Being an international fixed-wing air ambulance medical crew member is a demanding role. Typically, as part of a team of two, you have charge of a patient who may require monitoring and intensive care, with limited equipment and little back-up in the cramped confines of a business-class jet thousands of feet above the Earth. It’s no wonder that this specialised work requires a wealth of training, both before first stepping onboard and on an ongoing basis.
Even before applying to join an air medical service, there’s the small matter of completing the training to become a doctor, nurse or paramedic and building up time hands-on with patients, likely in a hospital setting. Regardless of medical experience on the ground, however, a new medical crew member will require specific training in the peculiarities of working onboard an air ambulance.
Compared to a hospital, for example, the air ambulance offers a more limited range of equipment, and crew members often work in relative isolation. Importantly, crew members also need to understand the effect that flying has on the patient’s physiology. For one thing, even in a pressurised cabin, the air pressure during flight will be lower than at sea level, which reduces the amount of oxygen the patient takes in with each breath and can cause any gas pockets within the body (for example trapped air after a traumatic injury to the chest or head) to expand. Other factors to consider include the physical effects of lifting and shifting the patient to get them into the plane, and the impact of acceleration and deceleration at different phases of the flight.
Some skills are more likely than others to require refreshing
While such initial training is good practice everywhere, in some jurisdictions it’s mandatory. For example, Inger Lisa Skroder, CEO and Founding Member of Trinity Air Ambulance in Florida, US, commented that her company offers in-house training for flight physiology, which is a requirement of the Florida Department of Health.
There may also be aspects of training that are required by an accrediting body. For example, Chaleece Caldwell, flight nurse at Angel Medflight of Arizona, US, commented: “We are required to provide documentation of our education logs, certifications and licensure to NAAMTA [National Accreditation Alliance for Medical Transport Applications].”
AirCARE1 International’s training is also designed with accreditation requirements in mind. Conducted in-house, initial training includes classroom and practical sessions, said Denise Waye, President. She explained what the training involves: “The didactic training covers Commission on Accreditation of Medical Transport Systems (CAMTS) / European Aero-Medical Institute (EURAMI) requirements such as patient assessment, patient loading and unloading procedures, flight physiology, stressors of flight, fatigue factors, air medical resource management, aircraft orientation and safety, in-flight medical emergencies, quality management, survival training, and HAZMAT … Our new hires then take training flights where they are exposed to the different types of patient transports.”
Flight physiology is a complex subject. In his capacity as aviation medicine specialist, Dr Thomas Buchsein trains doctors starting work at FAI Air Ambulance, Germany, on the essentials of flight physiology before their first mission. Along with a 45-minute presentation, candidates are provided with a web link to a free download of a comprehensive flight physiology textbook to further their learning.
Currency and upskilling
After initial training, medical staff benefit from ongoing training to keep their skills fresh, referred to as staying ‘current’. Some skills are more likely than others to require refreshing. As an example, intubation (inserting a breathing tube) is a tricky procedure that must be done quickly and done right, but it’s seldom performed mid-flight as patients in fixed-wing aircraft tend to be fairly stable and either do not require intubation or are intubated before transport.
Speaking as CEO and Medical Director of AMREF Flying Doctors at ITIC Global 2014, Dr Bettina Vadera commented that currency training is particularly important for staff who work on air ambulances full time. This is because they don’t have regular exposure to critical care cases due to their lack of hospital-based clinical work. She mentioned that a review of the service’s past cases had shown that staff rarely performed intubation in the field and during flight, but it was nonetheless a crucial intervention, and one that can affect the outcome for the patient.
To knock off the rust, medical crew members can attend periodic refresher training. At FAI Air Ambulance, Dr Thomas Buchsein said: “We require [flight medics] to show evidence of a yearly ALS refresher (offered by us once a year, but we also accept ERC or AHA-approved providers).”
Alternatively, staff can spend time working in a ground-based clinical setting focusing on areas that they rarely see in the aircraft, but should be prepared to handle. Medical crew members at Air Alliance Medflight, which has its HQ in Germany, spend at least a quarter of their time working in a hospital – either in intensive care or anaesthesia – to stay current in these fields, noted Medical Director Dr Gert Muurling. Trinity Air Ambulance is another provider whose staff benefit from exposure in other settings, explained Inger-Lisa Skroder: “99.9 per cent of our staff are actively working in a healthcare setting such as a hospital and/or rescue.”
Of course, going beyond maintaining currency, crew members can work to upgrade their skills. Skroder commented: “Our staff are very proactive, with most continuing their education. For example, some of the paramedics have become registered nurses (RNs) and the RNs are obtaining their Masters.”
