Hello, I'm Dr. Heather Lee Bailey, an emergency medicine intensivist and a past president of the society. Welcome to this next session, which is on the thought leaders for pre-hospital critical care transport. It is my pleasure to moderate this session. These thought leader sessions are new to Congress this year and will allow for a more in-depth view of specific topics in both presentation and discussion. It is my pleasure to introduce the speaker for this pre-hospital critical care transport is Mr. James Hauser. He is the president and CEO of UPMC's Center for Emergency Medicine of Western Pennsylvania. UPMC brings over 20 years of experience and a diverse background in the field of critical care transport. CEM is a world leader in emergency medicine in care, education, and research. It accomplishes its mission with over 400 employees who include pilots, mechanics, aviation and communication specialists, educators, and administrators. The educational team trains over 60 paramedics and 300 EMTs every year. The organization supports UPMC and the University of Pittsburgh researchers who continue to lead in the EM research community. CEM is a certified by the Federal Aviation Administration direct air carrier. Its infrastructure is similar to that of a small airplane. STAT-MEDEVAC, which is the critical care transport arm of CEM, operates 18 helicopters and four ground units across five states, providing over 13,500 critical care transports every year. Jim, the virtual floor is yours. Thank you, Dr. Bailey, for that kind introduction. It is my honor to be here presenting in front of the Congress, and I appreciate Dr. Bailey taking the time to moderate this session. I look forward to spending the next 30 or so minutes discussing pre-hospital care with a focus on the critical care aspects of what we do out of the hospital. Again, thank you for taking the time to join us. I really do regret not being in person in Puerto Rico. Interestingly enough, my canceled trip to Puerto Rico transformed into a last-minute business trip to Donaworth, Germany. So please forgive my hotel background, and I'm keeping my fingers crossed that my bandwidth will be stable throughout this presentation. So with that, I'll go over my disclosures. You'll see them listed on the slide here. I don't have anything other than what's listed to disclose. The objectives we'll cover during this session are pretty generalized. To get us started, I'm going to review some history, give some general background on pre-hospital care and EMS. We'll then focus and move into operational and clinical structure, and finally, we'll discuss some basics around what it takes to keep forward motion outside of the hospital. So to start, we'll look at the Napoleonic era. We have learned through various stories that the first recognized ambulance was put into place by Napoleon surgeon Dominique Jean-Laurie. He was charged with developing a method for army surgery, field hospitals, and ultimately an ambulance system. Interestingly and ironically, for me to present today, he coined the ambulance, the flying ambulances. It was said that he coined that term in homage to the French flying artillery as they made their way over the battlefield. Later in the U.S., we found the need to move battlefield wounded during the Civil War, and from there, it is believed the first civilian ambulance corps was formed in 1869 in New York City out of Bellevue Hospital. Moving into the 1900s, World War I introduced motorized vehicles, and then through World War II, we continued the evolution of ground transportation and the use of motorized transportation. In parallel and more relevant to critical care transport, we saw the birth of air medical transportation in the early 1900s. Amazingly, only 20 years after the first flight in Kitty Hawk, North Carolina, we flew our first patient in 1923 out of Ardmore, Oklahoma. It was a plane essentially fitted with a cot just outside the fuselage to transport a high-risk pregnancy. Then in the 30s, we saw Ellen Church fight her way into aviation as a woman. At the time, she couldn't fly as a pilot, but she felt that it was important to have a presence in the aviation history, and so Church, who was also a registered nurse and a licensed pilot, appealed to the chauvinism of the airline executives and found a way for women to work in the skies. She led the way to what we now have as flight crew on the aircraft, and given her history as a nurse, we like to consider her and her team some of the earliest flight nurses. Then in 1943, we saw our first formal class of flight nurses walk across Bowman Field in Louisiana, Kentucky. This is where the military initiated the training of nursing staff to help with emergency evacuation. This day, February 18th, is now known as Certified Nurses Day. We celebrated every year in homage to those nurses who served during the World War. In the 50s, we saw the very, very early use of helicopters in the Korean War, certainly made famous later, much later, with the television show MASH. In the 1960s, the 7th Cavalry led to the Huey helicopter and medevac operations being commonly used in Vietnam. So while we saw the prevalence of military helicopter use during the Vietnam War, we also saw the introduction of civilian helicopter use. We believe the first civilian patient transported was a child, transported around January 10th in 1967. This was a premature infant. The transport took place from Zion, Illinois, near the Wisconsin border to what is now known as Children's Hospital of Illinois at OSF St. Francis Medical Center in Peoria. It was more than a 400-mile round trip. The baby was in the hospital within eight hours of being born, which got that child to the appropriate care at the time, and it was all made possible by the nursing staff in transporting this child in a media helicopter. So as these various transportation efforts continued, we as a system didn't have a good plan in place. The federal government continued to view EMS as a transportation agency. As you noticed in my early slides, most of the history I highlighted really revolved around the transportation and not the medicine. It was at this point we realized we needed to do better to have a coherent policy and move EMS into what we slowly started to see occur in the late 60s and early 70s. Right about the time we were having that reform occur, many of us, at least most of us that have been in the EMS industry for some period of time, either grew up with this television show, saw reruns of this television show, or have at least heard references to this television show in our EMS journey. So in January of 1972, NBC launched Squad 51, and they also inspired a whole lot of six and seven-year-olds into professional careers in emergency medical services. We recognize this pop culture to the point that they actually have honored this show in the