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Lack Of Ground Cct?


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#1 gradyambulancedriver

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Posted 12 July 2008 - 06:35 AM

Let me throw out a question I have asked my rotor-head friends and have had varying responses: Why is there such a seeming lack of ground CCT while there is an overproliferation of superhigh-overhead-costly rotor services?

I am not starting an us vs. them; RW does serve an extremely useful purpose for time-sensitive medical patients and intellectually extricating scene trauma from the hands of the volunteer fireman first responder, even if the pt. is sub-acute.

But, let's face it, us ground CCT people are highly trained, have much more room to work in, have much more room to put exotic equipment, pharmacological agents, bair-huggers, yadda yadda and so forth in. I come from ATL, where there was only ONE true adult CCT truck, and I don't even think that was staffed 24/7. All the interfacility transports with ALS level monitoring or drugs (not even intubated) seemed to be done by one of the RW companies.

Are we just not sexy enough? Have we just not sold ourselves well enough? I think ground CCT fills a very huge niche that is wide open in a lot of markets, and all of the sad events surrounding HEMS lately only illuminate that vacancy. So, have we shorted ourselves, and how does one go about fixing it?
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#2 BackcountryMedic

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Posted 12 July 2008 - 08:29 AM

Are we just not sexy enough?


Maybe you should follow the lead of the olympic womens beach volleyball team.
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#3 nursemedic

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Posted 12 July 2008 - 05:56 PM

In my view, there are a significant issues that affect ground CCT:

1. There exists far more ground than air providers.
What you can do: promote advanced education for all providers and as ground CCT providers, focus attention on ground to build a coalition and interest in critical care especially among paramedics...show there's far more to paramedicine than 911 work. CCT nurses get involved with ASTNA and speak at schools of nursing. Share your experience.

2. Ground is less regulated than air. In some areas anybody can hang out a shingle and say they're a CCT provider...it's easier to do than air because there are more ground providers and companies and some state regulatory boards license operators generically rather than distinguish CCT from 911 operators.
What you can do: advocate for ground CCT standards and spell out what those ought to be. For example, I believe a CCT crew ought to incorporate an appropriately trained nurse and a CCT vehicle ought to meet certain criteria (please, folks, don't highjack this thread by going off on me about this, I'm just using my beliefs by way of example).

3. The Medicare fee schedule (and CMS' approach) is a post-transport view of what the provider DID and does not sufficiently recognize the full value of CCT. Medicare, it seems, lumps all ground transport together insofar as the provider's are all the same. The fee schedule is graduated based on a level of service PROVIDED and CMS reserves the right to downgrade the charge if CMS doesn't think it is justified (and justifying charges is quite difficult). Moreover, CMS looks at these graduated levels (BLS, BLS-Emergency, ALS1, ALS1-Emergency, ALS2, CCT) based on interventions PERFORMED once something has happened and doesn't take into account that ANTICIPATING patient needs (which requires discerning judgment) and taking simple PREVENTIVE measures can sometimes thwart untoward reactions (i.e. careful and thorough assessment, elevating someone's head to avoid increasing ICP, etc). Having a high index of suspicion and taking precautionary measures can reduce bad outcomes but CCT is not sufficiently rewarded by CMS for prevention or reduction of illness/injury.
What you can do: become an informed provider, educate and write your legislators. Get involved in trade associations (Ambulance Association, AAMS, others). Lobby.

4. Education. In some instances CCT providers are those who (I don't want this to be offensive) wouldn't or couldn't or want to work in HEMS.
What you can do: Recognize the difference between education and training. Advance your education constantly. Inform yourself and your practice. Once you are educated no one can tell you you're not smart enough or you're poorly educated. You'll make better, more informed decisions. You'll be taken seriously. Your world view will broaden.

5. Disparate hiring standards. CCT programs ought to have the same hiring standards for air and ground providers. We shouldn't be hiring people into ground who won't be successful in air. You hear all the time on FlightWeb how program's are lowering their standards and there are increasingly more ill-prepared providers in the industry. I posit we don't have standards at all. We have generally accepted ideas of what kind of experience might make a good provider but no real data on what it takes to be successful. I further submit there are cognitive, performance, and behavioral components that make a good transport professional but we don't know for sure and we certainly don't know what they are. There has to be a common foundational minimum set of characteristics upon which a successful transport provider can be educated, trained, enculturated, and nurtured.
What you can do: Advocate for research identifying the essential foundational criteria for a successful transport professional. Conduct your own research. Think about it. Wonder. Let your mind go.

