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[Music] hello and welcome to the EMS nation podcast I'm your host Faison Arshad I have on the line today dr. crisp aligarh of ampa the air medical physicians association and today we bring you the last lecture podcast from CC TMC 2016 with sharon walsh and brian p 0 welcome to the show Chris we're going to be chatting about simulation and complex transports well thank you very much a phazon it's a pleasure to be here it's kind of bittersweet that this is the last one but there is plenty more to come at CC TMC 2017 which we'll talk about at that at the end here you're in for a treat here with simulation we oftentimes youth simulation for the education a component but in order to use it to troubleshoot the logistics of your system is something that I think is fairly underutilized and these two folks here have a number of years of experience between them and they're here to share that experience with you today so Sharon and Brian are both fantastic educators and they work with dr. bill Hinckley at UC air care and they take their quality very seriously and you know degeneration of a patient's clinical status and route or end in the middle of your transport in the middle of the air it's something that is very real and happens and they want to make sure that their providers are prepared for any situation yeah Sharon is the clinical program developer and brian is the simulation manager you see health is a very progressive program and they do quite a lot in this realm I'm excited to hear what they have to say fantastic so EMS nation enjoy this one and the last one from the cct MC lecture podcast series it's one of the instrumental people as we develop this simulation scenario so the objectives you all can read the objectives I don't need to read this to you so I'm going to move on all right so a little history about F mode transports at Air Care mobile care this is back in 2011 stop 10 15 on july twenty first phone call comes in comes through the communication center and as the person said hey we have a dr. Lewis who wants to transport a patient's on ECMO from Jewish Hospital to University Hospital can we transport a patient on ECMO all right oh and dr. Gibbler here's one of our ed physicians and president of a hospital the time he already called and said he that we can do it and he will take full responsibility of every anything goes wrong and you all know how that works because they have our back don't they every time so what everything about it is like no no no we are not going to do this this is a bad idea we cannot just out of the blue to attack my transport but we did do the transport it was a success but some things we found out collaboration with the equity matthieu CMC is a must okay we are bringing people who do not transport patients on board our ambulances and so they need to understand what happens during the transport environment all the crews need to have hands-on education about loading ECMO unit how to handle the patient this is something completely new to them so we started doing some education with our staff at air pear mobile care on ECMO during transport then we did 14 transports over that the past five years leading up to last year but we did that thing spot oh yeah that's how it starts and later there's running and screaming and everybody wants to do the transport but when it's time to do the transport no one wants to do the transport um so Brian's going to take over for now but what happened was you started seeing up tech uptick in atmo transports we the hospital decided they were going to reinstitute their heart transplant program which meant we were going to see even more ECMO transports so we had to do really something significant great thank you so in spring of 2015 the idea started coming together is the newly canoe form simulation center at University Hospital of you know what can we start to do to make these transitions a lot smoother those of you who have done simulation already pretty much you get that feeling of oh it's for codes right anytime you you know you start doing a simulation or the simulator comes into your area or on the floor people always think the other streets going to drop but it the place that I come from previously we're using simulation a lot differently not just for this so we started bringing together again this multidisciplinary group we want to practice like we play so books from perfusion anesthesia obviously the simulation center and then the personnel that we're going to be making with transport and then so we you know sat down and start talking about how do we make this thing happen how do we make this as real as possible that folks get the idea because it's here and said before you had perfusionist and anesthesiologist with perfect hair colors etc in the back of an area and an ambulance that they were not familiar with and then you also had you know pre-hospital personnel nurses and paramedics and sarah that were in the back trying to help folks when you know we started finding a lot of things of just obviously the basic communication between who does what you know who's in charge of the ECMO machine who's in charge of drugs if they have to give there's a lot of things up in the past we just kind of made work really we needed to address so again we want to build a device that so we're going to put some on an ECMO we needed something that could be put on an ECMO machine and then kind of get some readings etc so you know we had that feeling of hand it is this one and we got to come through we gotta find