Smithsonian Museum. There are many folks that believe the combination of the policy reform, the military activity in this show converged to create the momentum for us to move forward as a more unified system. So just a year after that television show premiered, we had a lot of activity occurring in the EMS sector in Pittsburgh, Pennsylvania. In 1973, Freedom House was taking care of patients. Pittsburgh, like many other cities, were segregated by race, but people of all colors suffered from lack of ambulance care. At that time, most often, people were served by police responding to medical emergency calls. Ambulances existed, but they were not prevalent everywhere. There was a need, and people saw a way to help, and in fact, one of the society's founders, Dr. Peter Safra, was critical in the service to these communities. He engaged a woman pioneer, Dr. Nancy Caroline, who assisted not only in training the Freedom House paramedics, but she took that training for the Freedom House paramedics and created what became the groundwork for standard EMS training. In fact, her book, Emergency Care in the Streets, is now in the eighth edition, and her teaching continues to live on. Right around this time, Dr. Ron Stewart moved from Los Angeles as he was recruited to Pittsburgh to found the Center for Emergency Medicine of Western Pennsylvania, Inc., where I'm proud to serve as part of that leadership team, and we continue building upon the history that was born in Pittsburgh, Pennsylvania that relates to how we serve patients today in pre-hospital care. So moving away from history, let's talk about system development. So modern pre-hospital services come in all shapes and sizes. The organizational structure is largely dependent on community history and finances. There are still communities served today by the funeral home-based ambulances that initially responded to calls where patients couldn't be transported in the police cruiser. In these communities today, there are private, for-profit, not-for-profit organizations that contract with communities and health systems. There are fire-based EMS programs where the ambulances are staffed by firefighter EMTs and paramedics. There are also municipal structured services that are separate from police and fire departments and are considered a third community service or a third service. In the 80s and early 90s, many hospitals operated ambulance services or supported response units that covered BLS volunteers with paramedic supplementation, providing advanced life support to those communities. We saw many of these programs decline, excuse me, in larger ambulance, when larger ambulance programs came into play. Interestingly, we're seeing a return of these paramedic support programs because EMS is in a staffing crisis. They are suffering the same shortages that we're seeing all over the healthcare segment. In fact, EMS was suffering a shortage of paramedics well before COVID-19 and well before we started talking about any type of staffing crisis in healthcare. So to simplify all these types of systems, because they're very broad and wide-ranging, I've classified into two areas, scene responder and retrievalist. Scene responder, think of someone who's responding to a home, the site of an accident seen on a highway, and then retrievalist, which I think would resonate with the critical care folks in this audience when you think of individuals that are responding to hospitals to transport patients from one facility to another. But the reality is, within each of these areas, scene and retrievalist, there are many different flavors. In our public sector, we are now seeing community paramedics that are responding to patients' homes outside of the acute setting, outside of the emergency need. Within each of them, you have different levels, which I'll talk about. And then, of course, you have critical care transport for retrieval that goes all the way back to its roots with the Ardmore plane and the Flying Nun. Many specialty transports were built upon the need for transporting high-risk obstetrics in pediatric patients. This resulted in supplementing provider types, many of which we saw on the ground, to create specialty teams in advanced training. So of course, you can't have a system without regulations. I could spend a lot of time talking about regulations. Pre-hospital care is very similar to our inpatient oversight. The EMS operations fall under the Department of Transportation at a federal level, probably going back to our history and views of EMS being primarily a transportation service. And then, of course, there's variability depending on state, region, where the EMS office is located within the state's governance. Some states have specific offices, such as Ohio, where they have the Department of Public Safety. Even in Ohio, though, with having a Department of Public Safety, EMS is a division within a department. I highlight that because oftentimes your EMS partners get lost in much of the discussion when it comes to health care at a state level. Similar to hospitals, agency organizational licensure is separate from providers. Each organization has to meet licensure requirements based on intended scope and mission. In addition to general regulatory requirements, there are a myriad of other certifications and licensures required to operate. Examples include CLIA and DEA. Finally, there are accrediting opportunities. The Commission on Accreditation of Medical Transportation Systems is one example. CAST, we also see on our ground ambulances. These are accreditation options to give the organization an opportunity to prove how they exceed regulations by meeting additional accrediting standards. So just to touch upon providers very quickly, it's important for you all to know that not all EMTs are the same. So when you think of an EMT or an emergency medical technician, an EMT is a basic life support provider. In some states, there is an intermediate life support level, which is now called EMT advanced in the states that are functioning. This provides an EMT with additional skills and interventions. They can start IVs, administer certain critical medications. When you think of advanced life support or ALS, this is where the paramedic comes into play. And then finally, when we talk about critical care, most often you'll see a combination EMT paramedic and nurse providing that response. Often the teams can be subbed out depending on the type of work that they do. Some specialty teams function with a nurse, perhaps a respiratory therapist, or perhaps an advanced practice provider, or in some institutions, they may function with a physician as part of the team. So the scope of care, what can they do? The scope of care, of course, is relevant to those providers that I just mentioned. It's also relevant to the environment and the equipment. Unfortunately, it's difficult to broadly