CAMTS Representative
Thomas J. Cahill, RCP, RRT, EMT–P
3229 Burnet Ave.
Cincinnati, OH 45229–3095
tcahill@shrinenet.org

As I sit down to draft my Notes column for this newsletter, it’s hard to believe we are already publishing our summer edition. The 50th AARC Congress is a mere seven months away. They say time flies when you’re having fun, but things obviously move at light speed when you’re busy as well.

In late April, I had the opportunity to travel to Dallas, TX, to attend a neonatal/pediatric transport conference sponsored by Children’s Medical Center Dallas and Cook Children’s Hospital in Fort Worth. The trip also gave me the opportunity to stop by the new AARC office, where I received the red carpet treatment, including a tour of the new building and lunch. I also had the great opportunity to sit down and visit with AARC Executive Director Sam Giordano and Chief Operating Officer Kevin Shrake.  

This was my first trip to Dallas, and with the expert directions I received from the AARC office, I was able to easily navigate my way to Love Field where Dallas Children’s bases its transport team. There, fellow section member Lee Crawley, RRT, gave me a tour of their operation, which consists of a dedicated ground ambulance and Citation Jet. Then I ventured off to Dealey Plaza, where President Kennedy was assassinated. It was very eerie to be in such a historic location where a tragic piece of American history occurred. If you are ever in the Dallas area and are even remotely into history, I would highly recommend it.  

The conference was excellent, covering legal and ethical issues in transport, pediatric trauma, and a case study “rodeo” presentation, among other interesting topics. Speakers were top notch. The case study rodeo was especially fun because it was interactive, with the audience deciding what was wrong and what treatment was indicated. This is something we may have to try at next year’s AARC Congress in San Antonio, with programs or teams submitting interesting cases for presentation and perhaps some sort of award for the best case.  

The Dallas conference also gave me a great opportunity to meet with some transport RTs I had previously only traded e–mails with or spoken to on the phone. It is always so much nicer to meet people in person at such events and help build networking links.  

This edition of the newsletter is, in my view, outstanding, with contributions from section members sharing exciting news, an article onpediatric shock in the transport environment, and a case study. We hope to continue the trend, and encourage all of you to submit ideas and articles. Simply e–mail your contributions or suggestions to me.

Last but not least, if you haven’t checked out the section web site lately, (especially the photo gallery), please take the time to visit. There is always room for more photos of teams, ground rigs, or aircraft. Please note too, that accessing the section site is now easier than ever before. In response to member requests, the AARC has added a direct link to the Specialty Sections on the front page of the main web site. Look on the blue menu bar on the left–hand side of the page. “Specialty Sections” is listed right under “RC Links.”

Until next time, may all your transports end safely for you and your patients.

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On July 2, an Air Trek fixed wing aircraft out of Punta Gorda, FL, crashed in Panama with a total of seven fatalities. Flight RT Steve Heberle, Flight Nurse Barry White, and Pilots Morris Morrow and Hayward Daisey were killed, along with a patient and passenger and one person on the ground. The team was making a refueling stop en route from Ecuador to Washington, DC, at the time of the accident. More information and an electronic condolence book are located in the archived news area on Flightweb.  

Please say a prayer for all the crew, passengers, and their surviving family and friends.

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Michelle North lost her hard–fought battle with cancer on July 11. Michelle was an author, helicopter pilot, teacher, and unending source of energy to all who had the pleasure to meet her. I first met Michelle about two years ago when we had a safety stand down day. All aircraft were grounded, and the adult and specialty teams (peds and neonatal), along with the fixed wing crews, attended a daylong seminar with Michelle. Her sense of humor and teaching methods made the daylong safety event enjoyable. Many in the air medical transport arena will miss her smile, friendship, and knowledge of safety.

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A major topic of discussion among CAMTS board members recently has been the use of human patient simulators (HPS) for the training of flight teams.

