Forum
Article Outline
IAFP
Advocates for advanced practice
Welcome to the 20th anniversary year of the International Association of Flight Paramedics (National Association of Flight Paramedics). Watch the newsletter, website, Air Medical Journal, and other publications for news of special projects throughout the year. Please join us in Phoenix for 2006 AMTC. We'll be celebrating achievements and optimism. There's bound to be some folks around you haven't seen in a while, some people you always wanted to meet, excellent educational venues, and generally interesting goings-on.
While we celebrate years of accomplishment, we've also got big projects on our slate for 2006. One of the most important is the National EMS Scope of Practice. The document was published and distributed last year, causing waves of state and national policy discussions. “That's old news,” you say. It's starting to affect your states already, and it's not old news. It's simply a framework for changes that may affect the rest of our careers. It's up to all of us to build on that framework. Each of you will help interpret document wording. We all have the authority and responsibility to use the National EMS Scope of Practice to build health systems that optimize patient care without sacrificing providers.
A little help as you began to advocate. I called Drew Dawson at the National Highway Traffic Safety Administration, who is as familiar with this as anyone is. He emphasized two points in the existing document. First, the National EMS Scope of Practice recognizes specialized local or regional needs that necessitate thoughtful tailoring of EMS systems. No one is attempting to apply a one-size-fits-all approach to every EMS community in this country. He also asked that people read the document carefully and thoroughly, at least once, before they initiate sweeping changes. The document outlines a common floor for EMS professionals. It is not and was never meant to be the ceiling.
The National EMS Scope of Practice work group sidelined the Advanced Paramedic Scope of Practice in the interest of unity and expediency. The IAFP board of directors is working with other groups to complete that final portion of the document. Like any national EMS process, the strongest advocacy exists in local systems. This involves all of you. It will determine how you practice, where you practice, and how you are recognized. Help us help you by voicing your concerns.
As you do, I would like you to consider what Advanced Scope of Practice is. Also, consider what it is not. We like things to be defined. Lists seem to help. We list our years as paramedics. We list the skills we can perform. We list the medications we can give. I don't think those are the heart of advanced practice. Advanced practice is expanded scope and expanded responsibility for enhanced patient benefit.
The difference between practice and advanced practice is what you doYou look at lab values and consider potential medication interactions. You adjust ventilator settings based on patient physiological response. You can integrate complex pathophysiology in your treatment plan. You discuss interesting presentations and dilemmas, listening to alternate approaches. You follow up on patient outcomes. “Did I catch everything? Was there something we could have done better?”
The difference between practice and advanced practice is what you don't doYou don't attempt procedures without back-up plans in mind and in place. Common medication side effects don't surprise you. You don't blame others to cover your difficulties. You don't initiate procedures on patients because you need the practice. You don't place provider comfort ahead of patient outcome. And you don't practice in a vacuum.
The difference between practice and advanced practice is why you do and don't do thingsYou participate as part of a health care team because it is good for the patient, the community and, ultimately, the team. You attend educational venues to learn, not for the patches. And you take responsibility for difficult decisions because you did the best you could for that patient in that situation. You do the right thing.
Advanced practice isn't about a skills list as long as your arm. It's not about the years you've carried your card in your wallet. And it's not about being one-up on someone else. Advanced practice includes both the art and science of paramedicine. It comes from education, awareness, and hands-on, mind-open, patient-touching experience. It is what you do for your patients; it is not what you do to them. That is the floor of advanced practice. All of us working together can write the framework. I encourage each of you to reach for the ceiling.
If you would like more information on Advanced Scope of Practice advocacy or any other IAFP project, call your board of directors, write us, or stop us in the halls.
NEMSPA
Sometimes people say the dumbest things!
Several years ago, while branding cattle, my boss was holding a red-hot piece of steel against the flank of a calf. The calf, like anyone else in that position, was bawling and wiggling, trying to escape the heat of that branding iron. I will never forget the words that came out of the boss' mouth, “Hold still, you stupid &#$@%!” I wish I could speak cow because I'm sure that beast had some words he shared with the boss.