a way to make this fit into the hole for this using nothing but that let's get it okay okay what building filter right so it was kind of here's the machine makes something in simulation that's going to be that's going to work we wanted it to be as real as possible we just didn't want to have kind of you know much like would you ACLs we just didn't want to verbalize things okay I give up every three to five and then the reality is we give it what about every minute and a half in reality right we didn't want to do that we wanted folks to actually have the hands-on and see what the knobs do on the ECMO machine let the greatest line in this whole thing was what better get a pot of coffee on right that's all that all the best ideas come from you know good cups of coffee so we had yet we just didn't want to bombard the learners with all right here's 20 objectives that we have to accomplish in one scenario right so we wanted to break it up and so we put it in stage one was realistically let's look at the logistics of the simulation we didn't want to throw a high acuity patient in here to where folks that weren't familiar with simulation kind of like oh I didn't realize that that was just a simulation thing or I thought that it was this and it really took away from know you know Bible provided you know the simulators that we hands can actually give you real-time vitals in real time you know end then type of co2 and things like that and we just didn't want the cop out to be oh I didn't treat them because I thought it was a simulator thing or the most famous one is what well had it been a real patient I'd have done it completely different right so again we want that so we looked at the policies really just want to look at logistics how do things flow so the acuity the patient was very very low there was no dramatic change for this patient but we looked at the process of the systems process and then so as we start adding on to this as we continue to go on we're going to put in more equipment you know the QT the patient's going to change once we've had a good baseline of people understanding how this and ones as well as given the opportunities for folks to work together often right so you're bringing the perfusion team and the new people that they're hiring in your bringing as these here there could have repair folks and then our you know from Air Care mobile carrier standpoint we wanted to give a good platform for those folks that just practice together obviously the challenges were scheduled we were pulling crews off the road on a regular schedule you know programming time to come in and again they got dispatched as it was you need to respond to now that give away while you had respond to University Hospital for a necro patient which is where the receiver not the sender hyper agree the reason before that was we wanted the comm center to work through the process when that call comes in I'm not just sending a squad out to pick up this patient I got to get the squad from a very aid area be I've got to get the perfusionist in that team from area seat area B and we want to each group to work through the process with a simulated patient and then then you know it's all the issues so what's it going to be a safety issue what it really happened Thank so again the whole thing of you know we have a sim center but we really wanted to work in the real environment that they would because I would see our students enter is nice but and you'll see here we have pictures it's you know it's a big Paul essentially at times and you don't have the space restrictions that you would in an ICU room or something like that so and then insurance sets up getting the communications in there involved so this is our Simpson with the collaboration between the United States Air Force Seacat team emergency medicine and the hospital so it's again there's space on either side and a long way but again it's nice but the problem was if I have 30 people in here you don't really feel the restriction to 30 people so again we wanted the actual see you that we had that we either transporting the patient out of saying it and that would look very similar to something that we would pick up from as well as receiving bringing that patient into the actual you know rude that they would be coming into and looking at all the logistics that go around that so these are just some of the pictures of how this would go so when you're when you go to build a simulation like this scenario what works best is take a transport that you've done so like I said we had 14 ECMO transports I was able to take a patient we had done I used to land I use the whole layout that's how he built the scenario wrote it out we have the same template we use for all of our scenarios so that their similarities should anybody take that over after we're gone and then we actually the day that we decided to come together we actually just stood around a stretcher we didn't have a simulator in it nothing like that we talked through the whole process so we can solve some issues and there were little tweaks even just doing that that we found that we needed to do to make this as real as possible we did have somebody who built a device so that actually fake blood could flow through the ECMO machine so people would actually see red stuff on through the tubes again to make it as realistic as possible because that was the whole goal is suspension of disbelief so things we come along the way as we started do our actual live simulations we got two new trucks last year or auxiliary gave us money thank goodness to