The HPS is an interactive, computerized mannequin that can respond to interventions from the team. CAMTS has recognized that these simulators are an appropriate alternative to cadaver or animal models for training flight teams in Advanced Trauma Support, the Flight Nurses Advanced Trauma Course, and the Trauma Nurses Core Curriculum. The HPS has also been approved for initial intubations during orientation. However, for an HPS to be considered appropriate for these uses it must meet certain criteria:  

• It must be dynamic.
• It must provide a real–time response.
• It must provide real–time feedback.
• The operator must be able to make changes without the participant’s knowledge. 

There are several manufacturers and companies offering these mannequins and programs for training across the United States. I was able to practice on a couple of models recently, and was very pleased with how realistic the scenarios were and how well the mannequins responded to interventions that were and were not appropriate. As this new technology evolves I am certain we will see dramatic changes in how these mannequins look and respond. This is the future, and it looks bright for our patients and us.

Check out these companies for more information on human patient simulators and what they can do:

Medical Education Technologies, Inc.
Laerdal
Simulab Corp.
 

On another note, CAMTS is also working on the next edition of the accreditation standards. If you have any comments, ideas, or suggestions please feel free to contact me at:

Thomas J. Cahill, RCP, RRT, EMT–P
Shriners Hospital for Children–Cincinnati
3229 Burnet Ave.
Cincinnati, OH 45229
(513) 872–6191
(513) 872–6145 fax
tcahill@shrinenet.org

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The pediatric transport setting presents the respiratory therapist with a patient population whose diverse diagnostic categories demand an extensive knowledge of clinical disease pathologies. Some of the most common disease states include respiratory–related illnesses (40%), neurologic disorders (16%), congenital cardiac disease (9%), gastrointestinal diagnoses (8%), and sepsis/septic shock (7%).(1) Providing care for patients from each of these diagnostic categories requires rapid assessment and intervention focused on the establishment of a patent airway, effective respiration, and hemodynamic stability as stated by the American Heart Association’s Pediatric Advanced Life Support (PALS) guidelines.(2) While these guidelines are specific as to the assessment of respiratory failure and shock, often shock remains unrecognized.  

What is shock? It is a “state in which profound and widespread reduction in tissue perfusion leads first to reversible, and then if prolonged, irreversible cellular damage.”(3) If this state of hypoperfusion is not reversed, the resulting tissue damage can lead to multi–organ dysfunction and ultimately death. Shock can be easily identified by the presence of sustained tachycardia, prolonged capillary refill (> 2 seconds) or flash capillary refill, mottled appearance, cool extremities, decreased peripheral pulse, hypotension (< 5th percentile for age), decreased urine output (< 1 cc/kg/hr), and/or altered mental status (Table 1).(4,5) It should be noted that hypotension in the pediatric patient is a sign of uncompensated shock, and intermediate intervention is indicated. Once the shock is identified, the use of early goal–directed therapies to correct perfusion and blood pressure can decrease morbidity and mortality in pediatric patients in shock.

 Table 1: Signs and Symptoms of Shock

Recently, Han, et al investigated early resuscitation of pediatric septic shock by community hospital physicians as related to patient outcomes. The group demonstrated a mortality rate of 4% in patients who were aggressively treated at the referring hospital and achieved shock reversal by arrival of the transport team.(6) They defined shock reversal as the return of normal perfusion (capillary refill < 3 seconds) and systolic blood pressure (> 5th percentile for age). This is a considerable finding when compared to the national mortality rate of 10% reported by Watson’s group, which investigated the outcomes of infants and children with severe sepsis.(7) Han, et al also showed a greater than twofold increase in risk of mortality for every hour shock was not reversed.(6) This evidence supports the importance of rapid recognition and early treatment of infants and children in shock.

