Tabatha Dragonberry, MEd, RRT-NPS, RRT-ACCS, C-NPT, AE-C, CPFT, EMT
As I get older the years seem to go by faster and faster. It’s hard to believe 2015 is already more than half over. In just a few months we’ll all have the chance to take some time away from work and head to Tampa for the AARC Congress. I was perusing the Congress schedule, and as always, there are interesting topics across the board. Our Section Meeting will be Monday, Nov. 9, 9:55-10:25 a.m. If you are going to be at the Congress please join us. It’s always fun to meet the members of our group in person and discuss where we are heading as a community.
I am excited to see so many good transport lectures on the schedule. Symposia include “Reducing Risk & Improving Patient Safety During Transport” and “Neonatal & Pediatric Airway Management: Drug Regimes, Techniques, and Controversies in the Transport Setting.”
Other lectures of interest to our section run the gamut from “Transport of the Trauma Patient” and “It’s Alright to Cry; PTSD in the EMS/Transport Settings,” to “A Detailed look at Respiratory’s Role in the Transport industry.” And if you have never seen Steve Sittig lecture on the most interesting transports he has been on, you won’t want to miss his talk at this year’s meeting.
It is great to see how we, as a group, impact our profession with so many lectures dedicated to transport at our annual conference. I will be there and look forward to meeting the members of our section. Please feel free to wave me down and say hello.
On another note, I am looking for writers and/or topics for the next Bulletin. Please email me with your contributions and ideas.
Richard P. Mitchell, RRT-NPS, Dartmouth Hitchcock Medical Center, Lebanon, NH
It is estimated that approximately 68,797 inter-facility neonatal transports occur each year in the United States.1 The largest percentage of those transports are from smaller to larger facilities where definitive, next level care is available. Transports are generally by aircraft or ambulance in infant transport systems (isolettes) specifically designed for the task.
The environmental effects of infant transport may have an impact on the infant’s condition and health. Acceleration/deceleration, vibration, and impact shock occurring during patient transport have been described and studied by several investigators.2-4 Investigators agree that these effects are deleterious to the patient. Our observations have been that the effects of ground transport may be more significant than those of rotor wing.
Modern transport systems utilize foam mattresses or gel pads. Despite these features, the negative effects remain significant. Consideration should be given to developing enhanced methods and/or devices that may mitigate the impact of these effects. One solution is the placement of shock mounts between the infant mattress tray and the bottom of the isolette chamber, where the tray is attached.
Shock mounts come in a wide variety of designs for many types of applications. These devices isolate, dampen, or dissipate motion effects and energy from one body to another. Shock mounts can be active or passive.
Active Vibration Isolation utilizes motion feedback mechanisms that counter these forces with servo actuators or other active mechanisms, much like noise cancelling headphones. Active mounts are complex and expensive. Proposed systems are currently under investigation.5-6
Passive Vibration Isolation refers to vibration isolation or mitigation of vibrations by rubber pads, viscoelastic material, or mechanical springs. Passive mounts are relatively inexpensive and have been used for many years in ground, sea, and air vehicles to prevent acceleration, deceleration, vibration, and impact shock from disrupting or damaging electronic equipment. The patient tray mounting pins that attach the tray to the floor of the isolette chamber would be replaced by a series of passive mounts.
It is important to utilize a mount that is tuned to the frequency of the unwanted vibration or shock. The band of this frequency can be narrow or broad, and the device used to counter it needs to be specific. In the case of ground transport, impact shock (high frequency) and vehicle vibration (mid frequency) are probably more harmful than the effects of acceleration/deceleration (low frequency).
Once some control measurements can be made, several types of devices can be tested to find out if these negative effects can be mitigated. If passive shock mounts can minimize or eliminate these effects, an evaluation of the design change needs to be completed to ensure that the modifications are economical and safe. It is important that this modification does not interfere with the nominal functions of the isolette. If you are interesting in participating in a project of this type, please contact me via email.
Wade Scoles, RRT-NPS, Northwest MedStar, Spokane, WA
As the helicopter circled over the accident scene, I thought to myself, “Wow! A car really can get literally wrapped around a tree.” I also remember thinking, “What am I, a respiratory therapist, doing here? This is a whole different world from the ICU.”
My stomach was churning, a result of my anxiety and the pilot banking the helicopter into a hard right turn as we circled the scene, double-checking that the landing zone set up by the EMS providers was free of hazards. Even the most well-coordinated accident scenes are a bit chaotic and loud, and as I exited the helicopter, my ears were assaulted by the sounds of the helicopter rotors, diesel firetrucks idling, and the extrication equipment that had almost finished cutting the roof off a car that was, indeed, literally wrapped around a large ponderosa pine tree.