Angel Medflight requires that all clinicians (paramedics and RNs) become certified as FP-C (Flight Paramedic Certification) or CFRN (Certified Flight Registered Nurse) within six months of joining the company, explained Chaleece Caldwell, adding: “Those who do not have certification when hired are provided with study materials and classes to assist them in this process.”
External training providers
Air ambulance operators typically provide at least some elements of training in-house, but may also make use of courses offered by external training organisations. Dr Muurling said that even with the wealth of knowledge and experience of its staff in bases across the UK, Germany and Austria, he can see a benefit in gaining outside input. Giving his personal opinion, he said: “It is good to have an external presenter from time to time, who might highlight different details of certain topics compared to the ones we highlight.” By way of example, Denise Waye of AirCARE1 International, said: “We outsource our initial intubations at a skills lab for our new hires at a centre that provides military clinical training. We felt this would provide the highest level of training for a skill that has low volume, but a high impact if done incorrectly.”
Patrick Schomaker, Director of Sales and Marketing at European Air Ambulance (EAA), said that although EAA conducts most of its training in-house, external providers are used for specific topics such as infectious disease or tactical trauma. EAA uses a number of providers, a requirement being that they are certified by the National Association of Emergency Medical Technicians (NAEMT). As examples, he listed mass casualty situation training at Rambam Health Care campus in Israel and the Anvers Institute of Tropical Diseases in Belgium. Conversely, EAA recently created a new training facility as part of building its new headquarters, and this year, the centre began accepting students from other providers. Patrick commented: “We are gradually expanding the selection of courses we offer and also can do custom-made courses for clients with specific requirements.”
While FAI Air Ambulance doesn’t send its new doctors on external courses, the service does prefer applicants who have passed the three-day DIVI Intensive Care Transport Course. The course is offered several times a year in various cities around Germany, by medical bodies such as NGOs, universities and rescue services, according to a curriculum established by the German Interdisciplinary Association (Deutsche Vereinigung) for Intensive Care and Emergency Medicine, Dr Buchsein explained.
going beyond maintaining currency, crew members can work to upgrade their skills
One organisation that specialises in training air ambulance medical crew members is CCAT Aeromedical Training, which is based in the UK but has an international following. Director Dr Terry Martin described how the educational packages cater for a range of training needs – from initial training to highly experienced healthcare professionals working in patient transport, retrieval, commercial airline repatriation, medical assistance and travel insurance. The main base is at the University of Surrey, Guildford, UK, which Dr Martin said attracts students from around the world – most participants on the basic foundation level entry course are from overseas. He added: “CCAT Aeromedical Training currently uses training bases in Thailand, China, the Middle East and Canada on a regular basis. Often, the courses delivered outside of the UK are bespoke for local needs and resources, but they follow the structured format of the UK core curricula.”
Students who successfully complete the CCAT foundation level training package are encouraged to sit an advanced level course within three years, and/or to attend higher level courses or study days in specialist areas such as HEMS and helicopter retrieval, paediatric intensive care transport, neonatal retrieval, ECMO transport and commercial airline repatriation.
Medical staff can also access training remotely via the internet. For example, prior to attending the CCAT Aeromedical Training basic foundation level entry course, students are offered a pre-course distance-learning package that introduces ‘new concepts and a unique way of thinking about aeromedical risks’, said Dr Martin.
In many ways, training is a way of life, a journey without end. For example, Denise Waye explained that AirCARE1 International provides monthly training sessions based on CAMTS/EURAMI requirements, in addition to what the company feels the training needs are. She said: “This training takes place online where our employees read the information and take the required quizzes. They come to class prepared and are given scenarios based on the monthly training. There is a high level of discussion on treatment plans/actions and appropriate outcomes. During monthly continuing education meetings, we also discuss appropriate quality management reviews along with our operational risk assessments. Our trauma training is on an annual basis with information written specifically for our scope of practice by our medical director.”
Medical science and practice is constantly evolving, so quite apart from initial training, maintaining currency and skills building, there’s always something new to learn. Chaleece Caldwell noted that Angel Medflight supports clinicians to attend conferences and outside education opportunities such as the Air Medical Transport Conference (AMTC) and cadaver labs. The service’s staff also benefit from monthly online education, guest lecturers and education provided by the medical directors.
At CCAT Aeromedical Training, Dr Martin is continuously updating the information taught on his courses: “Every training package has a ‘living curriculum’ that is constantly updated and improved, based on current practice, related best evidence, and feedback from our students and our faculty of instructors.”
The expertise of flight doctors and nurses who are so dedicated to their roles comes at a price, for sure – but it is without doubt an investment that pays for itself 100 times over. Proper preparation, after all, is the key to success in most aspects of life, and when it comes to medical treatment onboard an aircraft thousands of feet over the ocean, then successful outcomes are what matter most.