Respiratory Reaches New Heights

Think of a tough day on the job as a respiratory therapist: You can’t get an airway started on a critically ill patient, and a nurse is inspecting your every move. Now think of that same moment playing out in a 5×10 foot box – dark, cramped and hot. Imagine that you have to wear a uniform that’s clinging to your sweaty skin. And worse, there’s a heavy helmet on your head matting down your hair and adding tension to your already cranked neck.

Can you withstand more? You must. Your crowded, swampy little space starts shaking, jolting, and you fight to overcome your own nausea and mounting stress as you race against time trying to work on a faltering patient. You, yes YOU, have to start an IV line. Be precise. Get it done. And hurry. There is a life in the balance.

It may sound like the RT job from hell, but those who do exactly these things under precisely those conditions call it something else.

“This work is the experience of a lifetime,” said William “Andy” Fullerton, RRT, EMT-P. Fullerton is one of a team of flying transport RTs working for MedCenter Air of Carolinas Medical Center, home-based in Charlotte, N.C.

“It’s the best job in the world, a 10-plus on the satisfaction chart,” agreed colleague Scott Prater, RRT-NPS, CPFT, NREMT-P, CMTE.

In the Carolinas, transport RTs work under an advance practice act that allows them to carry out the same level of practice as the RNs who accompany them as equal partners on every flight. RTs insert IV lines, push medications, control hemorrhages, intubate patients, oversee drip lines, maintain balloon pumps, and keep ventilators going. Conversely, the flying RNs learn to carry out the hallmarks of respiratory care as well.

“We have to be able to switch off duties,” said fellow transport therapist Shellie O’Day, RRT,NPS, EMT-B. “No one can do this alone.”

Speed and uncertainty

MedCenter Air has three base locations, strategically located throughout its primary coverage area. Along with the rotor wing aircraft, MedCenter maintains fixed-wing aircraft for longer-distance transports, as well as trucks for shorter ground hops. But when speed is a matter of life and death, it’s often quickest to transport as the crow flies, and to do it in a copter.

While there’s a hurried immediacy involved in launching a transport mission, these three team members said they feel safe once aloft, thanks to state-of-the-art flight technology. “We have all the bells and whistles, like ‘terrain awareness’ equipment that tells the pilot if we are going too close to the ground, or a mountain, or another aircraft,” Prater said.

The team also stands by a “three to go, and one to say no” policy. That means if any one member of an RT/nurse/pilot three-man crew is uncomfortable about a mission for any reason whatsoever – be it weather or a “gut” feeling – the craft simply won’t take off. No questions asked. Period.

When the transport team hears the call, “We need you to launch!” they often don’t have many details about the circumstances they’re getting into. “It could be anything and everything, from a burn patient, to a woman in labor, to a code STEMI,” Prater said. “You just never know.”

That’s when the respiratory adventure really kicks in because every call results in a different situation. “In a hospital you may have the same patients for a couple of weeks, but not us,” Prater noted. “I love the constant variety – from geriatric to pediatric.

Lack of confinement

To public onlookers, the idea of flying off at a moment’s notice may have a certain “Come Fly with Me” allure, but any glamour associated with the job is strictly an illusion. “We wear a regulation flight suit – hot in the summer and really cold in the winter – wind cuts right through it,” said O’Day, noting that anything underneath the suit should be cotton so that it won’t injure skin should there be a mishap. “Forget Spandex,” she said. “It melts.”

And then, there is the constant uber-close proximity to others. “You better like your partner,” laughed O’Day, “because let’s face it: People get cranky, they get sweaty, and antiperspirant only can do so much.”

Yet despite working in the tight and unforgiving dimensions of an aircraft, Fullerton said it is precisely a lack of confinement that he embraces most. “Sure, that may sound odd since my work space is basically the size of a box,” he said. “But I get to take respiratory care beyond the walls of a hospital and out into the world. There’s no way to describe how amazing that is.”

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Such a breadth of possibility requires extensive RT training, experience (critical care is an essential), confidence and a great sense of autonomy on the part of each transport team member. The RTs function under a medical director and provide care using specific protocols as guidelines.

