Thoughts on critical care trucks

[MedicSqrl]

Our hospital based EMS IFT system is starting to put nurses on trucks with CCEMTP's and running "critical" calls. I was wondering if this type of setup is used elsewhere and how well does it work. Right now, our paramedics are having turf issues and they feel like their being reduced to a scribe that can intubate. They do all the paperwork and almost none of the assesment except airway. The paramedic is responsible for all the drugs, but only can use them if the nurse lets them. While the program is still in it infancy, all the medics don't want to work that truck anymore despite the cut from being CCEMTP certified.

Is this how it is or do places run it differently? They are trying to mimic the flight crew on the ground, but with rotating medics and nursing they can't seem to agree on anything and I see fighting over pt care. Something as simple as a DNR not being sign and refusing to sheet the pt over just incase they code.

Maybe I could bring some suggestions to them to help improve this transition. Thx.

 

[VentMedic]

Nurses have critical care experience and Paramedics do not.

If some of the paramedics can not see past "intubation" then they are not suited for critical care transport.

The Paramedic is not always necessary since nurses can also intubate.

The state of Florida does not recognize the CCEMTP or CCEMT-P as a level.
Even if a Paramedic takes a critical care course designed for Paramedics, there are no standards in most states at this time so it can consist of 2 hours of training in the back room of an ambulance service or FD to 80 hours at UMBC which that course is now being taught by our most famous medic mill in Florida.

Not every critical care patient needs a helicopter to go across town so yes there should be teams that have the education, experience and skills of a flight team that does high acuity IFT critical care patients.


Florida Hospital uses RN/RRT for flight. They use RN/RRT or RN/RN for specialty as do many of the other teams.

The RNs generally have no less than a BSN and at least 5 years of Critical Care experience. There are no such requirements for a Paramedic except to have worked on an ambulance for 2 or 3 years. Some employers may want the CCEMTP (Critical Care Emergency Medical Transport Program) course and many don't. Some believe you know it all after passing a FP-C or CCP test given by the BCCTPC which is an independent certification agency not associated with any state.

California uses predominantly RNs and occasionally RRTs with EMT-Bs to assist on their CCT trucks. The scope of practice in that state for Paramedics even at the expanded level is not enough to transport sick ICU patients.

Patients are sicker and require more expertise.

The state of Florida has also changed its IFT rules for neonates and no longer will just any ALS truck be able to run real fast from point A to point B with a baby and under the orders of a doctor who may have little to no neonatal experience.

Before:
http://www.doh.state.fl.us/DEMO/EMS/RulesStatutes/RulesPDFS/NoticeChangePublishedFAW12112009.pdf

After:

http://www.doh.state.fl.us/DEMO/EMS/RulesStatutes/RulesPDFS/NoticeChangePublishedFAW12112009.pdf

There are exceptions for some areas where the Paramedics can be well educated and trained for some ICU patients. However, these programs should mimic the better flight teams where they require a solid base education with at least an Associates degree before they invest a mininmum of 500 additional hours for training and educating these Paramedics to care for a critically ill patient effiectively.

 

[BLSBoy]

In NJ, anything over BLS interfacility requires at least an RN/EMT and EMT.
We use (for standard staffing) an MICN and MICP for our SCT/CCT/Medic trucks. Their primary role is critical/specialty care transport, backing up 911.
About half the RNs are RN/MICP, and were medics long before they went to RN school, and have an extensive background in nursing as well (emergency/ICU), so you really get to learn a lot.
However, for real sick (bad burns, sick babys) there is usually a retrieval team sent from the accepting hospital. Usually RN, RRT, Medic and EMT driver, or some mix thereof.

 

[redcrossemt]

Our hospital based EMS IFT system is starting to put nurses on trucks with CCEMTP's and running "critical" calls. I was wondering if this type of setup is used elsewhere and how well does it work. Right now, our paramedics are having turf issues and they feel like their being reduced to a scribe that can intubate. They do all the paperwork and almost none of the assesment except airway. The paramedic is responsible for all the drugs, but only can use them if the nurse lets them. While the program is still in it infancy, all the medics don't want to work that truck anymore despite the cut from being CCEMTP certified.

Is this how it is or do places run it differently? They are trying to mimic the flight crew on the ground, but with rotating medics and nursing they can't seem to agree on anything and I see fighting over pt care. Something as simple as a DNR not being sign and refusing to sheet the pt over just incase they code.