categorize the scope. There is variance by state and region regulation and specific requirements put forth by the individual agency. Over the past 20 years, we've seen a rapid growth and expansion of capabilities. However, in recent past, staffing and reimbursement models have made some of our advancement slow and rare cases even reverse. As an example, in the state of Ohio, they are currently looking at ways to create a level of service that separates BLS to allow access for non-ambulatory transports that do not require specific intervention. So essentially creating stretcher vans that don't have any type of healthcare provisions within the ambulance. So I hit upon this again, as we start to dive into some of these practice capabilities, I just encourage you all to learn and understand the resources that you have available within your particular region. Get to know your transport entities. If you're typically involved in the transport of a patient, whether you're a referring provider or a receiving provider or part of that team, you should really have an understanding of what their capabilities are. So let's talk a little bit further about capabilities of modern pre-hospital care programs. So these services are structured to meet the mission it is in place to achieve. They could be responding to a residence, as I mentioned, when you're talking about those scene responders where they're landing on a highway of an accident scene or transporting complex patients from one hospital to another. So when we talk about capabilities, medical direction and physician engagement are critical to the success of high functioning transport teams. As an example, our system at Statt Medevac is led by a four physician medical direction team. They are board certified in emergency medicine and EMS. They are supplemented by a multidisciplinary medical advisory committee where we have pretty much every subspecialty that we engage with within our academic health system. Protocols. So the easiest way I can describe a transport team's protocols for those that are not familiar with the out of hospital medical oversight is they're very similar to a comprehensive set of standing orders. They are typically structured in a decision matrix style. Some are broad guidelines depending on the organization in the region and others are very detailed. These protocols are designed to walk the provider through the expected care standards put forward by the institution and the medical leadership. I mentioned guidelines. So you may see organizations that have wide ranging opportunity and then you may have some that have very structured approaches. Our organization tends to follow the ladder and our medical direction team doesn't look at that as micromanaging the care rather they look at providing additional resources when they're going through their critical care thinking on how they're managing the patient. And as our medical director, Dr. Frank Guyette says, really the art is understanding which pathway to go and what protocol to use at what time. And to that supporting our protocols, consultation is the way that our protocols are supplemented. Consultation thresholds vary by protocol. Again, they vary by organization. Some organizations have very, very liberal consultation process. Others like ours consult up to 60% of the transports. Our organization has two levels of thresholds. The first level being anything beyond those standing orders. And then the second would be when they need a direct operational consideration. And that's when we engage one of our four medical directors who have a higher level of understanding of the equipment and operational aspects of our capabilities. So of course those lay the foundation and then there's procedures. These two are dependent on the region and the permitted scope of practice at a given state. This will tie to the provider and the functional level of the transport team. This is often where a multidiscipline team may come into play. So think of that nurse paramedic combination. In some states, the paramedic may be engaged to do out of hospital scope of practice things such as intubate or other areas of pre-hospital care where they're trained to do specific interventions that a nurse may not receive in a nursing program. Again though, this is region by region. So in our organization, we train both our paramedics and nurses to the same level, to the same scope. Our nurses intubate, our paramedics intubate. Our paramedics manage the balloon pump no differently than our nurses manage the balloon pump. So you will see different interoperability based on scope and region. Minimum equipment is dictated by regulation. However, equipment may be added as the organization's mission changes or there's a higher need based on acuity or the type of patients you're transporting. And of course, financial ability comes into play. So when you're looking at retrievalist, high functioning critical care programs, you'll typically see equipment that allows them to continue the management that you have started in the ICU or the critical care setting. So that'll require things such as ventilators that can provide complex mechanical ventilation strategies, IV pumps to provide continuous infusions to maintain the medications that have been administered, et cetera. And of course, training thresholds are set by this complexity. So the more you're doing, the more you have to train. So to that, what do the transport teams do? Well, it's a complex question to answer and it's truly dependent on a myriad of factors. Most highly functioning critical care transport teams function at the mobile ICU level. So if you can imagine what kind of care you're providing in that ICU setting, these teams are capable of continuing that. In addition to continuing, they often can initiate medications, interventions, or other things that may require the patient to be managed to the point that they can be transported out of the hospital. Many of the retrievalist programs or high functioning critical care transport teams are able to provide complex ventilator management as I mentioned. We transport inhaled vasodilators, we transport prone patients, we commonly transport all types of ventricular support devices. So when you think of a critical care transport team, they truly should and can continue the care that's occurring in that ICU setting. The rate limiting factor, what I think is important to share with this group for most of our capabilities are truly related to the environment and the resource limits. So first of all, imagine your patient whose blood pressure drops with the slightest movement. The same patient has to be moved multiple times from bed to stretcher to vehicle, whether it be a plane, an ambulance, or helicopter back out into the next hospital, and then you get the point. The movement alone can be challenging. Coordination and