6. Trade Associations obsessive focus on air. The CCT industry pays little more than lip service to ground providers. Oh, sure they want your dues but what have they done for you ground providers lately? AAMS doesn't change its name because it has earned a certain level of recognition. OK..so how does that make ground providers feel? How are they assured AAMS will act in their best interest? ASTNA has changed from NFNA but more can be done.
What you can do: Join the CCT-related associations and advocate loudly because more can be accomplished within than from outside. You must be tireless in this.

7. Air is sexier than ground.
What you can do: Understand it. Accept it. Move on. Knock any chips off that might be on your shoulder. Have pride in yourself and your peers. Expect to be treated with respect and call out those who don't. After all it's the machine (aircraft) that makes it sexy and sometimes the transports...but as ground professionals you know you're providing care for longer periods of time than helicopter folks. You have to know your stuff.

If ground CCT were sufficiently organized, properly represented, and interwoven into the fabric of medical transport at-large, I feel confident good change would come about. We hear often on here of the over-reliance of HEMS. Here's one solution to that: Advocate for integrated transport solutions (ground and air) that focus on meeting patient needs rather than the existing short sighted and procedurally-based reimbursement criteria. Sadly, though, as long as reimbursement for ground is so poor that's not likely to occur.

Whew....I could probably come up with more but this is enough for a start but my fingers have grown tired!
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Greg

#4 fire_911medic

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Posted 13 July 2008 - 06:15 PM

I can't speak for other areas, but I know in my area, and across the state in general there is a larger push to bring all services to the ALS level (yes there are still some BLS only paid services) and within those to have some be designated CCT. There's a huge push for CCT medics across the state and finally the designation is being recognized by the state. I do think that ground has a definite place in benefiting patients that may not be appropriate for HEMS (first thing that pops in my mind is bariatrics, but there are others). I've personally transported some patients with just about everything going and I've often wondered how in the world they would fit everything into a chopper, especially some of the little ones, god love you all where do you sit? I feel crowded in our nice big truck sometimes I couldn't imagine a confined chopper, but hey you work with what you've got. CCT I guess is more popular via ground here because there are frequent occassions when we can't get a chopper due to weather, so our trucks get a good bit of use. My truck alone averages between 10-20 per week. Also, alleviates some of the strain on HEMS despite their current overpopulation. We've made scene responses, have high risk OB/neonate transfer teams, and ran just about everything in between. Yes, we are abused too and given stuff that a regular medic could transport, but I think abuse is widespread across the EMS board (ALS gets BLS, BLS gets stuff that could drive themselves, etc). Unfortunately as long as we maintain the you call we haul attitude, this will continue - emergency or interfacility transports (or rescues in some cases as you all well know ! I thought I'd seen it all 'til I showed up at a hospital without a vent !).

I am with you though that standardized certifications/treatments need to be brought across the board. Right now, it's a free for all with some states having their own CCT courses, many using univeristy of maryland's course, and some others creating their own. Also, continuing training needs to be enforced as tightly for ground crews as air, but for some reason people think that because you are ground you see less acuity, and though that may be true in some areas, it is not here.

Be safe all.

Fire_911medic
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#5 MedicNurse

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Posted 14 July 2008 - 08:24 PM

I think in a perfect world - (hell, what am I typing....) I can't even type that and face myself in the mirror... :P

Sure, there is a definite NEED for CCT - and Greg (nursemedic) this medicnurse is in total agreement. Great post!

IF there was a true RN/CCT medic staffed transport I would work there INSTEAD of rotor. Sexy ain't got nothing to do with it - sexy just detracts from all that I am trying to do well. :o FOCUS!!!

Geographically, certain parts of the county are near desperate for a service that does true CCT. The key for any private service is profit and that is a big problem to solve. HEMS transport - $12K, same ground CCT $3K - when time is not the issue - it would be so much more impotant. We will see a correction in this industry and I'm betting that money will drive it. However, the need to still get "sick" folks to tertiary care will remain. So, when 1/2 of us are "gone" how/when will sick folks still get to definitive care? Maybe well done CCT will be one answer.