A recent abstract by Orr, et al reviewed the incidence of shock in children with a primary transport reason of respiratory distress.(8) The data were collected from five pediatric critical care specialty transport teams from various regions throughout the United States. The database included 4,905 patients who were transported to pediatric specialty facilities. Respiratory related illnesses included respiratory distress and respiratory failure. The total number of patients transported for respiratory related reasons was 1,636, or 33% of the total transport population.

In the patients referred for respiratory illness, 555 (34%) (Figure 1) were found to be in shock when the transport team arrived. Shock was defined as having either prolonged capillary refill (> 3 seconds) and/or hypotension (< 5th percentile for age). None of these patients were reported to be in shock at the time of the initial call. These two simple signs to define shock are advocated by the PALS guidelines for the early identification of shock.(2) The group also analyzed the outcomes in children with and without shock. They found a mortality rate of 10.5% (58 deaths) in the shock group vs. 2.8% (30 deaths) in the non–shock group [p< 0.001; OR 4.1 (2.6–6.4)].(8) This demonstrates greater than four times the risk of mortality in patients who were defined as having shock.

One would expect children in shock to receive more major medical interventions such as fluid resuscitation (> 20 cc/kg.), endotracheal intubation, and vasoactive support. Orr’s group demonstrated that 57% (315) of patients in shock received at least one of these interventions versus 20% (217) of those who were not in shock (Figure 2).(8)

Goal–directed therapy for the resuscitation of shock should be time sensitive and directed at restoring effective respiration and normal perfusion. Respiratory support may include supplemental oxygen or require more aggressive interventions such as endotracheal intubation. Treatment of poor perfusion may require aggressive fluid resuscitation and/or vasoactive support. Administration of 20 cc/kg of isotonic saline or colloid boluses has been recommended up to and over 60 cc/kg in children with septic shock by the American College of Critical Care Medicine.(9) If a child requires greater than 60 cc/kg of isotonic crystalloid, then he is considered to be in fluid refractory shock and vasoactive support should be considered.(9) The definitive treatment of the various types of shock is determined by the underlying cause of decreased cardiac output. The exact interventions undertaken may be based on the individual transport team’s protocols or the recommendation of their command physician.  

Shock is commonly under–recognized in children who are transported with respiratory illness as the primary reason for transport.(8) Those involved in the transport of children should have a high suspicion for shock in patients with respiratory distress. Early goal–directed therapy can significantly affect the outcomes of these patients, and resuscitation must begin at the referring facility and be continued throughout transport.(4) By placing greater emphasis on the recognition and treatment of shock, we can positively affect the outcomes of a significant population of children we transport.

References

1. Developing a Pediatric Severity of Illness Model for Transport System Evaluation and Triage. Emergency Medical Services for Children (EMSC) Target Issues Grant #1–MCH–424003–01–0, Maternal and Child Health Bureau, Health Resources and Services Administration, Public Health Service.
2. Zaritsky AL, Nadkarni VM, Hickey RW, Schexnayder SM, Berg RA, eds. Pediatric Advanced Life Support Provider Manual. Dallas, TX: American Heart Association; 2002.
3. Kumar A, Parrillo JE. Shock: classification, pathophysiology, and approach to management. In Parrillo JE, Bone RC, eds: Critical care medicine: principles of diagnosis and management, St Louis, 1995, Mosby.
4. High K, Yeatman J. Transport considerations for the pediatric trauma patient. J Emerg Nurse. 2000; 26: 346–351.
5. Carcillo JA. Pediatric septic shock and multiple organ failure. Crit Care Clin. 2003; 19: 413–440.
6. Han YY, Carcillo JA, Dragotta MA, et al. Early reversal of pediatric–neonatal septic shock by community physicians is associated with improved outcome. Pediatrics 2003 Oct; 112(4):793–799.
7. Watson SR, Carcillo JA, Linde–Zwirble WT, et al. The epidemiology of severe sepsis in children in the United States. Am J Respir Crit Care Med 2003; 167: 695–701.
8. Orr RA, Kuch B, Carcillo J, Han Y, et al. Shock is under–reported in children transported for respiratory distress: a multi–center study [abstract]. Crit Care Med 31: 2003.
9. Carcillo JA, Fields AI. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med. 2002; 30: 1365–1378.