be purchased two new trucks and one we purchased only had three seats in the back what's wrong with just three seats in the back only three people can ride in the back safety issue so of course like those every time we would do the scenario that was the truck that we were using so we set up paying no more truck 20 great and actually more issues that track 23 only having three seats the bag that we're taking up pardon my french the damn captain's seat on the side he putting in a bench seat so we can put four people in because you have your critical care paramedic your critical care nurse the perfusionist and probably it's going to be the critical care in CT ologist who needs to ride in the back create a thoracic surgeon they can ride up in the front of a they feel like they need to come to the event so that's the one thing we did we found some issues with lifts on the trucks how long did the lips were the first review that we did a simulation what they thought they could just lift the patient without the lip like know there is so much stuff on the patient save the issue you will use a lift hanging equipment astana the first time we lowered the stretcher we watched the chest tube container or chest tube drainage system of course so what you'll see a safety check books that we build and that's something that people do the walk around the stretcher to make sure before we lower it it doesn't get crushed or nothing gets crushed how much oxygen will be used by the ECMO machine and ventilator do we have enough in the tank so one dangereux simulation remember you were here on the first day you heard dr. Murtagh McDonald talk about how the team ran out of oxygen so we watched we stood back and watch the scrape and you can stand back and watch what happens because you see a different picture than if you're actually in it the profusion is she was going through their scenario hooked up immediately the o2 tank e cylinder to their ECMO machine and then we just watched to see when with the tank run out of oxygen because we knew it was going to happen it took 30 minutes but I'm everything was ready to roll out the door and they came very lever like hey check the level oxygen on your tank so they were born on e so the one thing that we then drilled in everybody is how to do tank calculations so that you know if I have this much in my tank and I'm flowing at this many liters how much time do I have left in this whatever tank you have or make you switch of the lattice the last thing you do is to make that switch so there are things that we worked out and much better to do it on simulation than on a live person so the first day we do simulation this is not our ambulance honest forgot our team we call them there at our sister hospital that is about not only a 20-minute drive northwest on i-75 semi has a rollover and we're like waiting and waiting and waiting and we're waiting and waiting for the team to get down here and they call and say you know the traffic's backed up we don't know what you know we just backed up and I'm like they're staying begging they don't want to do the simulation they're making this up so I got my phone out like check on wcpo our local TV station and sure enough there's a second much pulled over on the highway well so what they made our team do is we needed to be grown an alternate route so now that's in the back of our team's minds all the time when they have a transport like this if something goes wrong on the road I'm on how can I jump up and go somewhere else so I can expedite this transport it also gave our communications and an opportunity to start doing some logistical change potentially as well do I need to call that cool off and it's or another three become available that might you know vehicle to transport better so kind of the unintentional basis that you get the back of playing out in a real-time setting so all the parties that were included and all of a sudden then you had the crew you had the confusion sir when they're going you know are we going our weekend are they coming to get us and said or so again in the realistic world of kind of hurry up and wait it gave folks of which again insurance said things like oxygen tank do at that point did the crew you notice I wow you know we're not making train you know we're not transferring its much over yet when we make all these decisions so I'm not reading this whole thing to you but what we did was like I would make notes of issues that I would see during the simulation the lead perfusionist she would make notes so everybody would make notes never we were kind of coming together with our heads that we were making up issues that we saw and then from that we made a flowchart so when that call comes into our communication center they pull out this chart and now they know what to do is they go through the process who to contact who needs to make sure of what's doing what so I don't have to go through the whole flow chart but now we have this flow chart of how to make the process work after we did this simulation and built this flow chart we also have OB extenders on our team so if we have a high risk OB patient that's coming from another hospital to our hospital we will pick up one of our OB nurses to do the transport so then I made a flowchart on how that process would go because again you have teams out here going here picking up somebody that's over there and how can you best logistically get that worked out so having a flow chart so everything happens the same way every time after you've worked through the process with simulation is the way to