Maybe I could bring some suggestions to them to help improve this transition. Thx.

Our hospital based SCT program uses a EMT-CCEMTP-CCRN team.

First of all, no team will succeed with a huge rotating personnel base. You need stability in the team, and a certain few, who are qualified, to work together and build rapport between the team members. If the rotating personnel, especially medics, are not doing ICU/CC work otherwise, then their skills and knowledge will also be lost. I think having full-time CCT staff makes a lot more sense than part-time/rotating staff.

As Vent said, paramedics typically have no critical care experience. We really have no clue when it comes to most of the assessment and treatment needed for IFT at the level of CCT/SCT.

I will say that nurses coming out of the ICU or CC units often are lacking in their scene management skills, and some skills we take for granted like backboarding. However, it's much easier to train nurses in these few skills than to educate paramedics up to the nurse's level.

So, things I suggest:

- Full-time CCT staff pool... draw from your regular staff only when needed.

- Nurses and medics need to understand each other's knowledge base, skills allowed in scope, as well as weaknesses.

- Clear protocols and operating guidelines as to who does what and is responsible for what.

 

[grich242]

I would have to agree with both previous posts. Rn's and medic's even medics with a critical cert are like apples and oranges. Very different jobs and philosophies than share some similar traits. Icu's have low rn to pt ratio's for a reason these pt's are extremely sensitive and complex. a facility around here uses an rn, a medic, and a basic. mostly because the medic and basic are required to meet the minimum standards for an ambulance. its a small group and seem to work very well together with lots of teaching both ways. Lots of have taken pt's with vents, pumps with drugs hanging we are not familiar with, and bells and whistles, but that does not always lend itself to good pt care.

 

[JPINFV]

I will say that nurses coming out of the ICU or CC units often are lacking in their scene management skills, and some skills we take for granted like backboarding. However, it's much easier to train nurses in these few skills than to educate paramedics up to the nurse's level.

I don't think that either of those are a huge deal for CCTs anyways. In terms of scene management, the vast, vast majority of CCTs aren't time sensitive and it's better to stabilize critical patients on the transport equipment in the hospital than while screaming down the road. Outside of the 'critical patient who needs specialty care like trauma surgery or cath lab yesterday' patients, what scene management skills? There shouldn't be a 10 minute goal to start transport. Haste makes waste.

Also, how often are you at the hospital and needed to backboard a patient being transferred? In California, at least, RNs can't operate as RNs outside of the CCTs. If I'm on a CCT with an RN and/or RT and we get flagged down, we're no better than a basic level crew since the RN and RT doesn't have a set of standing orders for that patient.

 

[VentMedic]

Also, how often are you at the hospital and needed to backboard a patient being transferred? In California, at least, RNs can't operate as RNs outside of the CCTs. If I'm on a CCT with an RN and/or RT and we get flagged down, we're no better than a basic level crew since the RN and RT doesn't have a set of standing orders for that patient.

However, there are other states where the RN has a prehospital level such as the PHRN and they do work EMS in some areas. Flight RNs also can do scene response.

We also wouldn't divert a CCT or Specialty truck with an IABP on board or a newly born neonate with a ductal dependent congenital heart defect either. While many CCTs are not "emergencies" since they are in a hospital, they may still need a ventriculostomy or a special type of dialysis like CVVH urgently. The neonate may need our ventilator and meds to keep the ductus open which not all hospitals have available.

But, we may not run L&S either and that definitely includes when the patient is on board since we should have the same expertise to use as we would in an ICU. We do have an extensive set of protocols for IFT transport but we do not work under the EMS medical director. However, that goes both ways which is why there were changes to the Florida statutes for neonatal transport although a regular CCT probably would not be called for a neonate.

 

[MedicSqrl]

We have separate teams of RN/RRT for peds/neo. Great responses everyone. I do believe a lot of the frustration is lack of communication between the EMS personnel and the RN team. It was kinda thrown at them without there input and they are going through a culture shock.

 

[VentMedic]

We have separate teams of RN/RRT for peds/neo. Great responses everyone. I do believe a lot of the frustration is lack of communication between the EMS personnel and the RN team. It was kinda thrown at them without there input and they are going through a culture shock.

Is the ambulance service putting the Paramedics through an extensive training program with a written job description separate for these Paramedics? Or, are they just putting an RN on the truck to charge the higher rate under the reimbursement guidelines of the state and Medicare?