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Transport RTs in Charlotte, NC, are celebrating a major victory. Thanks to the efforts of RTs at MedCenter Air (MCA), we have received approval to widen our scope of practice in the transport setting.

MCA is a CAMTS–certified, comprehensive transport team (RW, FW, G) based at Carolinas Medical Center. Carolinas Healthcare System, the third largest health care system in the nation, owns MCA. We utilize two Bell 230s, two King Air 200s, a Citation V, and eight ground ambulances. As a team, we transport over 7,500 patients each year, staffed with an RN/RRT or RN/RN air configuration and an EMT/EMT–P, EMT/EMT–P/RN, or EMT/RN/RRT ground configuration. Our team transports all patients > 15 lbs Patients < 15 lbs are transported by our NICU specialty team.

On April 1, the North Carolina Respiratory Care Board (NCRCB) issued approval for transport RTs to perform advanced procedures such as RSI, needle and surgical cricothyrotomies, femoral and external jugular IV insertion, needle chest decompression, external/internal pacing, intraosseous placement, and IABP management. You can view the entire ruling, along with a list of pharmacology agents (click on the “advanced practice” link), on the board’s web site.  

How did this ruling come about? Once RTs became licensed in North Carolina in 2002 questions were raised regarding the roles of an RT in the transport environment. To start this ruling process, I contacted the AARC’s Transport Section chair, Steve Sittig, to obtain contacts for some of the programs that utilize the RN/RRT configuration. Then I contacted RTs from programs such as Mayo One in Rochester, MN; Northwest Medstar in Spokane, WA; StarCare V in Lincoln, NE; and Shriner's Burn Hospital in Cincinnati, OH; to obtain information on their scope of practice and learn about any issues that have arisen in their areas.

Following this, I contacted Floyd Boyer of the NCRCB and made a formal request to have the board review the advanced skills of RTs on our transport team. Then I sent the board copies of our policies and procedures, clinical protocols and competency requirements, drug manifest, and all of our continuing educational requirements. RTs from the team also attended all the board meetings to help answer questions the board had during our eight–month endeavor.

Then Mr. Boyer worked his magic. He contacted the AARC and other state respiratory boards to obtain their position on the advanced practice issue. He also contacted the North Carolina Office of EMS and found that RTs had approval to be used in the transport environment. After all the information was gathered, Mr. Boyer and the board issued the ruling that RTs can perform all advanced procedures outlined above, provided they:

• Are performing these procedures in the transport environment.
• Follow all clinical protocols and do not deviate unless given approval from Medical Control.
• Are licensed RRTs in North Carolina and have a minimum of three years experience as an RRT or a baccalaureate degree in respiratory care.
• Maintain competency with the provider's medical director and maintain certifications in ACLS, PALS, and NRP.
• Complete an additional ten hours of continuing education, with five hours related to pharmacological agents, for a total of 22 hours per year.

Other guidelines that were put into place can be viewed on the board's web site as well.

The RTs from MCA are very excited about this ruling. I think this will have a positive outcome for transport RTs across the nation as well, possibly helping to push greater use of RTs in the transport arena.

If you have any questions or would like more information, please e–mail  me.

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A local EMS service transports a 19–year–old patient to a referral hospital. The patient was found unconscious and lying face down in the water after being involved in a high–speed personal watercraft crash.  