logistics of all of the equipment can be challenging. Next, imagine the patient you have seen connected to every piece of equipment fully occupying your ICU room. Now, take that equipment and recognize it needs to transition with the patient, again, in the dark, cold, rainy night, and then be placed into a space of about 28 cubic feet. These devices all require power. Ventilators require oxygen. So every one of these considerations has to be put into play when you think about the logistics that we do. Oxygen demands dictate the evolution. In fact, now, just as an aside, the current topic is high-flow nasal cannula. How do we manage high-flow nasal cannula patients out of the hospital? We know that that's a common therapy that we're seeing right now. And quite frankly, it's a challenge for the pre-hospital critical care transport teams, because when you're thinking about patients that have 40-liter-per-minute oxygen demands, it becomes quite complex as to how you facilitate that transport when you're resource-limited with only having so much oxygen to carry in an E-cylinder, let alone in the aircraft. We literally have to facilitate, if you would imagine, oxygen bottles like breadcrumbs in some of these larger institutions so that we can get the patient from the ICU to the helipad in some of these situations. So it really does become the most challenging part of what we do when you think of the environment. So what does it all mean to you when we talk about capabilities, how we do these things outside of the hospital? It means you have to be familiar with your options. I touched upon this graphic last year in a shorter talk. This is a resource assembled by the Pennsylvania Critical Care Task Force. The X-axis is the importance of time, and the Y-axis is the level of care. I share this with you because it just gives you a taste of how we consider the utilization of these resources, specifically when we look at critical care transport. And I know the hot topic often is to use an aircraft or to use a ground ambulance. So to just call out a couple of quick examples, the easy ones, right? Lower left, non-urgent, stable, patient requiring, limited to no intervention. We think of a BLS patient, could be a psychiatric patient going from an ER to a mental health facility or a skilled nursing discharge. Doesn't require a helicopter and certainly is not time-sensitive. To the top right, you have emergency critical care. This is a peri-arrest patient requiring transfers for some type of immediate intervention. Again, those are easy. I think every one of you probably make those type of decisions every day. Where it gets tricky is the nuance in the center of this page. When you think about item number five, stable with increasing urgency. The physician group that we worked with to put this together mentioned an ocular injury where you have a ruptured globe. Depending on your geography and your topography, that may go by ambulance. Depending on your geography, your topography and traffic, it may make the most sense to send that by helicopter. The patient may not need the skills and the expertise of a critical care transport team, but they may need the time. And so that's where we've put together the consideration axis of looking at both time and the level of care you need when you approach your utilization decision. So looking at how it all costs, I could spend a whole lecture talking about how EMS systems typically generate revenue. The bottom line is it is a bundled charge based on volume. So you transport a patient, that creates a charge. It's normally reimbursed on a set schedule of fees that is based on emergency, non-emergency, level of service provided, BLS, ALS, specialty critical care transport. And then of course, distance comes into play. So in the helicopter transport billing world, you have your base charge and then you have your loaded mile charge. And then that total together comes up with the final cost. And of course, this is a very complex thing. It's a very narrow margin because we have high operating costs, particularly when you're looking at the use of aircraft as resources. So what's the return on investment? First of all, from the stance of the patient, it's taking care of the patient, getting them immediate access to critical care services, certainly affiliation with healthcare system. There's an ROI there. These transport systems create value for health systems, particularly for retrievalists, but also for seeing providers bringing in high value DRGs to those affiliated health systems. More importantly, I think we need to continue to remember the human toll costs. Physical impact, I mentioned that 28 cubic feet of space trying to get a patient into that space. It's not typically conducive to the best ergonomics. So we see a high rate of injuries. We continue to look at ways that we can minimize this. Our organization just invested a significant amount of resources in ergonomic training to try to help them take care of their patients. So there's the physical aspect, and then of course there's the mental impact, which is equally, if not more important for us to recognize. This has been a discussion before COVID. I think COVID has helped us to highlight the importance of taking care of each other. We do need to do better in this area. All of our people work in a high stress environment. Anyone that's involved with critical care knows that the type of patients we care for leave a mark on them. Peer support is critical to our success. And we are fortunate that we're seeing a continued growth in resources when it comes to this type of support. So keeping it going, of course you have to keep it going. We say often in our organization, keep forward motion. This can be done in a number of ways. High functioning organizations often have high quality, excuse me, have high quality care. Often have high quality, excuse me, have high expectations and they have quality management systems to drive those so that they can monitor their performance, set thresholds and assure that these goals are being met. Of course, research and academic affiliations are critical to success. I may be a little bit biased given our affiliation with the University of Pittsburgh, but we find that the research that we both participate in and learn from continues to make us better at what we do and ultimately take care of those patients that we're taking care of. Of course, you have to train. It requires an army, literally, particularly when you're talking about a large organization, let alone even the smallest of organizations. If you think about the amount of skills that we do, our teams really do approach this from the focus of generalists. That's how most critical care transport teams are. So when you think about those low frequency, high acuity events. So things that we don't see often, but require quite a bit of knowledge and