Abstract
In many parts of the world, emergency medical services (EMS) clinical care is traditionally delivered by different levels or types of EMS clinicians, such as emergency medical technicians and paramedics. In some areas, physicians are also included among the cadre of professionals administering EMS-based care. This is especially true in the interfacility transport (IFT) setting. Though there is significant overlap between the knowledge and skills necessary to safely and effectively provide care in the IFT and prehospital settings, the IFT care environment requires physicians to develop several additional competencies beyond those that are expected of traditional EMS clinicians. NAEMSP first published recommendations regarding what some of these competencies should be in 1983 and subsequently updated those recommendations in 2002. This document is an updated work, given the evolution of the field.
In many parts of the world, emergency medical services (EMS) clinical care is traditionally delivered by different levels or types of EMS clinicians, such as emergency medical technicians (EMTs) and paramedics. In some areas, physicians are also included among the cadre of professionals administering EMS-based care. This is especially true in the interfacility transport (IFT) setting. Though there is significant overlap between the knowledge and skills necessary to safely and effectively provide care in the IFT and prehospital settings, the IFT care environment requires physicians to develop several additional competencies beyond those that are expected of traditional EMS clinicians. We refer to physicians who are routinely practicing in this environment as transport physicians, who may or may not be the IFT service’s medical director(s). NAEMSP first published recommendations regarding what some of these competencies should be in 1983 and subsequently updated those recommendations in 2002 (Citation1, Citation2).
The Core Content of EMS Medicine (core content) has since been developed and serves as the basis for the definition of the subspecialty of EMS medicine for physicians (Citation3, Citation4). This core content is primarily designed to define the competencies that must be demonstrated by candidates for board certification as EMS physicians, and much is also applicable to care delivered in various IFT settings. However, not all physicians providing care in the IFT setting are, or necessarily should be, board certified EMS physicians. Depending on the nature of the IFT service, physicians who are specialists in emergency medicine, pediatric/adult critical care, neonatology, and obstetrics, among other domains, are often well-prepared, integral parts of the IFT team without obtaining board certification in EMS medicine.
NAEMSP believes:
The Physician’s Role on the Transport Team
Individual physicians may serve different roles when functioning as part of transport teams (Citation5). A physician’s role may be to function as a fully integrated crew member, to function as a supplemental clinician present to augment the resources of the crew, or to deploy only intermittently to perform a specific mission. Thus, transport services may choose to vary the transport physician’s training accordingly.
Medical Training of the Transport Physician
Transport programs should ensure that transport physicians have the foundational knowledge, training, and experience regarding patient populations relevant to the IFT service. They should also ensure that transport physicians are ready and able to perform appropriate resuscitative and emergency procedures as defined in the core content. Furthermore, transport physician programs should establish clinical development practices that support transport physicians in attaining and maintaining clinical competency in any other interventions that may be beyond the scope outlined in the core content but that are still appropriate to the transport program’s respective mission(s) (e.g., neonatal medicine, advanced hemodynamic support devices, and high-risk obstetrics). While board certification in EMS medicine may not be needed depending on the role of the transport physician, it is recommended for physicians routinely practicing as part of IFT teams as a component of demonstrating competency in the core content of EMS medicine.