By comparison, the hospital ICU is a quiet, organized, tranquil place. The hospital ICU also has a distinctive smell. The smells here were quite different — a mixture of diesel exhaust, gasoline, hydraulic and radiator fluids, asphalt, and pine trees.
There were two bodies covered up on each side of the car and our patient was still trapped inside, barely breathing with a weak carotid pulse. I had to crawl over the trunk of the car to intubate the young female still sitting upright in the back seat (something we obviously never practiced in the OR during intubation training). The car was traveling so fast when it hit the tree that she was now crushed between the tree and the back of her seat. (The front seat was obliterated.) The pressure being exerted on her abdomen was actually the only thing keeping her from bleeding to death, and tragically, once we extricated her from the vehicle, that is exactly what happened. They teach you that in EMT class, but you’re never quite prepared until you see it up close. We attempted resuscitation at the scene without success.
On our flight back to base, my hands were shaking from the adrenalin rush. I replayed that scene in my mind over and over again, wondering if we could have done anything differently to help that girl. To this day, I replay that scene in mind, but it’s these situations that prepare you for the next.
33 RRTs on staff
So, what was a respiratory therapist doing at the scene of a rural car crash?
There are many RTs working for air medical transport programs across the country, but very few programs utilize RTs on every flight. RTs are often part of the pediatric/neonatal specialty team and occasionally go on ventilated adult patient transports, but seldom do they respond to accident scenes. At Northwest MedStar, the RRT/RN team is the norm for all fights, so if it’s a scene transport, we’ll be there.
The roots of Northwest MedStar go back to the 1970s when the RTs and RNs (and sometimes physicians) at Providence Sacred Heart Medical Center flew along in National Guard helicopters to transport premature and critically ill newborns back to Spokane. The RRT/RN crew configuration (coming out of the NICU) was logical for the neonate population, and as the flight program grew and began transporting pediatric and adult patients, the vast majority of flights remained inter-hospital ICU patients, so the RRT/RN crew configuration remained.
When I started flying for Northwest MedStar in 1991 we had one base, two helicopters, one airplane, and seven RRTs. Today, we have six bases throughout the northwest, 21 modes of transport (helicopters, airplanes, and ground ambulances), and 33 RRTs on staff providing approximately 6,000 critical care transports each year. We have a high patient acuity, and a large percentage of our patients require some sort of ventilatory assistance. With this mix of critically ill patients, the RT is a valuable member of the critical care transport team.
Education is preparation
Once hired on the transport team, our RRTs go through a lot of additional training and education. Initial orientation starts with two weeks of ground-school in the classroom. Early on, we are taught survival skills and altitude physiology. Remember those gas laws from RT school? They actually come into play every day in the flight environment. ET tube cuffs inflate when you gain altitude and your patient with a small pneumothorax can potentially develop a large, life-threatening tension pneumo due to the expansion of air as the barometric pressure decreases.
Maybe most importantly, we spend a lot of time on aviation safety. We learn how we can do our part to help maintain a safe flight environment and what to do in case of an emergency. We learn to use night vision goggles and help the pilots operate the helicopter radios during flight. After completing ground-school, new RTs are paired with experienced transport RTs for 10-12 weeks of buddy flights until they are released from orientation and given their “wings.”
Becoming an emergency medical technician (EMT) is also part of our orientation process. In EMT class, we learn about the prehospital world of focused patient assessment and how to quickly identify and treat immediate life-threatening emergencies in a less than ideal environment. This course covers skills that we didn’t spend much (if any) time on during RT school. Things like immobilizing the cervical spine of a trauma patient, splinting a fractured leg or pelvis, and applying a tourniquet to a bleeding extremity. Advanced skills we practice over and over again include intubation, needle chest decompression, chest catheter insertion, IV and intra-osseous line insertion, and surgical and needle cricothyrotomy.
Preparing for critical care in the air
Northwest MedStar requires at least three years critical care experience but successful candidates usually have quite a lot more than that. ACLS, PALS, and NRP are all prerequisites for the job. We look for well-rounded RTs with time spent in all of the ICUs.
The job isn’t for everyone though. If you just like to stay focused in your area of expertise of mechanical ventilation and let the nurses, doctors, and other staff deal with the other stuff, you wouldn’t fit in here. It is just you and the flight nurse in the aircraft, so we look for RTs who understand the pathophysiology and management of critically ill and injured patients. Not just the respiratory management, but the entire critical care management of that patient, including his hemodynamic and neurologic status. We are already experts in the inhaled respiratory medications, but we also need to know about analgesics, sedatives, and paralytics for rapid sequence intubation; vasopressors and antihypertensive medications; and thrombolytics for heart attacks and strokes.