And the fire_911medic gets it right with acuity - just because weather/weight keep a patient out of the air doesn't mean they do not GO. They just go via ground - and taking care of a "sick" person for 2 hours and 100 miles via ground makes for some wicked high acuity. I think the well prepared ground CCT crew will really have to know their stuff - cause 2 hours will test it. A 20 minute flight might be difficult - so imagine the care the patient will require over hours. Something to think about. And I've taken the interfacility RESCUE out and had a LONG 45 minute flight trying to keep the patient alive and mitigate some of the "care" they received - I would think that doing it over hours would test even the best of us!

Fly SAFE!
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#6 Macgyver

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Posted 15 July 2008 - 03:12 AM

I think in a perfect world - (hell, what am I typing....) I can't even type that and face myself in the mirror... :P

Sure, there is a definite NEED for CCT - and Greg (nursemedic) this medicnurse is in total agreement. Great post!

IF there was a true RN/CCT medic staffed transport I would work there INSTEAD of rotor. Sexy ain't got nothing to do with it - sexy just detracts from all that I am trying to do well. :o FOCUS!!!

Geographically, certain parts of the county are near desperate for a service that does true CCT. The key for any private service is profit and that is a big problem to solve. HEMS transport - $12K, same ground CCT $3K - when time is not the issue - it would be so much more impotant. We will see a correction in this industry and I'm betting that money will drive it. However, the need to still get "sick" folks to tertiary care will remain. So, when 1/2 of us are "gone" how/when will sick folks still get to definitive care? Maybe well done CCT will be one answer.

And the fire_911medic gets it right with acuity - just because weather/weight keep a patient out of the air doesn't mean they do not GO. They just go via ground - and taking care of a "sick" person for 2 hours and 100 miles via ground makes for some wicked high acuity. I think the well prepared ground CCT crew will really have to know their stuff - cause 2 hours will test it. A 20 minute flight might be difficult - so imagine the care the patient will require over hours. Something to think about. And I've taken the interfacility RESCUE out and had a LONG 45 minute flight trying to keep the patient alive and mitigate some of the "care" they received - I would think that doing it over hours would test even the best of us!

Fly SAFE!


I was lucky enough to start flying in a service where sick IFT's STARTED at 2 hours airborne. I think I learned more about the practice of flight medicine there than I would have at a service that had a 20-40 minute hop...
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Ken BHSc, RN, REMT-P

#7 MedicNurse

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Posted 15 July 2008 - 02:42 PM

Ken - you are indeed very fortunate in many ways.

Although I am in area's that are settled and to compare is almost not possible.
I, too, have area's where the flight RW alone is about an hour.
I cover many bases and the ones that do the 20 minute hops - heck, even the bad patients seems like a breeze to do!

I almost "covet" getting to do work like you do - talk about getting to be "the best" or having to get out. I bet, the area you are in does cull out those that can't rise to the top super quick!

I know that getting to work in remote areas do provide the best experiences. When I started as a medic in 94, I would be the only one in a multi county area. I felt fortunate to get to practice in these circumstances. I was IT. No back up - well, except for the few (3) air services in the state then - I still advise to the newbies that want to get "good" - go to the "tough" areas.

Bottom line - In rural (you are rural extreme, rural deluxe - remote) you either get really good really fast - or, you get out!

Fly SAFE! Out there, WAY out there! :lol:
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#8 justlookin

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Posted 17 July 2008 - 07:55 AM

Let me throw out a question I have asked my rotor-head friends and have had varying responses: Why is there such a seeming lack of ground CCT while there is an overproliferation of superhigh-overhead-costly rotor services?

I am not starting an us vs. them; RW does serve an extremely useful purpose for time-sensitive medical patients and intellectually extricating scene trauma from the hands of the volunteer fireman first responder, even if the pt. is sub-acute.

But, let's face it, us ground CCT people are highly trained, have much more room to work in, have much more room to put exotic equipment, pharmacological agents, bair-huggers, yadda yadda and so forth in. I come from ATL, where there was only ONE true adult CCT truck, and I don't even think that was staffed 24/7. All the interfacility transports with ALS level monitoring or drugs (not even intubated) seemed to be done by one of the RW companies.