“The autonomy is incredible,” Fullerton said. “We assess the situation and utilize our experience and protocols in making critical decisions. When our backs are against the wall, the medical control officer is our outlet. Our decisions in the field are constantly being reviewed in order to ensure our patients receive the highest level of care.” But there is no denying that during air transport, it is ultimately the flight team that holds a patient’s well-being in their hands. “If we make a wrong decision, we answer for that.”

 

Most difficult transports

Asked to recall one of his more difficult transports, Prater remembered one burn patient in particular. The patient was up in the mountains scalding hogs, a practice of dipping slaughtered pigs into boiling water to remove their hair before shipping them to market. He fell into the vat of water with the pigs and had first, second, and third degree burns over 100 percent of his body.

The patient wasn’t fated for a recovery, although he was flown to the nearest burn center. “We got his pain meds in him though, and controlled his pain,” Prater said. “He felt good enough to joke and said, ‘Well, I guess I know what my hogs feel like.’ Sadly, he didn’t survive; he died two days later.”

Fullerton, too, recounted a mission, all in a day’s work. His team was called to a collision of two motorcycles. “We landed right on the highway,” Fullerton said. “The patient was a very big guy – a grade 4 intubation. We couldn’t pass an endotracheal tube through direct laryngoscopy. We definitely didn’t want to cut him. Finally, we were able to ventilate him with an LMA (laryngeal mask airway). We established IVs, stabilized him, moved him into the helicopter and got him to a Level 1 trauma center.”

For O’Day, it is the pediatric end of care that prompted her to take to the skies. Because most neonatal teams are in-house in ICUs, it is unusual to have RTs with neonatal and pediatric expertise assigned only to a transport team. As a result, when the youngest patients need respiratory care during transport, there is often a life-threatening lag in time getting the appropriate medical team in place and to them.

“There are so few people who do this [neonatal RT care and transport],” O’Day explained. “The response time for these innocent babies is usually terrible.”

This became abundantly clear to O’Day when her best friend’s 22-week-old twins died due to slow emergency response. “They were at a facility that couldn’t adequately care for them,” she recalled. “I thought gosh, if a transport team with some neonatal expertise had gotten there in time, they might have survived.”

Thankfully, O’Day also shared a memory with a happier ending. One yet-to-be-born patient had been diagnosed in utero with a type of injury that causes fluid to back up into the lungs. Mom-to-be was to deliver in New York City under the care of a specialist. But as fate would have it, she went into labor quite a distance from there.

“The mother was taken to a local hospital, and the baby was delivered by C-section. But the delivering hospital couldn’t provide adequate care. So we lifted off from the airport the moment we were told the baby was born,” O’Day said. “We were really booking it – yet by time we got to the hospital the baby was already in heart failure. We had to get that baby to the specialist in New York City.”

Since it was a long trip, patient and medical team travelled by fixed wing plane first to New Jersey to the closest landing field, and then by harrowing emergency vehicle drive to the hospital.

“The chances of this baby dying were about 80 percent – we all knew that. We pulled out every trick we had. We had this baby on meds to increase the blood pressure; I tried to tweak the ventilator to do amazing things that it’s not inclined to do when fluid is backing up in the lungs. Meanwhile I’m on a satellite phone talking to the specialist in New York and saying, ‘This is what we’ve got, what do we do next?’ There were no other options. My partner and I looked at each other and said, ‘Oh lord, can we make it?'”

That day the flight was the easy part, the drive into NYC, through the Lincoln Tunnel and into the traffic of Manhattan, with lights and sirens going, was an exercise in stress.

“My partner and I provided six hours of care to that baby, and six hours is a long time when your patient is on the verge of death,” O’Day said.

When they finally reached the hospital, O’Day and her partner were met by a team of surgeons, and the entire party was whisked away to the OR. Four weeks later, O’Day and partner went back to retrieve a healthy baby and deliver it to the grateful parents.

“One of the problems with the respiratory profession is that RTs don’t always feel like they make a difference, or worse, that the difference they do make isn’t fully recognized,” said a reflective O’Day. “But when you do this type of respiratory transport, you get to see the impact of your expertise almost immediately. You see that someone who was about to die now has a chance at life. What could be more rewarding?”

Valerie Neff Newitt is managing editor of ADVANCE. Contact her at vnewitt@advanceweb.com.

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