><ul><li>Staffing </li></ul><ul><ul><li>No longer cost effective to pull staff from floors. </li></ul></ul>
    22. 23. Thoughts on Professionalism
    23. 24. In Hospital Culture <ul><li>Must be able to adapt to hospital environment </li></ul><ul><ul><li>Remember that you represent the entire prehospital profession </li></ul></ul><ul><ul><li>“ You never get a second chance to make a first impression” </li></ul></ul><ul><ul><li>Use common sense and respect when interacting with hospital staff, patients, and their families </li></ul></ul><ul><ul><li>Be nonjudgmental when completing assessment and care </li></ul></ul><ul><ul><li>Ask before using hospital equipment, viewing patient charts </li></ul></ul><ul><ul><li>Thank transferring facility staff, and offer feedback </li></ul></ul>
    24. 25. Culture <ul><li>“ Scene Calls with Walls” </li></ul><ul><ul><li>Use common sense and respect when interacting with hospital staff, patients, and their families </li></ul></ul><ul><ul><li>Be nonjudgmental when completing assessment and care </li></ul></ul><ul><li>Be prepared for staffing and equipment differences than what we normally use </li></ul>
    25. 26. Remember: <ul><li>No matter how different or poor the care, patient care will NOT be served by pissing off the staff! </li></ul><ul><li>If they are pissed off, they wont call you for the next patient, who might need you help even more! </li></ul>
    26. 27. Professional Attributes <ul><li>Professional </li></ul><ul><li>Put patient care first </li></ul><ul><li>Practice skills to the point of mastery </li></ul><ul><li>Understand the importance of rapid response </li></ul><ul><li>Take continuing medical education seriously </li></ul><ul><li>Set high standards for self, crew, agency, and system </li></ul><ul><li>Review own performance critically </li></ul><ul><li>Check equipment before it’s needed </li></ul><ul><li>Nonprofessional </li></ul><ul><li>Put ego first </li></ul><ul><li>See no reason to improve </li></ul><ul><li>Get to a scene when convenient </li></ul><ul><li>Feel no need for continued education </li></ul><ul><li>Aim for minimum standards </li></ul><ul><li>Protect self, hide inadequacies, blame others </li></ul><ul><li>Hope that equipment will work when needed </li></ul>
    27. 28. Political Influence on Critical Care Paramedics <ul><li>Knowledge is power </li></ul><ul><li>Critical care paramedics should know the entities opposing their presence in CCT </li></ul><ul><ul><li>Understanding opposing forces better prepares critical care paramedics to interface with those forces at work </li></ul></ul><ul><ul><li>Helps to bridge the divide between health care team members </li></ul></ul><ul><li>Role of critical care paramedic in hospital is not to replace other health care team members </li></ul><ul><ul><li>Goals are integration and enhancement </li></ul></ul>
    28. 29. Nursing’s Longstanding Issues with Critical Care transport <ul><li>Medics Perspective </li></ul><ul><ul><li>“ Get er done” mentality </li></ul></ul><ul><ul><li>Broad scope seems to be a good fit. Areas of Expertise </li></ul></ul><ul><li>Nursing’s perspective </li></ul><ul><ul><li>Holistic mentality </li></ul></ul><ul><ul><li>Critical care paramedic is unlicensed provider concerned with skill provision, allegedly lacks breadth of knowledge offered in nursing school </li></ul></ul><ul><ul><ul><li>Sedom distinguishes between an EMT, a paramedic, and a Critical Care Paramedic. </li></ul></ul></ul><ul><ul><li>This is reinforced by nursing labor organizations fearing loss of nursing jobs. </li></ul></ul><ul><li>RECOMMENDATION: Walk softly, do the job! </li></ul>
    29. 31. 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)
    30. 32. <ul><li>National Association of Critical Care Paramedics (NACCP) </li></ul><ul><li>International Flight Paramedics Association (IFPA) </li></ul><ul><li>National Flight Paramedics Association (NFPA) </li></ul><ul><li>National Association of EMS Physicians (NAEMSP) </li></ul><ul><li>National Association of EMTs (NAEMTs) </li></ul><ul><li>Society of Critical Care Medicine (SCCM) </li></ul>Professional Organizations
    31. 33. Remember….. You must always strive to earn your status as a health care professional!