 

[medicdan]

My company routinely runs NICU trucks staffed by 2 EMT-Bs (one driving, one assisting in the back), accompanied by either MD/RN from the hospital or RN/RRT from the hospital.
When we run PICU, it is an EMT driver and Field Supervisor/EMT-P and RN in the back. We are offering our paramedics additional training along with ER, OR and PICU rotations to be able to attend to patients in the back with an RN, strictly for IFTs.

 

[exodus]

Our BLS SCT/CCT rigs are B/B/RN. And I have used a backboard several times when we get a trauma transfer from an ER to the Trauma center, most of the time hospitals will 'clear' C-spine without a CT just by pain / palpation, so we always re-backboard them.

 

[MedicSqrl]

Is the ambulance service putting the Paramedics through an extensive training program with a written job description separate for these Paramedics? Or, are they just putting an RN on the truck to charge the higher rate under the reimbursement guidelines of the state and Medicare?

Unfortunately they are just in it for the money. They really could care less for pt care. These same critical call were taken by our normal ALS units before this. Instead of putting more trucks on the road to take care of the new teams, they just pulled ALS trucks off the road so normal crews run more. The CCT trucks run like 3 calls a shift if that.

 

[JPINFV]

most of the time hospitals will 'clear' C-spine without a CT just by pain / palpation, so we always re-backboard them.

NEXUS criteria was last seen in the corner crying to itself. Heck, according to one database of prehospital evidence based medicine (and the only one I know of), prehospital clearance (which this isn't, but imagine how much better the exam is in a hospital than the field) has a higher level of evidence than spinal immobilization itself has.

 

[VentMedic]

Our BLS SCT/CCT rigs are B/B/RN. And I have used a backboard several times when we get a trauma transfer from an ER to the Trauma center, most of the time hospitals will 'clear' C-spine without a CT just by pain / palpation, so we always re-backboard them.

We may also reboard if there has not been a CT Scan done and read by a Radiologist. Often the regular X-ray does not give a good view of the upper vertebrae.

 

[redcrossemt]

We may also reboard if there has not been a CT Scan done and read by a Radiologist. Often the regular X-ray does not give a good view of the upper vertebrae.

Our CCT team, and even our regular ALS trucks, will often backboard intra-facility trauma transfers because doctors have removed the patients from backboards based on regular x-rays, even if the patient has point tenderness and neurological deficits. VentMedic's criteria (CT scan with radiologist reading) is what I look for to actually "clear" a patient if any of our immobilization criteria (NEXUS) are positive.

 

[redcrossemt]

In terms of scene management, the vast, vast majority of CCTs aren't time sensitive and it's better to stabilize critical patients on the transport equipment in the hospital than while screaming down the road. Outside of the 'critical patient who needs specialty care like trauma surgery or cath lab yesterday' patients, what scene management skills? There shouldn't be a 10 minute goal to start transport. Haste makes waste.

Scene management, as I was referring to it, doesn't relate solely to time, and that's not what I was thinking about. It could be important sometimes, as you explained, though.

What I was referring to is walking into a trauma bay, and working closely with doctors, nurses, respiratory, technicians, whomever that's in there, that we are strangers to, and that are strangers to us; and figuring out what's going on with the patient, what has been done, what immediately needs to be done, and what might have to be done soon. Scene management encompasses this assessment and treatment, as well as communication with physicians and many other staff members to provide treatment on-scene. Our CCT trucks can't do chest tubes, but it is often important for the patient to have one placed before leaving. Scene management, to me, is making that assessment, and getting the hospital to perform that procedure before we leave; while also evaluating the whole picture and formulating a plan of attack.

Nurses, especially those that may be thrown onto a SCT truck from a cardiovascular care unit, or step-down unit, may be unfamiliar with "acute" scene management. However, paramedics do this all the time. And, I will admit that many nurses, especially from the ICUs and EDs, have vast "scene management" experience and abilities.

Also, how often are you at the hospital and needed to backboard a patient being transferred? In California, at least, RNs can't operate as RNs outside of the CCTs. If I'm on a CCT with an RN and/or RT and we get flagged down, we're no better than a basic level crew since the RN and RT doesn't have a set of standing orders for that patient.

Described in my previous post. We backboard trauma transfers all the time.

We operate our trucks Medic-CCEMTP and EMT-CCEMTP-CCRN, so both are licensed as ALS transport vehicles and can operate outside of the hospital if it were needed. Our SCT truck with the RN does not, but it could. That's not why the nurse needs to understand backboarding, though.