Are we just not sexy enough? Have we just not sold ourselves well enough? I think ground CCT fills a very huge niche that is wide open in a lot of markets, and all of the sad events surrounding HEMS lately only illuminate that vacancy. So, have we shorted ourselves, and how does one go about fixing it?


Grady,
You are definitely on to something here, and its an idea that I'm sure has been considered before. However, there are lots of reasons both for and against ground CCT.

Obviously, we all know that helicopters are used to save time: Time sensitive medical and surgical patients, as well as trauma patients from both scenes and referring hospitals. But helicopters are also used to reduce the "out of hospital" time for those super sick ICU trainwrecks. Even though a ground CCT truck has all the drugs, equipment, etc as an ER or ICU, its simply not the same environment as actually being in an ER or ICU. In these situations, helicopters are beneficial because they keep shorten the interval from hospital to hospital. Sure, ground CCT could work in some instances, but remember that the total time to complete a trip by ground versus air is often longer than we think. Traffic, stoplights, accidents, construction, etc are all factors that generally do not apply to helicopters, but could impact ground CCT.

Remember its very easy to look back on a transport and say "this could have gone by ground, ALS, BLS, taxi, etc".

Sure, ground CCT may have more room depending on the truck compared to certain models of helicopter. However, its not really about how much room you have, its how you use the room efficiently and effectively. As far as exotic equipment and things of that nature, things like IABPs, VADs, etc are not an everyday thing even for the busiest programs. So sending a patient by ground simply because there is more room may work in certain situations, but is definitely not necessarily a reason to use ground versus air.

I think another reason that helicopters are used versus ground is that HEMS is more standardized compared to ground CCT. Obviously HEMS is not completely standardized either, but more so than ground CCT. Referring hospitals and physicians are accustomed to HEMS and generally know what to expect and what they are getting when they call. They know that most likely, a highly trained and experienced team of an RN and Medic (generally) will show up and be gone with the patient pretty quickly. They also know that these teams are efficient and self sufficient. I am well aware that this statement does not apply to certain programs or certain areas of the country. I think of this like ordering pizza. When I really want a pizza and I want it with no BS, I'm probably going to call Papa Johns, Dominoes, Little Cesars, etc instead of the new Mom and Pop Pizza place across town. Sure, after a while, I might try them and might use them instead, but not when I need a no-hassle, no frills product. Same thing goes for HEMS compared to ground CCT.

In my experience, ground CCT is unpredictable and unorganized. I've had ground CCT teams show up to transport patients from some community hospitals where I worked per diem in the ERs and ICUs. Some of the crews were totally clueless, even for the more basic transports. One crew didn't know what a swan was but stated "it was probably no big deal anyway". Another crew showed up and wanted to start all sorts of "higher level of care" because, after all, they were rescueing the patient from the little hospital's stupid doctors and nurses. A subtle mention that I worked for the well-respected HEMS program in the area quickly changed their minds. Having since relocated to another area of the country, I have not seen much of a difference: ground CCT here is still unorganized and unpredictable. Most of the non-hospital affiliated CCT crews are usually transporting trached nursing home patients, or TPN. However, the ground teams affiliated with HEMS programs are almost always organized and predictable, functioning much like the HEMS crews because they are accustomed to higher acuity and work in a more organized system.

The problem in many areas is that ground CCT has emerged from regular ground EMS services. They buy a big truck with lots of new equipment, send their staff to a two-week critical care class, maybe hire a couple nurses, and "poof" ground CCT is born. But, those services want to run ground CCT just like regular EMS, and we all know it doesn't work that way. They forget that unlike with regular EMS, referring hospitals and patients don't have to use their service. A long time ago, I worked in an area with one medium sized hospital, and one associated EMS agency that did both emergencies and transfers. They wanted to start a CCT unit much like I described above. The hospital was on board with the idea and the service assumed that they would be called for critical care stuff when the CCT unit was operational. However, the hospital continued to call for HEMS and ground CCT from the receiving hospitals (again because they knew what they were getting).

Ground CCT has alot of work to do as far as standardization, organization, and marketing. A new service familiar to me has very well-organized procedures and ground cct is strongly suggested to referrings when the use of air transport is clearly not warranted. This is working well so far and the service is saving $ because we all know that a ground unit is cheaper to operate than a helicopter.
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