Quick, independent critical thinking and trouble-shooting skills are required in the critical care transport environment. At Northwest MedStar, the job is so much more than just managing a ventilator while in a helicopter or airplane. When you come to work, you never know where you are going to go. You may be sent to a small rural hospital to assist in the delivery of a premature neonate, then be dispatched to the scene of a car crash or rock-climbing accident.
Our flight nurses and RTs receive the same orientation and work together as a team to care for the sickest of patients in-flight. You need the knowledge, skills, and confidence to perform at a very high level because there is no back-up to call. It’s just the two of you, and your partner is relying on you. There is a great deal of autonomy as a flight crew member. Even though we work under physician-approved protocols, we often encounter patients and situations that are not covered in any protocol. That is where critical thinking skills and independent decision making come in, and those are perhaps the most important criteria for the job. That is difficult to teach, but the successful transport RT thrives in that type of environment and that is what we love about our jobs.
Best RT job on the planet
Of course, it’s not all excitement and glory. There are those hot, turbulent days when a few of us struggle with motion sickness. And when we have a patient vomiting or bleeding in the aircraft, there is no housekeeping department to call. We do what needs to be done to get that aircraft cleaned, decontaminated, and back in service.
Our flight crews work long hours (12- and 24-hour shifts) and often on-call shifts as well, where we must be available to respond to the hangar in less than 25 minutes. Compensation is similar to the hospital environment, with opportunity for on-call pay and overtime. The flight environment takes some getting used to as well. It’s a small space and we do have a weight limit for our crew. It’s loud inside a helicopter, with constant vibration, and we wear helmets, so you learn to assess your patients without relying on your sense of hearing — and in less than ideal lighting conditions too.
You find out early on if critical care transport is right for you. It took me about two years to become completely comfortable with my job and stop feeling like a newbie. Today, I would have a difficult time leaving this position for a hospital job. Our crew, because of low staff turnover and a passion for flying, is a family, and this job really gets in your blood. As far as I’m concerned, it’s the best RT job on the planet.
Joe Hylton, BSRT, RRT-NPS, NREMT-P, FAARC, Carolinas Medical Center, Charlotte, NC, and Keith Lamb, RRT-ACCS, Unitypoint Health System, Des Moines, IA
Editor’s Note: This article was originally published in the Winter 2013 edition of the Adult Acute Care Bulletin.
There are four common events that can cause primary injury to the brain: ischemic events, trauma, hemorrhage, and anoxia. These can occur as a single event or may be present in combination. The most common mechanisms seen with these events are:
In some cases, little can be done to reverse the initial and often devastating effects caused by the primary injury and death is the result. However, many types of brain injury produce regional effects that can be survived if secondary injury can be prevented. The most common secondary mechanisms of injury are:
The primary focus of treatment for brain injury differs very little from that seen with other critically ill patients: ensure a balance between oxygen delivery and demand of the brain. Prevent secondary injury!
Patients experiencing brain injury frequently require advanced airway management. Rapid sequence intubation (RSI) can facilitate a safe, effective completion of intubation, preserving adequate brain perfusion and oxygenation while optimizing safe endotracheal tube placement. High flow, high FIO2 oxygen should be supplied to adequately preoxygenate the patient. A non-rebreather is preferred, as long as the patient has adequate chest movement/gas exchange to minimize gastric insufflation with air.
When it comes to pharmacological pretreatment agents, lidocaine can effectively suppress the cough reflex, as well as potentially mitigate an ICP response to upper airway manipulation during laryngoscopy. Fentanyl is another agent that can effectively be used in the pretreatment phase of RSI in patients with elevated ICP or cardiovascular disease, aneurysm, great vessel rupture, dissection, or intercranial hemorrhage (ICH). It can be used to attenuate the sympathetic nervous system response to laryngoscopy (increased blood pressure). Fentanyl does not cause histamine release and doesn’t directly affect pulmonary responses to laryngoscopy.
During the induction pharmacological phase, maintenance of mean arterial pressure (MAP) and cerebral perfusion pressure (CPP) is vital to minimize secondary injury. A single hypotensive episode significantly increases mortality in an acute brain injured patient. Etomidate is the most effective agent presently available for induction in brain injured patients. It decreases cerebral metabolic O2 demands and lowers ICP. It is a very stable hemodynamic agent, with minimal effects on systemic vascular resistance.
