Transporting a Pandemic

In the words of my good friend and now retired colleague Kris Nelson: “these are my thoughts, not yours…”

In the well-warranted mass hysteria generated over the past 6 weeks, I have put my role as clinical educator on the back burner. This current situation that we have found ourselves in has forced me to knock the rust off of some of my fundamental clinical skills. For that I am grateful.

Having said that, one of my many responsibilities that I take very seriously has been the keeper of this blog space. Its initial intent was to provide a clinical repository for Survival Flight nursing staff. While I had never intended the information contained here to make it out to the #FOAM world, it eventually did just that. Now, we have over 150 subscribers in 5 countries. While not impressive by today’s social media standards, I am grateful for each and every one of you for being interested in what we as a critical care transport system have to share.

It is because of this that I am truly sorry for not having posted for so long. If people actually look to see what we at Survival Flight and Michigan Medicine are doing to address the most important healthcare crises, it is our responsibility to share and disseminate, regardless of how “bogged down” we feel. The intent of this discussion is to re-engage in this mission.

As I was working on figuring this out, I started looking at some of my old presentations over the years. I have been fortunate enough to lecture in venues big and small; locally, regionally and nationally. One subject that audiences seemed to gravitate to has been our knowledge and skill in managing patients in respiratory failure.

While compared to today’s standards it doesn’t appear that we are horribly “cutting edge,” I can assure you that 11 years ago, we were exactly that. The 2009 H1N1 epidemic hit our region hard. We had no choice but to get creative in how we were going to move these incredibly sick patients. We partnered with intensivists and respiratory therapists from our institution to derive a management algorithm. We trained our staff in what was then nothing less than “radical” ventilator management strategies and implemented an “off-label” inhaled agent called nitric oxide. Long story short, we made a difference and generated some compelling data.

In 2010, my colleague Jeff Thomas (co-author of aforementioned journal article) and I presented our clinical findings at the Air Medical Transport Conference in Ft. Lauderdale, FL. The title of the lecture was “Transporting a Pandemic.” Looking back at this I am not sure if our choice in title was prophetic or naïve. Our experience over the past month leads me to believe that it is the latter.

The COVID-19 pandemic has hit the Southeast Michigan / Metro Detroit area especially hard. One month in, we have transported well over 50 patients. While I knew we would need to prepare and train our staff for what was inevitably coming our way, I was ill-prepared at best for what I thought we actually needed to do. It all comes down to one phrase that is now well known to even my wife (a High school English Teacher) as well as every news outlet on the planet…” Personal Protective Equipment (PPE).”

My advice to my fellow clinical educators who have yet to see these types of transports is simple. Your staff knows how to ventilate and medically manage these patients. What they will more than likely struggle with is exposure control. PPE in critical care transport is not a well-covered topic in any of the major core curricula and something quite frankly, we have all taken for granted until now. What you need to concentrate on is how to manage and move very sick people while ensuring that your crew and equipment are protected, and that you sufficiently decontaminate your equipment and vehicles post-transport. Knowing what you have at your disposal for PPE, how to “don” and “doff” (two pseudo-words that I have not heard since my Navy days), how to provide care and how your crew configuration and transport mode could conceivably change are things to discuss, drill down on and practice.

It’s not as simple as just putting on more stuff and doing your job in the manner in which you are accustomed. There is a lot of brain power in proper exposure control and these transports can become mentally and physically exhausting very quickly. This is on top of the fact that these patients are critically ill, difficult to oxygenate, difficult to keep sedated and at times hemodynamically unstable. The two areas that you should look to seek your management caveats are the blog spaces of folks that have been “battle hardened” by this (don’t look for robust RCT’s anytime soon), and the Infection Control department at your local hospital. While our Infection Prevention and Epidemiology (IPE) department had no idea what we did before, they certainly do now and were instrumental in assisting us in developing our policies and practices. We took them for granted before. We may have even rolled our eyes at them. We definitely don’t now. They have literally saved our lives.

In the beginning of this discussion, I promised that we would resurrect this Blog and continue to provide valuable information; not only for this current crisis but for the care and transport of the critically ill in general. I can assure you that this is not the only post that you can look forward to in the coming weeks and months. Having said that, I think that it is important to provide at least somewhere to get you started in learning more about this disease (if you haven’t started looking around already) and how from a consensus standpoint, we should be treating it.

The Surviving Sepsis Campaign (SSC) has released Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). As this disease seems to create what is referred to as a “cytokine storm” in the critically ill, this seems to be a good place to start in learning about the management fundamentals. If you have done any previous research on this topic, you will soon understand how the pathophysiology of SARS-CoV-2 and the management principles disseminated by the SCCM and European Consensus are in alignment.

This infographic, along with all of the supporting information can be viewed on the European Society of Intensive Care Medicine Blog. From an Instructional Design perspective, infographics provide the best “bang for the buck” in getting your staff a lot of information in a small amount of real estate in rapid-fire fashion (something my busy group appreciates). It is very well put together and has certainly assisted me with inspiration in how to disseminate information to my group.

I would be remiss if I did not acknowledge the excellent work that healthcare providers in my own neck of the woods were doing in order to share valuable information to the rest of the healthcare community. The Michigan Critical Care Collaborative Network (MCCN) has been developed as a statewide effort to connect healthcare professionals managing COVID-19 patients in the State of Michigan. In preparation for the ensuing surge in critically ill COVID-19 patients, tertiary facilities have gathered and collected their “best practices” in order to share what they have, and continue to learn. The website exists in order to “collect, curate, and distribute best practices from across the state of Michigan and externally to facilitate care for large numbers of COVID patients.”

Finally, I would like to dedicate this post to one of my strongest mentors, colleague and good friend Kris Nelson. Kris is enjoying his well-deserved retirement after 35 years as a Survival Flight Nurse. He has touched the lives and clinical practice of all of Survival Flight and his presence is missed more than he will ever know. Kris was the inspiration and one of the primary authors of this blog space and taught me that no one will hear you if you are too afraid to say anything.