Vent question/concerns

[JPINFV]

I've never seen my company's RTs push meds or titrate, but that doesn't necessarily mean they don't. The vast majority of vent transports that I've been party too have been either discharges or transports unrelated to the need for the vent. I know that the RTs do not carry any IV meds and the RNs do not normally stock narcs or benzos (they can pick them up from the transporting hospital if need be, for example seizure patients).

My company provides backup 911 services to a few cities, but paramedics in the county are solely with the local fire departments. If the fire department doesn't transport themselves, then a local ambulance company is contracted to provide a BLS ambulance that the fire medics use to transport.

[chbare]

I am still a little confused. When you have a CCT, who provides the non pulmonary interventions. For example titrating gtts and medication administration? You say that a RN may or may not come along with vented patients and paramedics do not work for the service, so who provides the other interventions during a transport with a RT but no RN? Perhaps I have simply misread your original post. :oops:

Take care,

chbare.

[VentMedic]

Our standards for our Respiratory Therapists are similar to NC's (see previous post). If the RRT is part of a designated transport team, they are expected to perform all of the duties including medications. The RN is also expected to have competency in the respiratory skills and medications. Of course, while on transport just like in the ICU, it is easier for documentation to keep some duties separate. On neonatal and pedi transports, the RRT takes care of setting up all of the medications (none of the sending hospital's meds are used in case of error) and ventilator while the RN gets consents signed with the parents.

Respiratory Therapists are normally a very cautious bunch. They like to have extensive knowledge about the technology and medications they are using. Paramedics and RNs sometimes perform functions that they have not been entirely trained in. This is seen in both the hospital and on transport. Sometimes it is through no fault of their own, just the situation and sometimes it is their "can do it all" attitudes. RNs should have a knowledge about all the medications they give patients. Unfortunately there are more medications than time.

As a young paramedic, I also did it all and welcomed any challenge. Then, I went back to school and got educated. That taught me something about "you don't know what you don't know".

RTs are often put into transports as part of an uncomfortable situation. They are sometimes requested to go on a transport by the Intensivist for various reasons. Now the RT is in the back of an unfamiliar ambulance with an RN and EMT-P they have never seen before. This happened to me recently when the CCT team thought Flolan was a bronchodilator like albuterol. Before I knew it I was told to hand off my other 5 ventilator patients to another RT and go on transport. We have our own protocols for transporting patients, but when functioning as a "guest" with another transport team, it puts us in a grey area. This also happened when a transport team admitted to not being familiar with their own ventilator and asked one of our RTs to accompany them. Now that RT must accept responsibility for their equipment or take ours which again puts the RT and hospital in a grey area.

RT is generic for Respiratory Therapist

RRT is Registered Respiratory Therapist - advanced practice and usually required to do conscious sedation, ECMO, intubation, IABP, A-Line insertion, hemodynamics, etc.

CRT - Certified Respiratory Therapist - lesser license, 2 year degree still required

[VentMedic]

I am still a little confused. When you have a CCT, who provides the non pulmonary interventions. For example titrating gtts and medication administration? You say that a RN may or may not come along with vented patients and paramedics do not work for the service, so who provides the other interventions during a transport with a RT but no RN? Perhaps I have simply misread your original post. :oops:

Take care,

chbare.

I, too, would like to read a little more from JPINFV about his job. I'm trying to piece together the details he's given us so far.

Not all ventilator patients require "critical care" transport. There are many times when the patient is going to a long term ventilator facility. They can also be a quad or ALS patient going to and from the hospital from home. Basically they are BLS except for the ventilator. However, an RT or RN (trained in trachs) usually has to accompany them for basic airway maintenance and ventilator. Many home care patients take care of their own ventilators and just need transport. The parents usually manage their child's ventilator. Policies vary among ambulance companies when dealing with these patients.

[chbare]

What?, a CCT educated crew did not know about Flolan? As long as you know that Flolan is for pulmonary HTN, you would at least know it's not a bronchodilator! Another team did not know how to set up or use their vent? I just do not know what to say....I hope Vs-eh? does not read this. I take it these are hospital based crew members that are simply pulled from the floor when a transport is required?

I wish EMS providers were more cautious in the way they think about patient management. I see allot of providers simply want to do things because "I can."

Take care,

chbare.

[VentMedic]

I take it these are hospital based crew members that are simply pulled from the floor when a transport is required?

No, they are employed by a well known private ambulance company that provides interfacility transport under a new contract with a neighboring facility. I am not sure about their training/education. I just know they are RN and EMT-P. The RN should have at least ICU experience. Of course, not all ICUs are created equal. Not all CCTs are equal in additional training/education. Not everyone is familiar with the nebulized prostacyclins. Some hospitals just use nitric oxide. However, when that is emphasized in report when making arrangements for transport, they could at least read a little on the way over to pick up the patient. We'd be happy to fill in the blanks if they demonstrate some knowledge of what they're doing.

I could tell of more stories from a service that has been attempting to be an established HEMS and also trying their hand at interfacility transport. Right now they are in negotiations with their county. After the dust settles I may post some of the articles from their local newspaper and website. It is a good example of someone not doing their homework prior to the starting this type of service in this particular location.

[JPINFV]

I am still a little confused. When you have a CCT, who provides the non pulmonary interventions. For example titrating gtts and medication administration? You say that a RN may or may not come along with vented patients and paramedics do not work for the service, so who provides the other interventions during a transport with a RT but no RN? Perhaps I have simply misread your original post. :oops:

Take care,

chbare.

Not all of our vent patients have drips. A lot of them are either going to or coming from a sub-acute center or the aforementioned vent patient on home care. If the patient does have a drip, then an RN would be with the transport along with the RT.

[VentMedic]

Sub-acutes are quite popular these days. As I mentioned earlier, I would advise anyone who sees working with ventilator patients in their future to spend some time in a large sub-acute. This includes new grad RNs, future RTs and CCEMT-Ps. Not only will one see many different types of ventilator patients and different modes of ventilation/airways, but also different ways of communicating with the patients. The patients that are able to speak, as Christopher Reeve did, will be able to answer alot of questions about what it feels like to be initially on a ventilator and the prospects of never coming off of a ventilator. That will put a human voice to a technology centered world. It will also give someone a view of what happens to some of those "saves". That part might be disheartening to some.

[chbare]

JPINFV, thank you for the clarification.

I think some of the problems faced in transport revolve around services not appreciating fully the level of care that they should provide. For example, I have very little formal education regarding the care of neonates and neonatal critical care. I would never consider transporting a critical neonate. In addition, I see allot of services flying non emergent patients, and I have to wonder if $$$ rather than appropriate level of care is the bottom line. However, I digress.

Take care,

chbare.

[WendyT]

I try to learn about things. It's in my nature.

What nature would that be, the forest of nottingham? :wink: