It was quickly becoming a huge problem, both literally and figuratively. Outside the temperatures continued to drop as fast as the snow, but inside, the staff working in the intensive care unit at San Juan Regional in Farmington, NM, was beginning to feel the heat.
Earlier that day, a 38-year-old man came into the emergency room complaining of acute left-sided weakness. An MRI revealed a bulging cerebral aneurysm pressing on his brain stem. The patient had a history of both CVAs and seizures. Adding to the dilemma, the patient was dangerously hypertensive, requiring anti-hypertensives to keep his pressure in check.
The patient was scheduled to be evaluated for neurosurgery in Albuquerque, 200 miles away. But at 6’6" and weighing over 450 lbs, simply transporting this critical patient was a logistical nightmare. The combination of weather and size of the patient eliminated both rotor wing and fixed wing as viable options.
The staff contacted Albuquerque Ambulance and had the agency dispatch its new ground critical care transport (CCT) team to Farmington.
Once there, the team performed a detailed assessment of the patient and started him on labetalol, an anti-hypertensive that no other ground ambulance service in the state is capable of initiating. The patient’s pressure was maintained under 100 mmHg systolic throughout the nearly four-hour transport (poor weather and visibility adding an extra hour of transport time) and delivered safely to the University of New Mexico Neurology Unit.
“That’s a perfect example of how effective this team can be and how I envisioned it being used,” says AAS Critical Care Operations Supervisor and CCT founder Jeremy Coombs.
Coombs initially thought of putting together a critical care ground transport team after several instances in which he, or one of his peers, were requested to transport a patient with medications being administered that were currently out of the scope of practice for New Mexico paramedics.
“Up until now we’d get called out to transport a critically ill patient with one, two or sometimes even three IV drips running that we wouldn’t be able to transport,” recalls Coombs. “The sending physician would have to make the decision to either discontinue the drip that was out of our scope or delay transporting the patient until the drip being administered was finished. I recognized that with the appropriate training and tools we could manage most of those patients and maintain their level of care.”
Being available statewide to transport critically ill or injured patients places a tremendous amount of responsibility in the hands of the new CCT team. It meant training them to a higher level of care, learning new tools and new procedures, and giving them the freedom to initiate and maintain a greater number of medications.
When Coombs pitched the idea of a critical care team to the senior leaders at AAS, they gave him the go-ahead to begin researching the project. However before budgets, logistics or staffing could be studied, Coombs ran into an unexpected roadblock: there were no state protocols for ground transport critical care. In fact, there wasn’t even a set definition of what critical care was.
“I quickly realized that we literally had to start from the ground up,” says Coombs.
Coombs decided to tackle multiple obstacles simultaneously. He formed a task force consisting of Steven Weiss, MD, a University of New Mexico physician board-certified in both emergency medicine and internal medicine, who agreed to be the transport team’s medical director, and AAS employees interested in creating a critical care program.
“That task force spent hours researching protocols, different equipment and crunching numbers,” says Coombs. The group put together a business plan that looked at costs vs. benefits numbers, the specific types of new medical equipment and medications they would want to carry, and how the new critical care transport ambulances would be set up and staffed.