Transport Medicine-Specific Competency Areas
In addition to appropriate portions of the core content, transport physician training and education should also include the following topics as applicable to the transport service’s mission and vehicle deployment model:
History and Purpose of Medical Transport
Development of air and surface medical transport in military and civilian settings
Models of program structuring
Hospital vs. non-hospital based
Vendor relationships
Transport brokering
Levels of care
Funding models
Purpose of medical transports
Rotary-wing transport
Fixed-wing transport
Ground transport
Special issues of international transport including transport via commercial airlines or military transport
Overview of roles for air medical transport
Overview of the relevant literature
Operational indications and contraindications
Advantages and disadvantages
Clinical transport criteria of trauma and non-trauma patients
Effectiveness of air and land critical care medical transport programs
Patient safety
Quality-adjusted benefits to life
Cost and economics
Overview of medical transport professional associations
Air Medical Physician Association
Air and Surface Transport Nurses Association
International Association of Flight and Critical Care Paramedics
National EMS Pilots Association
National Association of Air Medical Communication Specialists
Association of Air Medical Services
Association of Critical Care Transport
Commission on Accreditation of Medical Transport Systems
National Accreditation Alliance of Medical Transport Applications
European Aeromedical Institute
National Association of EMS Physicians
Others relevant based on site
General Transport Safety
Aviation incident/accident statistics, causes, and efforts to improve safety
Crew resource management/air medical resource Management
Appropriate crew member clothing
Personal protective equipment
Crew restraints and other safety equipment
Vehicle design
Vehicle inspection
General weather considerations
Safe response to the destination (consider an emergency vehicle operator course)
Patient and equipment loading and unloading
Safe use of equipment during transport (including appropriate securing)
Highway and roadside safety
Fatigue risk management
Just culture and culture of safety
Aviation, Aircraft, and Ground Vehicle Safety
Platform Specific Considerations
Rotor-wing aircraft
Fixed-wing aircraft
Ground/surface vehicles
Enhanced vision technology (as applicable)
Weight restrictions and weight/balance assessments
Overview of weather as it relates to air transport, especially with regard to minimum standards for operating safely in different weather conditions (i.e., “weather minimums”)
Routine aviation issues
Helipad/hangar safety
Routine aircraft ingress/egress
Routine maintenance and refueling
Aircraft startup/cool-down procedures
Landing zone (LZ) criteria and safety
Pre-designated landing zones
Emergency landing zones
LZ approach and assessment
LZ safety (rotor wash, rotor hazards)
Routine flight activities
Take-off and landing procedures
Aircraft and obstacle sighting/spotting
Emergency procedures/equipment
Battery master switch
Fuel shutoff
Door jettison/emergency egress for land and water settings (consider underwater escape training)
Fire extinguisher
Survival kit and emergency locator beacon operation
Rotor brake (where applicable)
Oxygen shutoff valve
In-flight emergencies
Precautionary landings
Survival techniques
Search and rescue operations/techniques
Emergency vehicle operations
Crew, patient, and equipment harnesses and restraints
Transport Regulations
Federal Aviation Administration (FAA) regulations
General knowledge of FAA Part 91 (General Operating and Flight Rules) and Part 135 (Operating Requirements, Commuter and on Demand Operations and Rules Governing Persons on Board Such Aircraft)
Visual and instrument flight rules operations
Legislative controversies
“Best practices and standards” provided by accrediting bodies for transport services
Medical Transport Equipment
Medical equipment
Oxygen supply
Noninvasive positive pressure ventilation
Inhaled gas adjuncts (e.g., nitric oxide)
Mechanical ventilator
Noninvasive monitoring
Cardiac monitor/defibrillator/pacer
End-tidal capnography
Pulse oximetry
Automated blood pressure monitoring
Continuous temperature monitoring
Venous and fetal heart tone doppler
Invasive monitoring
Arterial pressure
Central venous pressure
Pulmonary artery catheters
Intracranial pressure
Intravenous/medication infusion pump
Neonatal isolette
Automated/mechanical chest compression device
Intra-aortic balloon pump
Extracorporeal membrane oxygenation
Ventricular assist device
Other specialty equipment
Security, restraint, and electrical interference issues of medical equipment in the ground and flight settings
Communications equipment and procedures
Guidelines for Air and Surface Transport
Accessing the system
Interfacility/retrieval transfers
Scene responses
Dispatching procedure
Emergent and non-emergent transports
Approval issues (weather, weight/balance considerations, etc.)
Administrative approval
Pilot/crew duty time
Guidelines for scene response
Safety issues (extrication, fire, hazmat, landing zone selection, etc.)