skill. That means we have to build different repetition and training regimens into our transport organizations. So what does it mean to you? If the transport team is well-structured and highly functioning, they should be creating indispensable, excuse me, for their inpatient partners. They should be more than a transport entity, ideally. They should be a solution for you and your patient's problems. And we really like to consider our team at Statt Medevac highly skilled utility players. So while I have you, let's talk about what to expect when you interact with a critical care transport team. These teams are fixers. Ideally, they help you make the patients better for transport. Most of these teams are benchmarks, excuse me, benchmarked to have minimal bedside times. This is changing though. Like you, our goal is for the patient to have a positive outcome. We want the patient to survive the transport. Thus, the transport team may stay at the bedside of a referring agency to resuscitate and prepare the patient for transport. This is a critical thing to collaborate with these teams. We encourage our providers to ensure that they're collaborating with their referring physicians, their referring nurses, and the care teams that are at the locations where our teams respond. Oftentimes, we get to the bedside. It's a seamless interaction. It's a seamless handoff. But there are those times when we walk into the room and perhaps the unit has been busy or perhaps there's been a sudden change in the patient condition that requires additional resuscitation. In this case, we may begin interventions that we wanna collaborate with. And I share this with you because from time to time, there is a sense that we should just come in and quickly get out. That's what we were called to do. But at the same time, we have an expectation that we have the patient stabilized to a point where the patient can tolerate the transport. And this is where sometimes we see the necessity for resuscitation. The teams typically approach in a divide and conquer fashion. One member of the team is getting report and the patient handoff information while the other is assessing and preparing equipment. Much of our time at the bedside is tied up in transitioning that equipment. So when you think about ways that you could help us, talk about what you could have ready for your local transport providers. See what types of pumps they use. See what type of equipment they could have freed up and ready so that when they get there, it's an easy handoff. What medications need to be ready for their pumps is an easy example. Are there any current labs, particularly gases or other data that could help them in preparing the patient for transport that could be ordered ahead of time or ready for them? And then of course, the handoff is critical on both ends. We should have details that are clear and concise, standard closed loop communication and those types of things all help with that transition. So I have to throw in a COVID-19 slide. We couldn't go a lecture here today without talking a little bit about COVID-19. So here's a little bit about what we've been doing at STAT Medevac. We of course have our PPE procedures. We've gone up and we've gone down. With the current rise of Omicron, we are back up to N95 level respiratory protection on all missions. We've seen a sudden spike in what we call surprise cases. We go to a gunshot wound or a traumatic injury and then we find out the patient has COVID. So given the high likelihood in our environment for completing some type of aerosol generating procedure and the small confined space, we've moved back to this level of protection. We have masking and physical distance policies in place like everybody. We continue to urge vaccines, vaccines, vaccines. Doing a lot of work with assuring that people have comfort in seeking the vaccine. And we've been addressing concerns with trusted providers. Our medical direction team works closely with all of our personnel to assure that they have the latest information on these vaccines. And then from a patient care perspective, we continue to work through optimizing non-invasive ventilation. High flow nasal cannula, as I mentioned, have been a very significant challenge for the pre-hospital critical care transport teams. Just managing the oxygen is one aspect. But when you think about the current systems, they're not really made today for that transport environment that I mentioned earlier. We have gone through our second iteration of just figuring out how we can transport the heating element and the humidification system. Proning, we were fortunate as an organization that we were proning patients well before COVID-19 hit. In fact, we shared a lot of our literature widely and freely when the pandemic was unfolding so that we could just share our procedures for transporting prone patients in the helicopter. And of course, we continue to update our protocols. We now have deployed inhaled vasodilators. We have the NOX walks and the aerogen systems in place to support those things so that we can either facilitate initiation or facilitate continuation based on what's going on with the management of the patient. So before we talk future, let's talk cutting edge technology and high complex transports. When we were going through this, Dr. Bailey suggested I highlight ECMO. It is certainly one of our more complex transports and it certainly ties into what we're doing with COVID-19. Our organization's ECMO transport team goes back more than 20 years. So we were fortunate to be experienced with this type of work well before the pandemic. Our early teams consisted of specialized providers that had additional training and we supplemented those specialized providers with perfusions. We've now moved to the point where any one of our 18 bases at any given day could transport an ECMO patient. We do that so that we have better distribution for our communities and then we support and supplement still today with a dedicated perfusion team. This creates a three-person team to manage the transport and the care of the patient. We have also developed an ECMO response team where we activate a surgeon, perfusionist and other team to cannulate and initiate ECMO at a referring facility. So we both transport initiated and we will facilitate field cannulation. To give you an idea of what our COVID transport numbers look like, we were right around 26 in 2019. In 2020, we jumped up to 53. So in 2020, we transported 53 patients on ECMO. And then 2021, we saw a slight dip and there were some restrictions put into place as you all know that probably related to this as well but we still saying all that transported 53 patients on ECMO. So the future, not too far away really. We're always engaging in new types of activities, looking at technology, ways that we can do things differently. One of those highlighted