The patient initially presented to the emergency department with agonal respirations, a Glascow Coma Score of 6, hemodynamic instability, and a negative secondary exam with the exception of a small chest abrasion. He was intubated, then escorted to the radiology department for head and abdominal CT scans. These studies identified a critical thoracic aortic tear and free fluid in the abdomen (later attributed to grade 3 splenic and liver lacerations, a transected pancreas and gallbladder, and a duodenal injury). His head CT scan showed punctate cerebral hemorrhages, shear injuries, and a brainstem hemorrhage. An exploratory laporotomy, including a splenectomy and liver packing, was necessary to gain control of extensive intra–abdominal bleeding and to restore relative hemodynamic stability.

LIFE STAR was immediately requested postoperatively to transport the patient to Hartford Hospital for surgical repair of his aortic tear. However, poor weather conditions prohibited air medical transport. Teaming up with American Ambulance personnel, the LIFE STAR medical team assisted in providing critical care during ground transport to Hartford Hospital.

During transport, continuous arterial line hemodynamic monitoring, pain control, sedation, and mechanical ventilation using the Crossvent 4 transport ventilator were performed. The patient’s Glascow Coma Score was now 3.

Upon arrival to the ICU at Hartford Hospital, the patient was assessed. Nipride and Esmolol infusions were initiated for blood pressure and heart rate reduction, a repeat head CT scan was completed (unchanged from the previous study), and an intracranial pressure monitor was placed preoperatively. He was then taken to surgery where a tear in the descending thoracic aorta was identified and corrected with placement of a Hemashield. Further abdominal injury repairs were also completed.

After a 23–day stay in the ICU and another four weeks of intensive rehabilitation, the patient was discharged home without any signs of neurological or cardiovascular impairment. Today, the patient works as a manager and is in school part–time.

Discussion: thoracic aortic tears

Even though traumatic aortic laceration is identified in less than 1% of all blunt trauma patients, the lethal nature of this injury if undetected always merits vigilant consideration. An estimated 8,000 deaths each year are attributed to blunt traumatic aortic injury, with 80%–85% of these patients expiring in the prehospital environment. An additional 50% of patients who survive until hospital admission will die if this injury is not detected and corrected within the first 24 hours.(1)

As the site of fixed attachment for an otherwise mobile aortic arch, the ligamentum arteriosum is the most common site of aortic tears (90%) in blunt trauma. The physiologic cause of this injury is unclear. Theories citing rapid deceleration shearing forces, compression of the aorta and great vessels over the underlying vertebral column, and profound intraluminal hyperextension during impact are postulated.

Kinematics may be the most reliable predictor of aortic injury. Motor vehicle crashes are the most common cause of blunt aortic injury, with front seat occupants at greatest risk. A significantly higher prevalence of aortic injury is noted if side impact forces, intrusions of 15 inches or more into the passenger compartment, or rapid deceleration from speeds greater than 20 mph occur. Interestingly, the incidence of aortic injury is similar for unrestrained motor vehicle crash victims and those utilizing seat belts and airbags.(1) Falls from heights, especially when patients land on their feet, should also raise the index of suspicion.

Fifty percent of patients with blunt thoracic vascular injuries present with no external signs of chest injury.(2) If present, some general signs and symptoms of aortic injury may include visible chest trauma (seatbelt marks, flail chest), hypertension, hypotension, tachycardia, unequal upper extremity pulses or blood pressure, difficulty breathing, back pain, or a complaint of a “tearing” sensation in the chest. Historically, a strong correlation between isolated first or second rib fracture and an aortic tear was suspected. It is now known that the “positive predictive value of rib fractures for aortic injury is 15%, but patients without rib fractures have a statistically identical incidence of aortic injury.”(1)

The most accurate way to diagnose an aortic tear is by aortogram, but unfortunately, many facilities do not have this capability. Alternative methods to diagnose aortic injuries include chest x–ray to evaluate for a widening of the mediastinum or loss of aortic knob contour, chest CT scan, or transesophageal echocardiogram. Ultimately, these patients require emergent transport to a facility with full–time cardiothoracic surgical capabilities.

