CRITICAL CARE TRANSPORT

History of Ambulance Transports-Ground transportation

NAPOLEONIC WARS

•  (19^th Century)-->horse-drawn carriage-->ferry wounded soldiers
• Horse-drawn carriage
• Ferry wounded soldiers

Team Composition

Ideal Team Composition

• Patient and system driven
• Paramedic
• RN
• Supplemental team members:physician, Respiratory therapist, perfusionist

A team...

• Recognizes emotional and behavioral components
• Acknowledges that technical proficiency requires HIGH individual experience rates
• Provides depth of redundancy
• Demonstrates synergy
• Evolves

A team is more than the sum of parts

a competent partnership

a partnership of competencies

GOAL

Maintain the most stable clinical milieu for critical, high-risk or problem prone patients who must be transferred after careful consideration of risks and benefits.

Critical Care Team

OBJECTIVE

OBJECTIVE

Respond aggressively to deterioration en route with timely and skilled interventions.

Critical Care Team

Medical Direction

Reflect an interaction with on-line medical direction which is collegial in quality

Achieve continuity of care between each health care facility and clinician

REFINE AND IMPROVE CONSTANTLY

• Cricothyrotomy, Central Venous Line, Arterail Lines, hemodynamic monitoring, Transport ventilation, 12-lead ECGs, RSI,
• Umbilical venous line, Pericardiocentesis, IO, Thoracostomy, Blood administration, IABP management, IV infusers and pumps

On-board medical equipment

Speciality equipment

• Trauma
  • Fall >20ft
  • Amputation or near amputation
  • Scalping or degloving injuries
  • Severe hemorrhage/shock
  • Burns
  • Spinal cord/column injury

INDICATORS FOR TRANSPORT

TRAUMA (cont)

• face/neck injuries which compromise airway
• <5 or >55 yrs of age w/multiple injuries
• Objective trauma score indicating severe injury
• Severe injuries
• Severe mechanism of injury

INDICATORS FOR TRANSPORT

MEDICAL/SURGICAL ADULT

• Cardiovascular, seizures unresponsive to therapy, High risk OB, respiratory/cardiac arrest within 24hrs, cardiac output instability, unstable airway.
• Acute change in mental status, hypothermia, Swan-Ganz, IABP, A-line, ICP monitor, Acidosis unresponsive to therapy, Organ transplantation

INDICATORS FOR TRANSPORT

PEDIATRIC

• Cardiac dysrhythmia or pump failure
• Acute respiratory failure or arrest
• unstable airway
• status epilepticus
• Acute renal failure
• Unstable toxicological syndrome
• Multiple trauma
• Hypothermia

• Meets the transport criteria
• Policies for transport arrangement
• Medical Authority for transport
• Personnel and equipment
• Protocols/standing orders

TRANSPORT PREPARATIONS

(cont)

• records to accompany the patient
• Documentation during transport
• Contingency plan
• Financial responsibility

• Initial dispatch
• On Site
• En Route
• Arrival
• Post-transport

PROCEDURES,PROTOCOLS & STANDARDS

FOR A CRITICAL CARE TRANSPORT TEAM

Procedures and Protocols

• Standardized guidelines
  • what should be done
  • by whom
  • how
  • when
  • why

PROCEDURE a specific way of accomplishng a desired result

 PROTOCOL written procedure established by the medical director

• Official policy of the system
• diagnosis
• treatment
• transport

• Save lives in acute life-threatening emergencies
• Provide care during interfacility transport to definitive care

• Increase quality of performance
• Frame of reference for communication
• Avoids confusion
• Educates new employees
• Aids the decision-making process

• Defines accepted methods of operation
• Defines competent practice
• Provides legal protection
• Protes teamwork
• Promotes cost savings

• An agreed upon level of excellence
  • improves quality of care
  • contributes to economical care
  • provides a basis for determining negligence

• Yardstick for judgment
  • precise, objective, and measurable
  • Reflect the intent of standards
• Types of Criteria
  • Structure
  • Process
  • Outcome

• Focus on what is present in system
  • Physical assesment
  • Characteristics
  • Functions of system
• Process Criteria
  • Focus on way activities are carried out

• Focus on goals to be achieved as a result of the process and structure
• LIMITATIONS
  • Impossible to encompass every patient and situation
  • not always clearly communicated
  • Must be frequently revised

First US Ambulance Service (1865)

United States Army

America's first City Ambulance Service-Bellvue Hospital, NY (1869)

Records of Cincinnati Hospital (prior to 1865)

History (cont)

Belfast, Northern Ireland

Mobile Intensive Care Units introduced (1950's)

-staffed by physicians

The paramedic Inception

Dr. Eugene Nagel (1970)

Miami Fire Department

History of Air Transportation-Europe

-Prussian Seige of Paris (1870)

>>Hot air balloons transported wounded

-Retreat of the Serbian Army from Albania (1915)

>>unmodified French fighter aircraft transported injured soldiers

Korean Conflict (1950)

>>first use of helicopters

>>~20,000 transported

Vietnam Conflict (1962)

>>helicopter popularity increased

>>nearly 1 million evacuated

Air Transportation-United States

First Public Service Model

>>Maryland State Police (helicopter, 1970)

-First Hospital Based Models

>>Samaritan Air Evac. AZ (Fixed-Wing, 1969)

>>St. Anthony's Hospital, CO (Helicopter, 1972)