here is telemedicine support. The technology has actually been around for a while. We're now finding new ways to do it. We're looking at using this as a way for EMS to access physicians as a result of COVID. Reimbursement is still a question mark. We're also looking at how we can use telemedicine in the critical care area as well. Combining these tools with our providers perhaps will bring a new tactic to community ICU care where we can help perhaps help stabilize and resuscitate a patient in the community rather than emergently responding and transporting the patient. As I mentioned, the challenge here is coming up with a reimbursement model that will support these types of non-transport activities. When we look at automated decision support, I have a few things highlighted here. We at the University of Pittsburgh are partnering with CMU to come up with a concept called TRACER or Trauma Care in a Rucksack. This is an autonomous robotic-enabled cardiopulmonary resuscitation platform. This essentially is a device that will wrap around the patient and determine what type of vitals the patient has and then come up with a algorithm for next interventions. System status management was a big topic in the early 90s and 2000s for those that were involved in EMS back then. This is where we were trying to figure out where to put right resources at the right times. We have since learned that we weren't so good at that from a human perspective, but AI is helping and it's now being used to predict resource needs. We're also seeing AI in tools we already use today. Many of you are probably familiar with the Hamilton ventilators. We've invested in the Hamilton T1 transport version of the Hamilton ventilator so that we can support complex ventilation modes. As you all know, adaptive support ventilation is taking the Otis equation and using AI to help us manage these patients. The tricky thing with this type of AI is the providers need to know when and when not to use this type of intelligence. And then when we think about the future, Hamilton's already patented the IntelliVent ASV. And this is essentially where a clinician is gonna set a target for end title CO2 and SpO2. And then the ventilator is gonna take control and manage the patient from that point based on physiological input. So again, we're gonna see AI sooner than later in the transport realm of ventilation management. Butterfly, many of you are familiar with the Butterfly ultrasound. This is going to help us potentially with the deployment gap, trying to teach ultrasound as you all know, is a complex training and a very perishable skill. And to try to do that in a decentralized model where you have 170 providers, all at various levels of experience and various frequency of use can be complex. With the AI and Butterfly, we anticipate that that may help us bridge a few of those gaps. And as I mentioned, again, like the Hamilton, while these are all great tools and they're certainly fancy, we know that they come with great responsibility and we have to assure that we're using them at the right time. So when we look at the critical care transport and going back to the transport part of critical care transport, similar to the trauma in the rucksack, we know DARPA is developing autonomous drones to respond to the battlefield wounded. The idea is these drones will respond to the injured based on telemetry data and then have robots facilitate interactions to start the early management, particularly in unstable areas of war. We also know that we have drones today that deliver medical equipment. We've seen, I'm sure everyone is by now read up on the trial of drones using, excuse me, drones being used to deliver AEDs. We also know that there are much like Amazon delivering your packages, there are folks that are looking at using drones to deliver medications and other medical resources from campus to campus and help support rural communities. And then finally, we're going to see unmanned platforms in these various areas of operation. We were already seeing helicopters in the military segment, and very much on the heels of the military, the civilian world is going to see autonomous operations as well. We now have technology in our aircraft today using four-axis autopilot, where the helicopter can essentially hover to 10 feet. These things are really not that far away when we think about the future, and good critical care transport organizations are constantly looking at how they can deploy these in a safe and effective way in their organizations. So as I wrap up here, my takeaways, EMS, 1972, emergency, we remain a relatively young area of healthcare. We have history that goes back to the Napoleonic times, but when you think about the modernization of EMS, it is still relatively young. We continue to evolve. We come in many different shapes and sizes. I probably said relative to region or regionalization or some other comment like that more times than I should have in this presentation, but I did it with purpose because you really need to know what capabilities are available to you and not take for granted that there may be more capabilities than you're aware of as well. So certainly engage and understand with those teams, and then it does require continued effort to be good at what we do in the critical care transport industry. So thank you for your time. I really appreciate SCCM allowing me to provide this presentation, albeit virtually. Nonetheless, I am appreciative of the time and I'm appreciative of Dr. Bailey's time in supporting me in preparing this presentation and moderating the session. Thank you. ♪♪ Thank you, Jim. That was a really interesting and informative presentation on pre-hospital critical care transport. You are now listening to the discussion and question-answer session of the thought leaders on pre-hospital critical care. We have many questions that have been sent in, so I hope you are ready for that, Jim. First, you mentioned that EMS, as well as the rest of healthcare, are struggling with shortages of providers and equipment. What is the pre-hospital care doing about trying to get additional providers? I think we are, in many ways, mirroring our inpatient colleagues. So, we're looking at ways that we can recruit in areas that we've not done a great job of recruiting. We are looking at ways that we can provide the education. We're seeing a lot of different agencies and organizations talking about academy style programs where we're bringing individuals in with zero training certification or experience and essentially paying those individuals to go through these programs with the hope that we can have some type of retention or tying retention to the free education. So I think looking for different ways that we can put these individuals through the pipeline is probably the first step. And then from there, of course, looking at compensation, different