9-1-1 and/versus Critical Care

[ToxicMedicSZN]

The topic says it all, but has there been this discussion already? I feel like it’s a topic that’s been broached already. If anyone can direct me, that would be great.

Does it makes sense to add pumps to 9-1-1 rigs or should we keep critical care exclusively with pumps/vents and 9-1-1 exclusively without pumps/vents? What should be critical care and what should be 9-1-1? The reason I bring this up is because it impacts the service at large. If these are separate, they need separate lincesing, which costs money. Splitting them increases service cost. However, if they are coalesced entities, it can destabilize the 9-1-1 system in a busy system. Just thinking out loud.

 

[DesertMedic66]

There are already many 911 systems out there that carry and utilize pumps and ventilators.

Critical care is much more than just pumps and vents.

My personal opinion is that you have your normal 911 medics and then you have a separate group of paramedics who are your critical care paramedics. Those critical care medics should have multiple years of working as a medic, additional education, additional certifications, and at a bare minimum an associates degree in a relevant field.

 

[E tank]

IV pumps/portable vents nowadays are so compact and user friendly, any service with a 30 minute (or so) travel time to the hospital prolly has them, or should....not an either/or thing...

 

[ToxicMedicSZN]

IV pumps/portable vents nowadays are so compact and user friendly, any service with a 30 minute (or so) travel time to the hospital prolly has them, or should....not an either/or thing...

In some places like the state that I live in California, they usually have the services separate. I sometimes forget that states and counties outside of California have a broader and more aggressive scope. Services down here have a hard time even holding contracts so most of them refused to pay for the necessary tools. The county would have to force the service through protocol and mandates to force the service to purchase those tools as an EMS provider. I know a lot of people talk about how behind California is with EMS, but I have to live here and deal with it. No matter what argument I present to the county for the use or non-use of ventilators and pumps, ultimately, it’s gonna come down to the money. I personally have no issues with paramedics utilizing vents and pumps. I guess my question is what determines what is critical care and how is that different from standard 911 emergencies?

 

[DesertMedic66]

In some places like the state that I live in California, they usually have the services separate. I sometimes forget that states and counties outside of California have a broader and more aggressive scope. Services down here have a hard time even holding contracts so most of them refused to pay for the necessary tools. The county would have to force the service through protocol and mandates to force the service to purchase those tools as an EMS provider. I know a lot of people talk about how behind California is with EMS, but I have to live here and deal with it. No matter what argument I present to the county for the use or non-use of ventilators and pumps, ultimately, it’s gonna come down to the money. I personally have no issues with paramedics utilizing vents and pumps. I guess my question is what determines what is critical care and how is that different from standard 911 emergencies?

For CA specifically that is pretty much explained in Title 22 state regulations. It lists out what all a paramedic can do and then what all a critical care paramedic or flight paramedic can do. Then because this is CA, your county will also get involved. Most counties do not have critical care paramedics and instead utilize nurses for that role, mainly because of all of the regulations that the state or county has on paramedics.

Directly from Title 22:
In addition to the approved paramedic scope of practice, the CCP or FP may perform the following procedures and administer medications, as part of the basic scope of practice for interfacility transports, when approved by the LEMSA medical director.
1. set up and maintain thoracic drainage systems;
2. set up and maintain mechanical ventilators;
3. set up and maintain IV fluid delivery pumps and devices…

 

[E tank]

In some places like the state that I live in California, they usually have the services separate. I sometimes forget that states and counties outside of California have a broader and more aggressive scope. Services down here have a hard time even holding contracts so most of them refused to pay for the necessary tools. The county would have to force the service through protocol and mandates to force the service to purchase those tools as an EMS provider. I know a lot of people talk about how behind California is with EMS, but I have to live here and deal with it. No matter what argument I present to the county for the use or non-use of ventilators and pumps, ultimately, it’s gonna come down to the money. I personally have no issues with paramedics utilizing vents and pumps. I guess my question is what determines what is critical care and how is that different from standard 911 emergencies?

For the purposes of CCT, 'critical care' is initiated in the hospital, parameters for management are set there and the patient isn't going to get any more stable during transport. A 911 call is not that. Presumably, when a critical patient is being transferred, he's been the subject of a multidisciplinary team's attention and resources to optimize to survive transport to a higher level of care. That may just be a CAH ER, but it's not from someone's living room. FWIW.

 

[VentMonkey]

There are already many 911 systems out there that carry and utilize pumps and ventilators.

Critical care is much more than just pumps and vents.