do it we also came up with this cardiac device form because like I said earlier the hospital decided they were going to reinstitute their heart transplant program meaning we're going to get a lot more patients on ECMO patients on them tell us patients on Elba ads patients on balloon pops so the one thing if you were the sending hospital the last thing you want is somebody making numerous phone calls to you as you're busy with this sick sick patient that's out of your own to get information so what we came up with was this creative ice form and in the middle you see specific questions for FMF in the middle specific questions forum held or el bayit and then on the side balloon pops all we need is for our comm specs to factset to the setting hospital they can complete that form and then they fax it back to us and it gets cast out to the perfusionist the anesthesiologist the NICU team and they all have the same bit of information so now they all know this information with one interaction of phone call faxing whatever instead of numerous phone calls numerous people making that call to the second hospital the other thing that we could create it was an ECMO bide so as our teams are heading out to pick up a patient on ECMO these are the things that we want them to be thinking about if we want them to review this is a two page guide front and back we have one from pella we have 14 l vans we have 14 balloon pumps just our team can kind of do that quick review what they need to do before they get there so you see that no truck 23 that just was such a bone of contention for me it's like everywhere no truck 23 so look and they have that form and they just pull that up and they kind of go through it a good review the other thing we did was at air pear mobile care our EMT is not just the driver they are an important part of the team and so what we did with this was we gave them the title of safety officer during the ECMO transports and after we created this this whole thing that they are charged with taken care of during the trigger leading to the transport during the transport after the transport the information we got back from the perfusionist and the anesthesiologist and the cardiothoracic surgeon was you know that's with us at ease because you've taken us out of our environment where we're comfortable and you're making the speed work in an environment that's not familiar to us and when we have somebody saying this is going to happen this is going to happen will do timeouts here will do this it made them feel better knowing somebody else was taking care of that issue for that so now i'm going to let brian talk about Ebola or the latest infectious disease that comes down the line right so pick one they're probably gonna be many so again with the success that we had with kind of the ECMO transport we also then started identifying some other areas where air care mohair comes into a huge play not only just within our hospital system but within our region in our state you know obviously we sit kind of it you know at a pivotal point between Indiana Kentucky and Ohio so our reach is a little more than just say Ohio so with in ohio though within the area we have an agreement that states that our our ambulances will go either a pick up the patient from a hospital to take them to cleveland or we will go to a home to pick up someone that's on Ebola watch who happens to be sick and needs to be transported in 911 911 will not transport these patients we are tasked with transporting these patients and the reason he said Cleveland is in Ohio Cleveland is the receiving hospital for Ebola patients at this point I'm so the state of Ohio came up with a big plan on how the bullet patients would be managed within the state of Ohio so again we want to put policies and procedures to task so everything looks good on paper but then all of a sudden you go through your SOP and say okay let's try this and you get a real sense of how long it takes to prepare the back of the ambulance you know this is done I don't know if any of you've seen the TV show dexter right this is what it reminds me there's plastic everywhere i'm expecting you know blood to be splattered or whatever thing but you know again we had folks that we looked at how long did it take you know did we were we doing it correctly taking making sure there were no gaps and then we had folks and Brian and Mark were the two that volunteered to be legal yeah who are the ones that were in the back that we're making the transport so again we utilized our sister Hospital up north to bring an Ebola patient down to the main hospital so again we put them you know the receiving hospital we got up there what through the whole checklist of how to get suited up how to make sure that both were safe and then how easy or difficult was it to treat this patient from point A to point B in the suits one of the things that we found out mark the minute mark sat down in the back of the ambulance you know it's cut your the state plush Stay Puft Marshmallow Man he sat down and what happened mark the butt of the suit blew out right so obviously had it been a really good patient you know we would call TV timeout and we would have made a transfer but again I'm looking at the logistics of the suits and kind of the how do you operate in those things so the students have been changed there now plastic at the foes of paper so that people won't do that the other kind of bonus that we looked at that was how well did our crews clean up after the fact okay and so what they didn't know at the time was our boss put kind of