staffing models, different schedules, we're seeing and deploying all of the same tactics that you're seeing in the inpatient world. There were several questions comparing pre-hospital care in Europe to pre-hospital care in the United States, how Europe focuses in many areas on having physicians on the transport and the questions about what lessons may we be able to take from our European colleagues and employ that might be helpful in the United States? So interestingly, I'm sitting here having this discussion in Germany. There are certainly differences. From a physician engagement perspective, I think the biggest difference that we see in the United States from the European models that this question may be referencing is direct versus indirect engagement. So as an example, my organization is very fortunate that we have dedicated physicians in our communication center. We look to that team to provide medical command directly. So they're not functioning in any other capacity. They're not taking phone calls in between clinical care. They're in the direct setting. And then I have the fortune of having, in addition to that team, four medical directors who are highly engaged. We refer to them as our medical directors on call. It's our dedicated team. They have both the clinical knowledge and support and the operational understanding. They fly clinically. So they become an extension of our flight crew indirectly. So I think for the sake of time, I would summarize it from our perspective in our organization as very much indirect versus direct. Okay. I think this next one is a very pertinent question that says, you know, we have advances in skills, training, and technology. So there's a lot of things that can be done in the field, but what should be done in the field? And I think that's a very pertinent question in this day and age. It's a great question. And in fact, I could have spent more time talking earlier when I mentioned training and even the deployment of new technology. Our teams love foam. We're constantly following all of the latest trends, but there is that understanding of, okay, is it effective? Is it the right thing now? I'll use ultrasound as a perfect example. We have been following ultrasound for some time. We saw several of our colleagues do it early and not saying that they didn't make the right call by doing it early. But at the time we were really looking at, and I think this gets to the essence of the question, what are we going to use with that device that's going to dictate an intervention? Not give us a knowledge piece. As an example, if we know there's blood in the abdomen, what are we going to do? We're gonna put the patient in the aircraft and we're gonna fly to a trauma center for that patient to be managed. Now, if we see that the patient's not being resuscitated appropriately, whether it be with fluids or pressors or some type of therapeutics by looking at a different view of the heart or the inferior vena cava, then that is something that we can actually intervene. And then the second thing that I would comment to that question is, then you have, as I mentioned, the span of training. So one, is it going to produce a tangible intervention? And then I'd say the second thing is, can you maintain and train proficiently with the team that's going to be using it so that they can make the right assessment? Well, and that's a perfect lead into the next question, which was, how do you maintain competency and credentialing and qualifications across the wide range of critical care transport? It's hard. We have a great team. There are, like so many other things, there are the minimums and then going beyond the minimums. So for us, excuse me, we start with, what are those required elements for a regulatory and accreditation perspective? And then coming up with an education plan that we can actually deploy in a decentralized model, which I used that term a couple of times in the presentation and I should really expand upon it. We don't have the fortune of being in one location. Some organizations do, and to that, they can have their transport team come downstairs and meet in a conference room and go over a particular piece of equipment. My organization has 18 sites of operation spanning across five states. To try to do that, it's not practical. So then we have to look at deploying different things. So we have peer supervised competencies. We have a manager level review. Then we bring them in for interval training, where we have them come in at a quarterly basis for certain education. So I'm taking a long way to say it's a layered approach. And then we have certain things that quite frankly, we will not sacrifice. Our organization has stood by the importance of live intubations. Many organizations, because of challenges with OR access and academic depth and being able to get into those environments have foregone that and moved strictly to high fidelity simulation. We still value it. So we still require our flight crews and for the anesthesia folks out there, they're gonna think it's a low number, but in our world, it's very high. We require our flight crews to have 12 live intubations per calendar year. And they cannot be substituted with high fidelity. So I think it's layering, assuring that certain things are repetitively trained and then making sure that you don't sacrifice your education standards because of a challenge or a barrier. There was a question about medical command. You mentioned it briefly in your presentation, but who is, do you need certification to give medical command? And is it different for pre-hospital coming to the emergency department versus the inter-facility transport team? Who gives medical command for that team? Yeah, so I'll start with the regulatory thing first. Like I said, probably too many times in my presentation, it depends on the region. In Pennsylvania, there is a medical command certification process that physicians have to go through to give medical command. In other states, it's not required. I think to your question about incoming EMS command versus critical care, my answer probably would say you need that, that goes back to that engaged physician. Ideally, they should know not only the scope, the capabilities and the protocols, but they should have operational understanding of the equipment and the environment that they're working in. So you really do have to have a level of understanding, I think that is deeper than what you might have if you're giving command to an ambulance, bringing a patient into an emergency department when you're talking about the critical care medical command. The next question comes from one of our military members and specifically wanted to comment on ground versus air transport and what criteria, if you are the calling hospital asking for help and for transport, what are the set criteria you should know? Because