Three options for aortic laceration repair exist: 1) open surgical repair (most common but frequently associated with postoperative parapalegia), 2) endovascular stent placement, and 3) non–operative medical management. Incomplete aortic tears that spare a portion of the vessel wall allow mediastinal hematoma formation and offer the best chance of survival to care. However, an incomplete tear can progress to complete rupture and death in the hours immediately following the injury. Heart rate reduction with beta blockade and aggressive blood pressure control using vasodilators are recommended to decrease hemodynamic stressors on the vessel injury site until definitive care can be reached.(3) At LIFESTAR, the transport team may choose Nipride and/or Esmolol for this purpose.

In summary, traumatic aortic tears are almost always immediately lethal. But for those patients who survive the initial aortic insult and transport to definitive care, several treatment options exist that can positively impact patient outcome. A heightened index of suspicion for aortic injury, rapid detection, and expeditious cardiothoracic surgical referral are key to patient survival. In the case of this patient, the detailed description of the mechanism of injury given by EMS, early injury recognition by the referral hospital physicians, and Hartford Hospital’s cardiovascular and trauma services proved to be the winning combination necessary to beat the mortality odds of blunt aortic injury.

References

1. Horton T, et al. Identification of Trauma Patients at Risk of Thoracic Aortic Tear by Mechanism of Injury. Journal of Trauma: Injury, Infection, and Critical Care 2000; 48: 1008–1012.
2. Patel NH, et al. Imaging of Acute Thoracic Aortic Injury due to Blunt Trauma: A Review. Radiology 1998; 209: 335–348.
3. Gammie J, et al. Traumatic Aortic Rupture: Diagnosis and Management. Annals of Thoracic Surgery 1998; 66: 1295–1300.

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Portneuf LifeFlight is a county–owned, emergency air ambulance service based at Portneuf Medical Center in Pocatello, ID. Located in the foothills of the Rocky Mountains, Portneuf’s LifeFlight has flown over 6,000 missions within Idaho, Wyoming, Utah, Colorado, and Nevada since its inception in 1983. Portneuf has sped up its operation with delivery of a new Agusta 109–Power.

Portneuf has five RRTs who participate in all neonatal specialty transports and vent–dependent adult transports, but recently RRTs at Portneuf have been asked to fill a more direct role. With the support of Department Manager Bernard Boler, RRT; Medical Director Curtis Sandy, MD; and Chief Flight Nurse Tom Mortimer, RN/EMT–P; we are now stepping onto new ground as adult secondary team members for rotor–wing and fixed–wing inter–hospital transports. Along with the typical intubation training and protocol development, Portneuf RRTs will be cross training into intravenous access and administration. Portneuf Lifeflight is also preparing a transportable balloon pump to help compliment their new cardiothoracic surgery program.

The AARC and Transport Section Chair Steve Sittig have been a great help, providing the necessary information and IV course material. It’s nice to know there are folks out there who want to diversify the field of respiratory care and are willing to work off the clock to help others out.

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Steven E. Sittig, RRT-NPS

I would like to take this opportunity to remind everyone that nominations for the section’s Specialty Practitioner of the Year award are due by August 31. If you work with someone who goes above and beyond the call of duty, please consider nominating him or her for this special award. The guidelines are simple: any section member is eligible to be nominated and the nomination must come from another member of the section. Last year we honored Brad Carmen, RRT, from Shriner’s Hospital in Cincinnati, OH.

This is a great way to recognize those outstanding transport RTs who are out there every day delivering outstanding patient care and helping to promote our role in the transport environment. Submissions may be made online. Please fill out the entire form and submit it to the AARC. A committee will evaluate all the candidates, and the winner will receive his or her award during the Awards Ceremony at the AARC Congress in New Orleans this December.

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Specialty Practitioner of the Year: Submit your 2004 nominations now.

Recruit a new member: Know an AARC member who could benefit from section membership? Direct them to section sign–up. It's the easiest way to add section membership to their overall membership package.

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