Although I'm quite certain I had heard people say plenty of stupid things by that point in my life, it was this one that made me really start paying attention. I thought I would share a few of these jewels with you. Some of these occur so often they are almost commonplace.
A person returns from vacation. It is inevitable someone is going to say to that person, “Are you back?” My answer of course would be, “Nope, I don't know what you think you see, but I'm still on a cruise.”
Someone comes in covered with snow, and the brainchild of the office says, “Is it snowing?” “No, of course not; I was in the freezer rolling like a dog.”
There are an abundance of those out there in the world. We in the air medical community have some of our very own. A pilot and crew departed on a mission from their hospital base. The weather, although raining at the hospital, was reported to be clear everywhere else. In fact, less than a half a mile from the hospital, the weather was clear and cold—great flying weather. Upon returning from the uneventful transport, the pilot heard the following statement from the program director: “I just want you to know,” she said in a very authoritative voice, “I was monitoring that flight very closely.” The pilot thanked her and then asked why she was monitoring the flight. She said she was concerned because of the weather. My question is what was she going to do if there were a problem? Monitor the flight all the way into the ground? Or was she going to reach out with God-like power and pluck the aircraft out of any danger it encountered?
Another one involves a manager. Some pilots were concerned that all the safety issues in their company, along with other aviation issues, were dealt with by nonaviation personnel. When this was brought to the attention of the manager, he said he didn't need for him to conduct safety operations; he managed pilots. Following this logic I went to the CEO of my hospital and told him of a medical problem I had. He wondered why I was telling him about it and told me I should probably see a doctor. I told him that I thought he could certainly do just as well as any doctor since he managed doctors.
A crew accepted a flight to the other side of the state. The weather forecast indicated good weather until around 2300 local time. That gave the crew plenty of time to conduct the transport. Well, as we all know, sometimes the weather forecaster's crystal ball isn't quite as accurate as we would like. The crew ended up spending the night in a hotel due to low ceilings and visibility. One of the nurses said this sort of thing should happen more often. If it didn't, we were turning down too many flights.
All three of these examples would be very funny if they didn't have some serious implications. The program director monitoring a flight should have voiced her concern to the crew instead of “monitoring.” She would have been informed of the weather and therefore would not have said something quite so stupid.
Mr. “I don't need pilots to run safety programs” is the type who endears himself to aviators on a regular basis. My question to him is, when was the last time he managed a tail rotor failure, a brown-out or white-out situation, or any of a number of emergencies? I would like him to manage a pilot through spatial disorientation or even explain from experience what it feels like.
The nurse who thinks we should push the weather limitations and spend a few nights in hotels is advocating the very things we have been trying to get away from.
These are not secondhand rumors. Although they didn't all involve my company, I know the people who made these statements. They are not idiots, but they did make statements that caused me to wonder if we are making any progress at all in our quest for a safer industry. The above are just a very few samples. I'm sure if we asked around, we could write a book on the things people have said that just make you say, “huh?”
Our words reflect our attitudes, our attitudes affect our actions. I've heard a great deal of talk about teamwork, the community, AMRM, and of course, safety. When I hear statements like those above, especially from management types, it really makes me wonder. I hope the next time you hear something stupid that you have a chance to challenge the speaker, if for no other reason than to make fun of them.
AAMS
Zero Errors of Consequence. What exactly does this mean? Let me provide some background information.
At the AAMS Spring Conference in Washington, DC, last March, the AAMS board of directors adopted Vision Zero as our community's safety program. With several air medical crashes in a relatively short timeframe and an ever increasing scrutiny by the media, we believed that we had to bring safety to the forefront with a program that would reach everyone with timely information and educational opportunities.
Vision Zero was developed in Sweden to bring the motor vehicle accidents involving fatalities and serious injuries to zero. Cost analysis models were developed to determine what tools would be cost effective in getting to zero. Potential tools were then analyzed to determine those that would be worth investing in. We would like to thank our past public board member, John Wish, for suggesting the Vision Zero program based on his knowledge of the Swedish initiative.