as we know, sometimes, and you even commented on it, that ground is sometimes faster and better than air, even though it's really cool to fly the helicopter. Yes, yes, or vice versa. And I think when I mentioned that, that was a large topic of discussion when we were going through the ground resource challenges in Pennsylvania. And it was really coming up with what were the right things to think about when considering the utilization of ground versus air. So, as I said, everybody knows the easy ones, right? You're not going to use a helicopter to send somebody to the nursing home and you're not gonna use a BLS ambulance when somebody is in post-cardiac arrest and needs to get to the cath lab. Those are easy. It's the nuance in that globe injury that I mentioned. If the eye center is two blocks down the road and you have an ambulance and a crew in the emergency department, you would send that patient via ambulance, right? You have that resource right there and it's ready. If you're a rural community, and this ties into staffing, you have no ambulance and you have that same globe injury and it's gonna take you three hours to get that patient to the appropriate care to save their vision. You may use a helicopter. The patient doesn't require the critical care of the team necessarily, but they require the speed of the transportation. And that's where I think it really comes down to in the emphasis and why I was so glad that I could give this lecture is understanding your resources, right? Really as a provider, knowing what your resources can do and what your limitations are, and then understanding that there is a lot of nuance. We talk about staffing and the challenges in our EMS communities right now. We are seeing really hard things when it comes to these rural hospitals. You think about a critical access emergency department only having six beds, and you have one of those beds occupied by a patient that you can't get an ambulance for. In prior days, you may not have used an air ambulance to get that patient moved, but now because of the resource limitations of the ground ambulance, that may be what you default to just so you can get the next person out of the 50 in your lobby into the emergency department. So there is not a quick, easy answer. I think, again, it comes down to just knowing your resources and the appropriate ways that you can use it, and then feeling comfortable that you've made the right decision. And as you know, our new president, Sandra Cain Gill, is a pharmacist. So there's a question about what is the pharmacist's role in pre-hospital critical care transport? I love this question. I saw this one come through, and I thought it was a great question. So obviously the simple things, you talk about formulary review. We actually have, we have a lot of committees. We're very forward with shared governance and committees, and we actually have a medication committee where they talk about latest medication therapies, the ways to use them in the environment, when we should stop something for conservation of pump channels, when you think about those operational and environmental considerations, adverse reactions, line compatibility. I mean, I could go on and on and on to the point of saying, I think they very much have a place, and we found that we need to engage our pharmacy partners more, quite frankly. We have, I wanna say our formulary is somewhere around 190 medications. So we transport and carry a lot of medications, and we're constantly changing those. And then you think about drug shortages and other things. I'm rambling to the point of saying, I think it's an area where we could do a better job of engaging our partners, generally as an industry. And I know we have, as an organization, leaned heavily on our academic partners at UPMC. I think many individuals will be surprised to know that you carry 190 different medications. That really is impressive. And then I think in our last few minutes, I grew up doing pre-hospital care, and I think there are things that I know that you and your colleagues would like those of us on the critical care team, both on the receiving and on the transporting. And what should we know that will help you and your team make a successful transport for our patients so that it will help improve the care, both when they come to pick up the patient and transport, and when we're receiving on the other? And what is it that you and your pre-hospital colleagues would like us to know so that we can do a better job? Well, I think you do a great job. What I would say is understanding the complexities of what we do. I talked about moving that patient in your ICU setting with all of those things that you've intervened, the equipment that is connected to the patient, and these teams, whether it be an ambulance or it being in a 28 cubic foot helicopter, knowing that that's a challenging evolution without doing any of the medical care. Then you layer on top of that, the importance of understanding the complexity of that patient, all of the critical thinking that goes into that. And then you layer on top of that, the collaboration. So I would say understanding that it's complex, being a collaborative partner, knowing that our goal is to assure successful transport. And that may mean that we spend a little bit of time resuscitating. I mentioned that in my presentation because that has been a point of controversy, right? People sometimes call helicopters. I called you because the patient needs to be here. Our teams have heard that and we understand that. There is certainly an urgency with those patients and direct intervention is the only thing that's gonna help them. But at the same time, we wanna assure that the patient lives to get to that intervention. So there has been an increased focus on our teams to resuscitate and assure that they're going to survive. We're just not a fast ride. We wanna provide that comprehensive care. And we're grateful to have these discussions so that you can have that insight and we can continue to collaborate. I think that goes back to the adage of pre-hospital care, scoop and run versus stay and play. Yes. And with that, I'd like to thank the society and I would like to thank the program committee for creating these thought leader sessions because I think it allows us to give a bit more in-depth review on a specific topic. I'd like to thank Jim for his excellent presentation. I'm Heather Lee Bailey. I hope you enjoy the rest of Congress. Thank you.

pre-hospital critical care transport

capabilities in pre-hospital care

direct medical command

indirect medical command

Physician engagement

high functioning transport teams

differences between scene responders and retrievalist teams

competency and training in critical care transport

advances in technology in pre-hospital care

staffing and resource limitations in pre-hospital care