On-scene command
Timing of interventions
Collaboration with other ground or air medical units
Guidelines for interfacility transfer
Interaction with other care teams
Timing of interventions
Patient preparation for transport including safe loading and unloading
Receiving facilities and specialty capabilities
Coordinating ground transport of the air team if necessary
Flight following
Flight Physiology (as applicable to the transport service’s mission and vehicle deployment model)
Effect of altitude on:
Gas pressure, volume, temperature, and humidity
Liquid/gas interfaces
Patient oxygenation
Medical equipment
Noise, vibration, G-forces, and light/flicker
Acceleration/deceleration forces
Disease specific medical considerations
Human Factors and Clinical Logistics
Metacognition and visualization
Cognitive resilience and self-talk
Tactical breathing
Optimizing the out-of-hospital workspace
Team communications
Sharing mental models
Team leader: directive, yet flexible and encouraging of input from others
Handoffs
Post-mission debriefs
Legal and Ethical Issues
Non-transport
Utilization
Regionalization and system integration
Changes in mode of transport
Termination of resuscitation on scene or during transport
Licensure and practice when crossing state lines
Flight prioritization
EMTALA
Local Program-specific content
History of the transport program
Administrative policies and procedures
Clinical guidelines and protocols
Integration of transport program into regional disaster/mass casualty incident planning
Incident action plan for responding to a crash of a transport vehicle or serious duty-related injury/death of a transport team member
Search and rescue procedures, where applicable
Infection control
Documentation (medical charting and other documentation)
Logistics
Staffing/scheduling
Stocking/cleaning
Equipment maintenance
Quality assurance/quality improvement/utilization review
Public relations—services/team composition
Outreach programs
Community
Collaboration
EMS partners and landing zone safety
Hospital partners
Utilization
Team Members/Roles
Communications specialist
Flight follower
Flight crew (pilot in command, multiple pilots, air crewman)
Aircraft maintenance technician
Medical director
Direct medical oversight
Indirect medical oversight
Medical crew
Transport physician
Transport nurse practitioner/physician assistant
Transport nurse
Transport paramedic
Special medical crew members
Respiratory therapist
Neonatal personnel
Perfusionist/bioengineers
Physician specialist (i.e., subject matter expert)
Others
Crew member medical fitness for duty (for flight and/or ground)
Practical Orientation
A practical, hands-on orientation is critical to the training of any physician joining any transport team, regardless of his or her prior medical or transport experience. All members of the transport team should be involved in conducting this practical orientation. The practical orientation should be performed systematically, be overseen by dedicated training personnel, and should include experience with transports during an orientation period. Competency testing specific to the transport environment is a best practice. An interfacility transport agency’s practical orientation must address, at minimum:
Aircraft/ambulance operations
Safety
Communications
Equipment
Clinical guidelines and protocols
Review of an agency’s checklists and quality assurance practices
Case scenarios
Transport team physicians must be subject to at least the same level of rigor during competency verification and local credentialing required of other clinicians on the transport team. Additional physician-specific competency verification and credentialing may be necessary for clinical activities that exceed the scope of practice of other transport team members.
Ongoing Skill Maintenance and Verification
Transport team physicians must also be subject to at least the same level of rigor during recurring skill maintenance and competency verification standards as other clinicians on the transport team. Ensuring that a process to ensure ongoing competency exists is the responsibility of the medical direction team. It is reasonable for such a plan to include (i.e., for many requirements to be satisfied by) clinical activities outside of transport medicine.
Acknowledgments
The authors of this document gratefully acknowledge the work of the first edition’s authors: Jon R. Krohmer, Richard C. Hunt, Nicholas Benson, and Russell B. Bieniek. The authors also gratefully acknowledge the second edition’s authors: Stephen H. Thomas and Kenneth A. Williams.
Disclosure statement
No potential conflict of interest was reported by the author(s).
References
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