So how do we apply Vision Zero to our community? All of us must commit to zero errors of consequence with no fatal crashes or serious injuries. We must determine and agree on a timeframe in which this will happen. There must be an agreed system of measurement and commitment to identifying and implementing best practices that will enable us all to reach this goal. Donald Berwick, in an article titled “Heal thyself or heal the system: can doctors help to improve medical care?”, laid out the following precepts for quality in health care to improve.
How much more applicable can this be for our Vision Zero safety program?!
Let's look at what we have done thus far. Our first step was to form the AAMS Vision Zero Steering Committee in May 2005 with representation from the AAMS Safety, Standards, and Communications and Public Relations Committees; the Commission on Accreditation of Medical Transport Systems (CAMTS); and the Foundation Air Medical Research and Education (FARE). All of our community is well represented since these committees and organizations contain membership from all affiliated associations. The steering committee provides direction and is tasked in ensuring that the important work by each of these committees and organizations is completed.
The AAMS Vision Zero Steering Committee is now being chaired by Tom Judge, the AAMS Safety Committee chairman and our AAMS past president. Tammy Chatman, AAMS Communications and Public Relations Committee vice chairwoman, is serving as the vice chair of the steering committee. Other members of the committee include Eileen Frazier from CAMTS, Kelly Hawsey and Sandy Kinkade from the AAMS Standards Committee, and Chris Zalar from FARE. Also in attendance are ex-officio members Dawn Mancuso, AAMS executive director, AAMS Communications & Marketing Manager Blair Beggan, AAMS Government Relations Assistant Christopher Eastlee, and myself.
Some of the initiatives we have been working on include but are not limited to the following items.
This in only the beginning as we want everyone in every program to live and breath Vision Zero every day, every hour, every minute, and every second. Only by working together can we achieve Vision Zero or zero errors of consequence!
AMPA
Award winners
AMPA presents two awards each year at AMTC, the AMPA Distinguished Physician and the AMPA Medical Director of the Year. The Distinguished Physician Award is to recognize lifetime achievement and service to AMPA and the air medical community. The candidates are nominated by and voted on by the AMPA board.
This year's recipient of the AMPA Distinguished Physician Award has already had an impressive career in medicine. Currently the president of Grant Medical Center in Columbus, Ohio, he has served as chairman of the board of Medflight and as director of trauma services at Grant Medical Center. He has also chaired the department of surgery, the trauma committee, and the emergency services advisory committee. He has published widely and frequently speaks to physician, health professional, and community leadership organizations on a variety of trauma and surgical topics.
Congratulations to Dr. Robert Falcone as the 2005 AMPA Distinguished Physician.
In contrast to the Distinguished Physician Award, the Medical Director of the Year Award is intended to recognize that physician who has made outstanding contributions to his or her program. The nominee is an AMPA member who has shown exceptional personal involvement in the program, is considered an invaluable part of the team's success, and whose contributions to medical direction, education, quality care, outreach, safety, and team morale are considered to be essential to the fabric of the program—in short, a leader. The candidates are nominated by their crews and voted on by the AMPA board.
Congratulations to Dr. Andrew Hawk from Care Flight Air & Mobile at Miami Valley Hospital in Dayton, Ohio, as the 2005 AMPA Medical Director of the Year.
As the new year begins, safety in air medical transport continues to be the one of the primary goals of AMPA. In an effort to enhance the safety of our industry, AMPA is sponsoring (in association with Brown Medical School) a 1-day preconference immediately preceding the upcoming Critical Care Transport Conference in Las Vegas. Safety First – A preconference dedicated to the safety and well-being of our patients and crew is a collaboration of AMPA and members of NEMSPA, ASTNA, AAMS, and IAFP. The preconference is for anyone involved in air medical transport who is concerned about safety. The program offers a multidisciplinary approach to safety issues. Lectures include topics on Vision Zero; role of the medical director, medical crew, aviation staff, communicators, and program administrator in program safety; night vision goggles for pilot and crew; PAIP; error reduction, crew wellness; risk assessment and safety case studies. This will be an exciting forum on safety that is directed toward anyone in air medical transport. Please plan to attend and encourage your fellow crewmembers to attend as well.
