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ICU Goes Mobile

Herculean ambulance “78”

In the past, critically ill or injured patients had few options for continuity of care while en route to hospitals and tertiary care facilities. Paramedics were transporting patients with critical medical needs in a setting that wasn’t always accommodating, often resulting in an interruption in the patient’s pharmacological agents, procedures, and interventions necessary to provide critical care during transfer.

Another alternative was to utilize the transferring facility’s nurses or respiratory therapists to accompany the patient, reducing the facility’s staff and placing that person in an environment that was not familiar.

Today, those challenges are being addressed as more options have become available in ground critical care transport (CCT) with advanced equipment and specialty EMS personnel who are capable of performing those procedures that are necessary to save lives and improve outcome.

“What’s commonly been done to this point is you’ve taken a regular ambulance and put a nurse on board and called it a CCT unit,” said Scott Allen, Hall Ambulance’s public information officer. “We took the opposite approach and took the ICU unit out of the hospital and put it on wheels.”

The vehicle, also known simply as “78,” was put into service in December of 2009, and although the idea of transporting critical care patients by ground is not unique to Kern County, this is the first time a comprehensive ground CCT program has been made available for Kern County hospitals. The ambulance itself is the largest of its kind on the West Coast and tends to attract a lot of attention everywhere it goes.

“When we first started the program, people just saw this really big ambulance and didn’t know what it was,” said Bryan Newton, an EMT for 14 years whose job it is to pilot the behemoth. “The first time we went to San Francisco there were numerous local ambulance crews that were impressed with not only the unit, but also the dynamic of our team.”

Designed by Steve Prater, a paramedic field supervisor at Hall, 78 is a custom-built Lifeline Freight liner, extra-long quad cab ambulance. On the inside, the rig is designed for maximum safety and complete comfort of patients and their families, including a 10-inch flip-down flat-screen monitor with DVD and surround sound for patients to watch during transport, as well as a cushioned air ride system.

Michelle Lawrence, Hall Ambulance R.N. on-board “78.”

Beyond the comfort, is a plethora of high-tech equipment and a highly-trained staff that really makes this unit a flagship for critical care transport.

On-board, the three-person crew is comprised of an emergency medical technician (EMT), paramedic, and registered nurse, all of whom have undergone specialized training in order to provide many of the services offered in a level I trauma center or a tertiary care center.

“Having an R.N. expands the scope of practice we can provide,” said Allen. “When our team arrives on scene now, they can take over at that expanded care level and continue the intensity of that care uninterrupted all the way to the next facility.”

While aero medical (helicopter) transport is the fastest mode of CCT, the option can be rendered unavailable due to scheduled maintenance, inclement weather, weights and balances, and high demand.

“Until now, our rotor-wing program did the majority of our critical care medical transfers, and was already utilizing personnel that possessed the training necessary for ground transport,” said Myron Smith, Manager of Hall Critical Care Transport. “We developed a more extensive medical program for paramedics and nurses under the direction of a physician, and chose the air division with its background to run the program.”

A typical critical care patient may be intubated, mechanically ventilated, and sedated on several drips. The Hall CCT unit is equipped to do the job, as treatment does not have to be discontinued for the ride.

With its barrage of flashing lights and familiar reflective orange and white color scheme, 78 may just look like an ambulance on steroids. However, this is no run of the mill transport unit.

Besides its massive size, what sets this apparatus apart all begins when the patient is loaded via a rear door activated air system that lowers itself to accommodate the unassisted 700-pound capacity auto-lift gurney. The unit is also equipped with an isolette lift for loading and unloading critical care pediatric patients.

Once on board, the patient can be managed for treatment from 360-degrees by a crew that is equipped with a its own ventilator; state-of-the-art cardiac monitor that is 12 lead capable; and is able to handle invasive monitoring; defibrillator; triple compact IV pumps that can handle up to six drips; two main oxygen tanks with medical air; as well as a variety of pharmaceuticals not normally carried on a transport unit.

“Before the unit was developed, if a patient had to be transferred, we may have to suspend automated ventilation or certain intravenous meds,” explained Cindy Bernard, one of three registered nurses who is assigned to 78. “Not only can we provide the same treatment as most hospitals, but if a patient’s condition should deteriorate during transport, we can perform advanced procedures because of what we carry on-board—something that cannot be done on a regular ambulance.”

When transporting a critical care patient, time is an issue and it takes much longer to transport via ground than by air. As a result, ground CCT teams must be able to function autonomously.

“Each of us has a job on our team,” added Newton. “We also double-check each other so everything is ready to go quickly and efficiently from the time we arrive.”

The team has a multidisciplinary role and functions as a seamless link between the patient and a surgeon, respiratory therapist, attending physician, phlebotomist, anesthesiologist, and other personnel.

This new ambulance not only enhances the team’s ability to provide advanced care, but also provides family-centered care from the moment transport begins, with a safer location for parents to ride inside the patient-care compartment with the child, as well as providing comfort to a spouse that has been physically and emotionally drained.

“During an emergency response, there is a very limited window of opportunity to have an impact; and then you move onto the next call,” added Ed Bronowicki, a paramedic for 23 years who has also served as a flight paramedic. “This is actually a unique situation because we can run the initial call and then transport that patient to another facility. It allows us to be more interactive and we actually get more response out of the families.”

The CCT team’s response can positively impact a patient’s outcome. This is a tremendous responsibility for each team member, and having “78” provides the necessary life-supporting systems to optimize the delivery of care to those who are critically ill or injured in Kern County.

“A lot of the facilities still don’t really understand what we can do,” Bronowicki concluded. “We are on a constant education campaign everywhere we go. This program is the next evolution of what EMS personnel will be doing.”

Article appeared in our 27-5 Issue - December 2010