Some data indicate that succinylcholine causes a mild, transient increase in ICP. However, a recent study challenges that claim. Because of its rapid onset and short duration, succinylcholine remains the paralytic of choice in this patient population. Prior to administering a paralytic agent for RSI, it is imperative that an adequate neurological exam is completed.
The brain is enclosed within a rigid structure. The tissue and water enclosed by the skull and dura are nearly incompressible. These two very simple concepts are the principles of the Monroe-Kellie doctrine. The doctrine assumes that three volumes are present: the brain and medulla, cerebrospinal fluid (CSF) and blood vessels with blood, and CSF space. The expansion of any of these three volumes occurs at the expense of the other two volumes. Because of this phenomenon, controlling extravascular volume is an essential function for preserving cerebral perfusion and brain homeostasis. If brain volume increases, then blood/lymphatic/CSF flow must decrease. If these compensatory mechanisms fail, ICP increases and further injury will develop. A catheter may need to be inserted into a lateral ventricle for CSF drainage and monitoring, or into the brain parenchyma for monitoring.
Cerebral blood flow
It is imperative that cerebral blood flow is optimized in order to ensure adequate oxygen delivery and avoid cerebral hypoxia/anoxia and deficient metabolite delivery leading to neuronal death. Effective cerebral perfusion to the brain requires striking a tricky balance between systemic driving pressure and opposing intracranial pressure from injury and resultant edema. CPP is defined as MAP minus ICP (CPP = MAP – ICP). There is no Class I evidence for the optimum level of CPP, but 70-80 mmHg is probably the critical threshold. Mortality increases by approximately 20% for each 10 mmHg loss of CPP. CPP may be maintained by raising the MAP or by lowering the ICP. In practice ICP is usually controlled to within normal limits (<20 mmHg) and MAP is raised therapeutically. It is unknown whether ICP control is necessary, providing CPP is maintained above the critical threshold.
Assessment and management
The Glasgow Coma Scale (GCS) is commonly used to perform an initial evaluation of neurological status after brain injury. (See Figure 1) It is generally accepted that securing a definitive airway in those patients with a GCS score of <8 is preferred because of a decrease in their native airway protection mechanisms. Cranial nerve evaluation and complex imaging are also useful in determining the extent of injury, as well as deciding whether there is a need for surgical intervention. Computed tomography (CT), magnetic resonance imaging, and trans-cranial ultrasound have become the standard in determining the presence and severity of injury, lesions, and cerebral vasospasm.
Glasgow Coma Scale
Total score = eye opening + verbal + motor
GCS <5: 80% die or remain vegetative
GCS >11: 90% complete recovery
From Teasdale G, Jennett B: Acta Neurochirug 34:45, 1976.
Diagnosis and consideration
Head trauma should be suspected when consistent with mechanism of injury. GCS and CT imaging are standard practices when determining whether or not trauma to the brain has occurred. Diffuse axonal injury, or shearing injury, is common in high speed decelerating trauma such as motor vehicle collision or a fall from a significant height. ICH such as subdural hematoma, sub arachnoid hemorrhage, and diffuse cerebral edema are also common in trauma. Craniotomy for drainage of cerebral spinal fluid, and craniectomy by removing a bone flap to provide “space” for an edematous brain, are common surgical interventions. Concussive injuries are common as well.
ICH is a life threatening condition that can be caused by trauma as described above or by other etiologies such as vascular malformations and hypertension. ICH can also be related to therapeutic anticoagulation. Secondary injury can be attenuated by surgical intervention, close monitoring of cerebral perfusion pressures, and prevention of cerebral vasospasm. ICH can be intraventricular, intraparenchymal, subdural, epidural, and subarachnoid.
A stroke occurs when there is a disruption in cerebral blood flow. It can be ischemic or hemorrhagic in nature. Ischemic stroke is caused by a blood clot that stops perfusion to some portion of the brain. Hemorrhagic stroke occurs when a vessel ruptures and blood flow is disrupted to that portion of the brain. Time is of the essence when it comes to the brain, and treatment of stroke can involve the use of antiplatelet therapy, throbolytics, or interventional radiology. Primary treatment is to restore perfusion quickly and prevent secondary injury.
A lack of oxygen supply to the brain results in anoxic injury. It can be caused by cardiac arrest, asphyxia from hanging or drowning, or from the other injuries discussed above. Anoxia results in neuronal death and loss of cerebral function either focally or globally depending on the extent of the areas that become anoxic. Anoxic damage cannot be reversed. Anoxic brain injury varies in severity from no residual signs and symptoms to coma and death.
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