Another goal of AMPA is membership services. Over the years there have been numerous requests for information regarding medical directors' contracts. Most are specifically concerned with salaries and professional liability insurance. A survey addressing these issues was performed many years ago. In an effort to provide the most relevant information to our members, AMPA, led by Cathy Carrubba, has designed an updated survey and is in the process of gathering data from the membership. This is a very important project because this information will assist AMPA members with securing the most appropriate and protective contracts.
The AMPA membership has recently reached 400 members. This is due in large part to the recruiting efforts of our executive director, Pat Petersen. Thanks to Pat for her efforts in growing our association.
Lastly, I would like to remind everyone of two upcoming conferences, the 2006 AAMS Spring Conference and the 2006 CCTMC. The AAMS Spring Conference is held in Washington, DC, March 8-11. While this conference is usually directed at program leadership, there are many lectures that all crewmembers will find useful. In addition, there will be an opportunity to visit Capitol Hill and discuss air medical transport-related issues with your local legislators. More information can be found at www.aams.org.
The Critical Care Transport Medicine Conference will be held in Las Vegas April 2-5, with the first day being the Safety First preconference. This conference is for all involved in critical care transport and is considered to offer especially strong clinical lectures. Please encourage and support attendance of this conference by your crews. For more information and to register, visit the AMPA website at www.ampa.org.
ASTNA
Competition or collaboration– the choice is yours
“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.”
Margaret Mead
As I am writing this a “wintry mix” of snow and sleet is falling. Not quite a “wicked nor'easter” but definitely not suitable for flying. In fact, we have just declined a flight for weather concerns. The requestor is not one of our normal customers, and we are not the closest aircraft to their location. Almost simultaneously we received the flight request and a call from one of our sister programs informing us they had just declined this flight for weather concerns and alerting us to the fact that we might be getting a call from the requestor.
We are fortunate; all of the air medical transport programs in this region have worked hard to foster a spirit of cooperation and communication with the purpose of providing safe transport and doing what is in the best interest of the patient. This means we talk to each other frequently, work together on regional initiatives, and refer flights to each other as appropriate. This relationship has been formalized as the Northeast Air Alliance (NEAA). Other programs may not yet benefit from this type of collaborative relationship, but each and every one of you reading this article possesses the knowledge, attitude, and skill necessary to introduce a similar culture of collaboration within your region.
I think most would agree that a major concern in the transport community is the effect of competition on safety. There are those who feel very strongly that competitive practices and/or political rivalries create an atmosphere of undue pressure that has a negative impact on a safety culture. Some have gone so far as to suggest competition for volume can push crewmembers—pilots and medical crew alike—into unsafe or marginal decision-making situations. Speculation and anecdotal information abound.
Perhaps your program has safety policies in place. However, safety has little to do with policy and everything to do with culture. How can you monitor adherence to operational policy in the aircraft or ambulance? Do you really know how your crew or coworkers communicate and work together during a transport? Do you really know how your crews interface with crewmembers from other transport programs in your region? Does your program have a process in place to perform a structured debrief on every single call, not just those calls where something was identified as not going well? Does the process include loop closure? Does everyone in your program actively participate in a structured change-of-shift brief? Do your crew members feel safe discussing questions in a bidirectional manner? Does communication freely cross the authority gradient, or do crew members remain silent about their questions or concerns out of fear of repercussions or being seen as “unknowing”? It is an oft cited statistic that as many as 80% of EMS aviation accidents can be prevented by open and effective communication.
So, what can each and every one of you do to help decrease this alarming figure? Work to foster a safety culture in your organization, region, and company. Culture is defined as “the set of shared attitude, values, goals, and practices that characterizes a company or corporation” (www.merriam-webster.com). Safety is defined as “the condition of being safe from undergoing or causing hurt, injury, or loss” (www.merriam-webster.com). How then does one begin to promote a safety culture?
While this has been but a brief overview, it has hopefully provided some food for thought and action.
PII: S1067-991X(06)00002-2
doi:10.1016/j.amj.2006.01.001
© 2006 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
