Retrieval Medicine for Critical Care Paramedic - Essay Example

? Case 2: Coordination case of the Health sciences and medicine of the August 25, Case 2: Coordination Case The following assessment is related to the tasking and coordination of a physician led retrieval. Tasking and clinical coordination are vital aspects of retrieval medicine. Triage resource allocation and high level clinical oversight are key elements to this process. The following incidents need to be considered as being independent of each other. In each case the decision to mobilize, coordinate and support a retrieval team rests solely with you. You have the maps and communication equipment available to you to make each decision. For this submission you must: For all 4 incidents discuss key points in the allocation of physician based retrieval team resource allocation to these incidents. Include in your answer: 1. Justification for activation or non activation based on the little information you have 2. Problems that may be encountered 3. Your actions to gain a clearer picture of the incidents 4. What your team mix may be and why. Case 2: Coordination Case Introduction For health care personnel, every life is precious and worth saving. However, the reality of this field is that demand always exceeds resources. Thus, triage resource allocation skills are an important part of retrieval medicine. A successful retrieval program can significantly improve the outcomes of critically ill or injured patients and it involves tasking and clinical coordination amongst various members such as physicians, nurses and paramedics, and teams such as ICU team, ambulance crew, and helicopter retrieval team. In Australia, prehospital care and retrieval programs are an important component of emergency medical services owing to large and remote lands and distribution of population with geographical peculiarities. Thus, to provide emergency medical care, prompt communication, activation and response are performed. Organisation and functioning However, apart from the response time, another important factor in prehospital care is the skill level of the crew providing the care. Crew may consist of different combinations of the following personnel: physician, paramedic, critical care paramedic and nurses. Means of travel and transport can be air or ground. In most air retrieval programs, physician staffing is considered a standard of care (Garner, 2004). However, this opinion has been contested by Rashford & Myers (2004). Although, no difference was found in the outcomes of patients admitted during primary retrieval by an intensive care paramedic and emergency physician, it has been recommended that aeromedical retrieval should be performed by trained physicians (Cameron, Pereira, Mulcahy & Seymour, 2005). Most of the time, the information received is scarce and the coordinator has to use his own judgement in providing the response team, choose the destination hospital and activate the mode of transport. Tasking is done by a retrieval coordinator or consultant who is ideally an emergency physician with wide retrieval experience. This coordinator elicits maximum information that is possible about the site, mechanism and injuries and the patient. Ambulance services employ for triage Medical Priority Dispatch System which is an algorithm to stratify patient’s status depending upon the symptomatology (Rashford & Isoardi, 2012). The available resources are then mobilised and nearest team with the required staffing is dispatched for those in need. Maps and communication system aid in planning and organisation of the pre hospital care and retrieval. The following cases illustrate the problems that may be encountered in team allocation and response activation. Incident 1: The ambulance service has alerted you to an ongoing incident in an urban area of or your jurisdiction. Five minutes earlier multiple calls had been received regarding a motorcycle rider who had been struck at an intersection. Information you have received is that the Motor cyclist is unconscious. Information is gained about the motorcyclist’s vital signs from the first responders and the ambulance service. Apart from unconsciousness, other injuries, particularly with immediately lethal potential, are enquired about. In an urban area, a ground team may have a faster response than an air borne team. This situation relates to landing of the aircraft. Again, maps are utilised to make a decision for air vs. ground transport. Depending upon the topography and the geographical location, the response team is activated. Patient most likely will require transportation to a trauma centre and advanced airway management in view of unconsciousness. Thus, a physician based team is activated for response as well as retrieval of this patient. Other member of the team could be a critical care paramedic or nurse trained in intubation and related procedures. Challenges that may be encountered in this patient are spinal column injuries and need for rapid imaging and surgical management for head injury. All information updates should be communicated to the team en route. Incident 2: You receive a call about a shooting in remote area some 50 minutes by rotary winged aircraft. It is 2am and raining. A single call was made by a female reporting a gunshot and a figure laying face down in her front yard. A local ambulance crew has been dispatched but will