Editor’s Note: The majority of this article was researched and written prior to the COVID-19 pandemic. An addendum has been added that includes information on how some transport RT responsibilities and protocols have changed in the face of the COVID-19 outbreak.
Transport respiratory therapists need to be equipped with all the knowledge and clinical skills that traditional RTs have, plus the ability to handle care in difficult environments—including emergencies with the risk of COVID-19 infection.
By Lisa Spear
When the transport team from Texas Children’s Hospital in Houston arrived at a neighboring medical clinic to pick up a patient, they found the patient, a baby, had severely decompensated. The three-month old had become limp, the color had drained from the baby’s skin, and the child’s breathing had become shallow.
When respiratory transport manager Juliamaria Calvo walked into the facility, and scooped the child from the physician’s arm, she could tell immediately that the patient was in distress. In between giving the child artificial breaths with an Ambu bag, she asked her medic to ready the equipment to intubate the baby.
“I took a lead role in the team, knowing that the patient needed an airway, emergently,” said Calvo. The facility did not have the resources to perform intubation on this patient, so Calvo stepped in to assist. As the team got the endotracheal tube inserted, the baby stabilized, and parents watched as the color returned back to their baby’s body. “That was so rewarding,” said Calvo. “You feel like you made a difference and you know that you made a difference.”
Not unlike RTs who work in in the ICU, transport RTs need to have a great deal of calm under pressure, they need flexibility and attention to detail, but they also need to be comfortable working independently. Often, there isn’t always a physician present in the ambulance or helicopter, so the transport team can be responsible for making decisions about the patient’s treatment.
“We are able to function very independently to a certain extent and for that reason it has been very rewarding,” said Calvo. “…And when you arrive at a facility, [the patients and their families] are so grateful that you have arrived and they look at you with hope.”
Beyond Patient Care
The job often goes beyond just providing care to patients. When a flight respiratory therapist sees oncoming air traffic while monitoring a patient in-flight, part of their job is to alert the pilot. If the plane hits a patch of rough air during a helicopter ride, the jolt can send medical equipment flying. The duty of caring for patients in transport can become far more complicated and the equipment must be more specialized. All medical equipment that is used by flight crews must be approved by the Federal Aviation Administration, said Hratch Kayichian, RT, RCP, RTIII, neonatal and pediatric transport manager at Ronald Reagan UCLA Medical Center in Los Angeles.
“Transport is a different world. It is one I would recommended to someone who is looking to broaden their horizons and have a little bit more freedom when it comes to the decision-making process within your facility,” said Calvo, who has worked as a transport RT for a little more than seven years. “It takes a lot of drive and knowing that you are going to work sometimes outside of your comfort zone.”
At Texas Children’s the transport team consists of a nurse, an RT, and an EMT. Other medical centers have different staffing requirements. The pediatric transport team from UCLA consists of an RT, a nurse, and sometimes a physician.
The day at Texas Children’s starts with a quick check of all their equipment, including oxygen tanks, blood gas machines, equipment for intubation, pediatric stretchers, and neonatal isolettes. The team uses a ventilator called the Hamilton-T1, which is designed for use in helicopters and airplanes. The devices is also especially rugged, designed for military use, it is built to withstand varying environments and weather conditions, including exposure to rain and high humidity. The ventilator is also shock-resistant and rated for altitudes of up to 25,000 feet, which when the team ascends in flight missions.
“We fly almost anywhere in the US. Do we do go to South America as well,” said Calvo. The most far-flung location she has landed in, as a flight RT, is Guatemala, but other transport teams out of her facility have gone further. On these trips, they will sometimes spend hours in flight, and it is essential to have a versatile transport ventilator. While the Texas Children’s team recently switched to the Hamilton-T1, there are a number of options, including the Vyaire LTV devices, and Zoll’s Z-Vent.
The RTs at Texas Children’s Hospital have found that the Hamilton-T1 can ventilate a patient of nearly any age, including neonates. The Hamilton-T1 can run in a variety of modes, including bilevel positive airway pressure (BiPAP), continuous positive airway pressure (CPAP), synchronized intermittent mandatory ventilation (SIMV), and others. “We have been very happy with it. We have found that the modalities that the ventilator can function with are a lot of the same ones that we can use in the ICU,” said Calvo.
The Texas Children’s team is also testing the high-flow oxygen therapy feature on the T1, which is a mode typically only available in the ICU. “The high-flow via the ventilator is something we are trialing and it seems to be very successful,” said Calvo. “It is very important for that adult population that may need the extra flow, so we have been very blessed to have such a successful ventilator for us.”
Account manager at Hamilton Medical, Billy Hutchison, RRT-NPS, said that transport ventilators have seen many improvements in recent years. The latest in transport ventilators offer many of the critical care modes as found on ICU ventilators along with greater battery life and more powerful turbines to allow for greater flows. Some devices also have Bluetooth and Wifi capabilities to streamline charting.
A Day in the Life
Often the workdays for transport RTs are long and strenuous. At UCLA there is an RT on-call at all times to ensure that the pediatric transport team is covering in case of an emergency. Transport RTs there work 12-hour shifts, from 7 AM to 7 PM. This nonstop schedule makes it all the more important that the equipment is easy-to-use.