My personal opinion is that you have your normal 911 medics and then you have a separate group of paramedics who are your critical care paramedics. Those critical care medics should have multiple years of working as a medic, additional education, additional certifications, and at a bare minimum an associates degree in a relevant field.

100% this^^.

Then because this is CA, your county will also get involved.

Rofl. Sad, but also true.

Most counties do not have critical care paramedics and instead utilize nurses for that role, mainly because of all of the regulations that the state or county has on paramedics.

I know Fresno has had ground CCP’s for a couple of years and puts up an in-house critical care course.

Our county has a CCP policy in the works as well, but I am not sure how or when that will be adopted. As you’ve mentioned, LEMSA’s.

OC has a service whose paramedics do vent/ pump transfers. I don’t know that they consider them “CCT” because IIRC they still hire nurses. Maybe SCT, which could also be a billing thing.

OP, @DesertMedic66 layed the definitions out adequately.

 

[DesertMedic66]

100% this^^.

Rofl. Sad, but also true.

I know Fresno has had ground CCP’s for a couple of years and puts up an in-house critical care course.

Our county has a CCP policy in the works as well, but I am not sure how or when that will be adopted. As you’ve mentioned, LEMSA’s.

OC has a service whose paramedics do vent/ pump transfers. I don’t know that they consider them “CCT” because IIRC they still hire nurses. Maybe SCT, which could also be a billing thing.

OP, @DesertMedic66 layed the definitions out adequately.

It’s still really a mixed bag. There is now a company in San Bernardino that has CCT medics. They can operate ventilators and pumps with a select number of medications. However, when they get a 911 call they are not able to use the pumps or the ventilator.

 

[CCCSD]

For the purposes of CCT, 'critical care' is initiated in the hospital, parameters for management are set there and the patient isn't going to get any more stable during transport. A 911 call is not that. Presumably, when a critical patient is being transferred, he's been the subject of a multidisciplinary team's attention and resources to optimize to survive transport to a higher level of care. That may just be a CAH ER, but it's not from someone's living room. FWIW.

Bingo!

 

[DrParasite]

The topic says it all, but has there been this discussion already? I feel like it’s a topic that’s been broached already. If anyone can direct me, that would be great.

Does it makes sense to add pumps to 9-1-1 rigs or should we keep critical care exclusively with pumps/vents and 9-1-1 exclusively without pumps/vents? What should be critical care and what should be 9-1-1? The reason I bring this up is because it impacts the service at large. If these are separate, they need separate lincesing, which costs money. Splitting them increases service cost. However, if they are coalesced entities, it can destabilize the 9-1-1 system in a busy system. Just thinking out loud.

I'm likely showing my ignorance here, but should every 911 rig have critical care equipment? with the proper staffing/training, I agree that a CCT ambulance can handle a 911 call, but a paramedic might not be fully capable of a CCT run.

I do think that every 911 ambulance should have identical capabilities. Meaning, regardless of which ALS ambulance is pulled, they can do everything that an ALS ambulance is expected to handled. Similarly, every BLS ambulance can handle anything that a BLS ambulance is expected to perform. Closest BLS ambulance handles the call, if it's ALS, send the nearest ALS ambulance too. If pumps and vents are needed, and in scope for paramedics, add them, but that should be for all paramedics, not just a select few.

but CCT is different; the training is different, the pick up locations are different, and while CCT and IFT can refuse to pick up a patient, because they are too unstable, 911 can't refuse a sick patient. In addition, a CCT unit is picking up a patient who has already been stabilized by and MD, and the facility can specify exactly what is needed from the transporting unit.

 

[Akulahawk]

CCT is a different animal from 911. I'm a CCT-RN. Yes, I can refuse to transport a patient that is too unstable. However, a patient may not have been stabilized by the sending facility. I do NOT play in the 911 system even though I do (personally) have the knowledge and skills to do so. One of the bigger differences is that I do not have to follow local EMS protocol. Instead, I follow company medical protocols AND I follow specific patient care orders developed by the sending and receiving physicians. I can use vents, pumps (and monitor drips way outside EMS protocols), monitor A-lines (or any other invasive pressure lines), chest tubes under suction, basically nearly anything you might have in an ICU or ER that might be needed to care for a patient. Most CCT-RN's don't have any significant EMS education/training. From an equipment standpoint, any CCT truck should be able to handle any ALS/911 call. I can do ALS IFT in my sleep... but again, I'm not following LEMSA protocols, I'm following internal protocols and IFT transfer orders as if those calls were CCT. From a billing standpoint, CCT is SCT. SCT is considered Specialty Care Transport and encompasses things like Respiratory Therapy doing a vent transport through having a physician do the transport.