the little secret hidden ink on there to find out no all right we asked the crew clean up your mess and so what happened was at the very end how well do you think they did not put him on the spot but they did extremely loved it they got all the spots so we're extremely pleased that you know that they is the crew took this simulation seriously enough to act like as if it were a real patient so do the due diligence of truthfully cleaning up the back of the ambulance and making sure that we are following that policy and procedure as well as possible that you know the reason that we created it was make sure that people were safe in it that we were doing the right things at the right times you know even with the cleanup so we were finding that using the simulation again they were these were not the typical high acuity patients that you know we're thinking of you know it's the hard patient we're going through mega codes and we're going through a bunch of drips and things like that there are certainly places that we are doing that but when we were looking at these larger transports we were looking at more that logistical issue of are we doing it right now because again now adding the acuity so are going to muddle things up if we're not doing the bass lines correctly how are we expected to provide the best possible care for our patients so again that's what we were putting simulation views as we continue on as we move on obviously the acuity that patients going to move up the different types of equipment is going to be added on to the thing because again that are going to be the multiple distractions we're looking at we always look at things like teamwork communication crm you know we want to make sure that those are principles that all the proves adhere to not just because as well to simulation and we'll just kind of cheat on this one and you know but when the real creation comes you know again we want folks to be proficient at these things you know and again if we don't see it's you know kind of how can you expect someone to be proficient at something if they don't get the opportunity to do it or do it often so there's what we're finding a lot with our simulation program of putting these types of patients into the critical care setting not necessarily from a cutie standpoint but just also just at that very basic from that logistical standpoint up do our policies and procedures match our actual care of our patient so we be happy to unless sharon has anything else bad we'd be happy to answer any questions or it's actually I do so the one benefits of our simulations is that teams that didn't even get to simulate they heard discussions so much that they feel like they've attended the simulation and of course we get a call back in like November we need you to come and pick up a patient and good they're good sam and Dayton's that's an hour a half away the team that goes up it has not simulated this yet but they go up now the credit classic surgeon is not a fan of simulation think it's a waste of time it's not the way to Train blah blah blah well this team goes up there and they pick patience and everything is extremely smooth the hole-transporting and he's now paying simulation however this team never simulated and if anybody in this room tells him that I'll kill you the other thing too that happened as simple things like our team wanted to take is sending the hospital's IV pumps because it didn't want to take the patient off the IV pumps because what happens when you switch pumps their precious fall bad things happen so what we do know is our team will call to the hospital descending and say have pharmacy make me up fresh strips of everything that you've got hang on patient right now and then what happens is the med it goes to the corner of the room where all the drifts are laying they plumb all their lines they program their prom pumps they built a manifold the drips start running so everything's mixing and then they walk over and it's just switch switch everything's going smooth lyst trans or smooth transfer everything works great so those are some of the things that that benefits the simulation all right well I hope you've enjoyed this episode we've been really excited to present these talks to you from the critical care transport medicine conference 2016 and if that has whet your appetite for more I encourage you to join us in person at the CC TMC conference 2017 which will be April 10th through the 12th at the wyndham san antonio riverwalk hotel and for those who have not been to San Antonio a great city we have a great conference with a wonderful lineup of people and we hope to be able to talk to you and to meet you and to be able to share ideas so hope to see you next year in San Antonio April 10 through 12 2017 and you can go on amp org that's am PA org or more information as we get the rollout of this program in progress thank you so much Chris and EMS nation we want to remind you that after watching this lecture podcast your job does not end our lecture and conference speakers and educators would love to engage with you and really dig into these complex transport questions and optimize the critical care transport of our patients all across the country so please find us on Twitter at amdocs am PA Doc's do CS as well as ems underscore nation and tweet a question to the author of the lecture podcast and tag us as ampa dots and at ems underscore nation we would love to continue the conversation so we can optimize our patient outcomes this is faizan Arshad and crisp aligarh wishing everyone a safe tour [Music]