not be on scene for 20 minutes. In this case, given the distance and the weather condition, air ambulance is a risky proposition. Also, immediate air activation is not justified because the information about the patient is very limited. As the local ambulance crew has already been dispatched and it is likely to reach the scene in 20 minutes, the status of the patient will be clearer. Meanwhile, the air crew can be alerted for the possibility of an immediate retrieval for which they should remain on stand-by. Problems that may be encountered in this case are related to safety of the crew as well as patient, in view of bad weather and gun-shot mode of the injury. Cooperation of the local police department is sought. The patient has been reported to be lying face down. Injury may have already proven fatal. Once the vital signs and resuscitation requirements are communicated to the tasking agency by the local emergency crew, helicopter based retrieval team may be activated depending upon the weather, or patient may be transported by the ground ambulance itself. Incident 3: You are asked by a ground team to activate a helicopter to a semi rural property 25 minutes by air away. A 75 year old man has collapsed in his living room and cardio pulmonary is in progress. Cardiopulmonary resuscitation (CPR) is already being attempted in this patient. More information will be sought whether it was a witnessed arrest and whether trained personnel are administering CPR. Although, ground ambulance team has requested for activation of helicopter, helicopter retrieval is usually not indicated for patients known to be in cardiac arrest (American College of Emergency Physicians and National Association of EMS Physicians, 2006). In fact, utilisation review considers the transport of a patient whose cardiopulmonary resuscitation is in progress as inappropriate (Hafner et al, 2012). The plan may evolve and change once more information is available. The ground crew should try to resuscitate the patient and if the physician decides to transport the patient to the hospital, resuscitation can continue en route (Eisenburger, 2008). Incident 4: An ongoing incident has been phoned through. A car has been struck by a van on a freeway 25 minutes by rotary winged aircraft. Information is one person dead at scene and another trapped with severe abdominal pain and SBP of 90mmHg. The aircraft is immediately sent for retrieval with the crew consisting of a physician and a critical care paramedic. It is ensured that a local ground team is on its way as it may reach the accident site faster than the aircraft depending upon the traffic. Here regional and logistic considerations come into play. Patient has probably suffered blunt trauma abdomen and is in shock. More information is gained about any obvious source of bleeding and communicated to the response and retrieval team. As the patient is responsive, he should be asked about pain in the neck or spine to rule out spinal cord injury. Immediate transfer to a trauma centre is required. Also, it’s important that the retrieval team has skills for fluid resuscitation, and advanced airway placement, if required. Challenges in this case are related to the extrication of the patient and need for resuscitation and time critical need for transportation to a trauma centre. Tasking agency keeps a track on the extrication status of the patient and forwards this information to the response team which is on its way towards the scene. Conclusion A clinical coordinator involved in tasking and coordination of prehospital care and retrieval team relies upon recommendations as well as his clinical judgement. Each case and its surrounding circumstances are unique and careful planning is essential for triaging of these patients. Both over-triage and under-triage are inevitable and counterproductive and maximum effort is made to avoid both these conditions. References American College of Emergency Physicians and National Association of EMS Physicians. (2006). Guidelines for Air Medical Dispatch. Retrieved from http://www.acep.org/uploadedFiles/ACEP/Practice_Resources/issues_by_category/ mergency_Medical_Services/GuidelinesForAirMedDisp.pdf Eisenburger, P., Havel, C., Sterz, F., Uray, T., Zeiner, A., Haugk, M. et al. (2008). Transport with ongoing cardiopulmonary resuscitation may not be futile. British Journal of Anaesthesia, 101(4), 518–522. doi:10.1093/bja/aen209 Cameron, S., Pereira, P., Mulcahy, R., & Seymour, J. (2005). Helicopter primary retrieval: Tasking who should do it? Emergency Medicine Australasia, 17, 387–391. Garner, A. A. (2004). The role of physician staffing of helicopter emergency medical services in prehospital trauma response. Emergency Medicine Australasia, 16, 318–323. Hafner, J. W., Downs, M., Cox, K., Johncox, J. E., & Schaefer, T. J. (2012). Inappropriate helicopter emergency medical services transports: Results of a national cohort utilization review. Prehospital Emergency Care, published online ahead of print, 1–9. doi: 10.3109/10903127.2012.689928 Rashford, S., & Myers, C. (2004). Optimal staffing of helicopter emergency medical services is controversial. Emergency Medicine Australasia, 16, 269–270. Rashford, S. & Isoardi, K. (2012). Optimizing the appropriate use of the emergency call system, and dealing with hoax callers. Emergency Medicine Australasia, 22, 366–367. doi: 10.1111/j.1742-6723.2010.01325.x Read More