Battery life is an essential consideration. Many devices can run on the power of the vehicle that they are used in, but transport teams also make sure that they have enough backup battery power to sustain them if the vehicle were to lose power. For instance, the Hamiton T1 can run continuously on stored battery for nine hours. The Vyaire LTV series ventilators can run about eight hours in a single charge and the display will alert providers that the battery is low 10 minutes prior to shutting down.
On the road, oxygen supplies can also be limited, so LTV series ventilators are built to reduce oxygen consumption. “You need to have a ventilator that is reliable and durable and the key is that it needs to be easy to use,” said Daniela Valentgas, RRT, a former ICU respiratory therapist and the national account manager at medical device company Vyaire Medical, specializing in transport respiratory therapy.
Another essential piece of equipment while on the road, said Calvo, is a portable blood gas analyzer. The Texas Children’s Hospital team uses the epoc system, a handheld, point-of-care, wireless device available from Siemens Healthineers that provides comprehensive blood analysis testing at the patient’s side on a single room temperature test card, with results delivered in less than a minute.
Tips for Entering the Transport Field
The path to become a transport RT varies since each medical facility has their own requirements, but the first step for most people will be to start working in an acute care setting as an RT to gain a base level of competency in the field.
When considering candidates for UCLA’s transport team, managers ask that candidates have a minimum of three years of ICU experience. Often, RTs will do rotations in specific emergency care units, including the neonatal intensive care ICU, said Kayichian.
Since some transport teams specialize in certain types of medical cases, such as OB-GYN or adult emergencies, those jobs may require applicants to have experience in those specialties as well.
For instance, those interested in pediatric transport, it is a good idea to get certified by the Neonatal Resuscitation Program, a course that provides education on how to handle cardiopulmonary emergencies involving newborns.
“In addition to your skills and your mindset, you also need to be physically active, agile and able to climb in and out of a helicopter,” said Kayichian, who has worked in pediatric transport for more than 20 years.
During a flight, the team members will all wear helmets with built-in microphones, so they can speak to each other seamlessly over the noise of the aircraft. When they enter the plane, they will buckle their seatbelts, further restricting their movement. “You are really confined to your seat,” said Kayichian. “You position yourself in such a way that you can reach the patients if you need to, while in route.”
If all goes well, the nurse and the RT work together like a well-oiled machine, sometimes snapping into action without even speaking. “Everybody knows just what to do,” said Kayichian. “You need to be able to function with sick patients in confined environments with limited resources and you also need to have that kind of personality, where you are going to handle any mishap, minute by minute.”
A Day in the Life: During COVID-19
Since the novel coronavirus began to spread throughout the United States, transport respiratory therapists had to quickly adapt.
“The planning and preparing for the COVID-19 surge was a major takeover of our lives. There was so much unknown and we are still learning every day. We are also collaborating with the other UC medical centers and we share information with each other,” said Kayichian.
The team has upped infection control procedures. They clean ambulances with bleach in between patients and routinely request infrared light sweeping. The facility also has infrared light built into the pipes that circulate the air in the ECMO mobile unit.
Also, the team is continuously evaluating aerosol generating therapies and taking preventative measures to minimize generating aerosol particles. Their mechanical ventilators, BiPAPs, oxygen delivery setups are all assembled with disposable single patient use parts and circuits.
In general, Kayichian said his transport team has been successful at transporting many COVID-positive patients in grave condition, by placing them on ECMO support during transport, and eventually recovering and weaning them off mechanical ventilation support to go home.
“This is due to the advanced care given by UCLA ECMO program and multidisciplinary medical teams,” he said.
In other parts of the country, therapists who were needed to treat coronavirus patients had to take a hiatus from their normal transport duties. At Stony Brook Medicine’s Respiratory Care Department in New York, RTs typically responsible for neonatal and pediatric transports were needed more urgently to care for coronavirus patients.
“Of course, things did change when the pandemic hit our region. We became really just fully involved in primarily critical care of patients,” said Ken Okorn, associate director of Stony Brook Medicine’s Respiratory Care Department in New York.
The number of Stony Brook Medicine’s transports dropped dramatically in the New York metropolitan region as providers focused on trying to control the spread of COVID-19. At Stony Brook, paramedics and other clinicians were able to manage without the assistance of the respiratory care department.
“We needed to keep our therapists really in house. These patients required so much care. They were so labor intensive,” Okorn said. In normal circumstances, the department has 40 to 50 ventilators running at once. During the worst of the outbreak, that number ballooned to 122 ventilators at once.
But despite the flood of cases, there was a great sense of community within the department, he said. “Everyone was watching out for each other to maintain safety, and make sure that we were providing the best care for all patients. There was a lot of communication within the hospital to ensure that the necessary steps were taken.”
Okorn’s advice for other respiratory therapists to get through the pandemic: Make sure you protect yourself using proper PPE and procedures. He said that other therapists should always remember that caring for patients is a team effort. “Rely on your fellow therapists, nurses, and physicians. Remember to lend a hand to anyone that needs one,” he said.
He also emphasized that “taking care of ourselves and each other” is key. “Make sure everyone takes mental breaks at work. After your shift ends, go home and take your mind off of COVID. It’s important to find something to distract, even for a few moments, and get some rest,” he added.
“Wake up each day refreshed, knowing you will do your best to make a difference.”
Lisa Spear is associate editor of RT. For more information, contact [email protected]