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IAFP
Are You The Paramedic?
“Are you the pilot?” asked the child in wide-eyed wonder as we stood waiting for the elevator.
“No,” I said with a smile. “I am the paramedic.”
“Oh,” said the child and immediately lost interest in me.
In 18 years of flying, I have never been asked, “Are you the paramedic?” (Cue angelic soprano voices) I have to wonder why that is. Is it because we have not had really cool paramedic movies and shows for our industry since (in my humble opinion) Johnny and Roy? Maybe we need a movie like Top Gun or Backdraft that will bring paramedics into the limelight.
Perhaps we are already there. Flight paramedicine is by nature a high profile job and is evolving rapidly. When I got into EMS, I was told paramedicine is a 5-year career; now we see silver-haired (for those who still have hair) flight paramedics who thrive within our profession. Many come to the table with advanced degrees. So do we need to be recognized more than we are?
Sure we do. We first have to decide who exactly we are. Our profession is advancing in leaps and bounds. We see paramedics who work in the air and on the ground performing critical care procedures that would have been unheard of when I first started into EMS. The IAFP is growing and changing as well.
The IAFP is working hard to stay on the forefront of issues that will impact paramedics around the world. We are involved in projects such as the accident analysis project conducted by Dr. Ira Blumen along with our fellow organizations. Data from the project will help us understand why air medical accidents occur. This is a tremendous project we are excited to be a part of.
We have terrific relationships with fellow associations such as AAMS, CAMTS, ASTNA, AMPA, NAACS, and AMSAC. It is very refreshing to have friends and colleagues who we can go to for resources and collaboration. There are some wonderful people involved in these groups and a wealth of talent.
The IAFP has been working with Creighton University to survey what critical care paramedics do. This data, along with the fantastic work that the Board for Critical Care Transport Paramedic Certification (BCCTPC) has done, will define our roles as members of a critical care team.
We continue to work to bring educational opportunities to paramedics through a variety of sources. Check out CentreLearn through our website for online CE. This also includes a series of practice questions that will help the paramedics prepare for the FP-C exam. Watch for ongoing educational and leadership opportunities at CCTMC and AMTC. We have something very special lined up for AMTC 2009—you will not want to miss it!
The IAFP is working with the military on issues that will have positive outcomes for our armed services medics. We continue to explore ways we can be of benefit to military flight medics as they serve our country in some of the most challenging conditions.
We continue to be active in our Government and Legislative Affairs Committee. We monitor issues that will impact paramedics on the state and national level. We have worked in conjunction with ASTNA to help ensure safe transport practices for critical care paramedics and nurses.
So, with all of this, do we need a better publicist? We are doing pretty well, all in all—but it would be nice to be asked someday, “Are you the paramedic?!”
Stay safe everyone.
NEMSPA
Is Territorialism Just a Historical Phenomenon?
American history contains stories of territorialism and the problems that developed because of them. In many cases the whole intent was to develop a competitive edge. The competitive edge is usually masked as a need to survive, and only by looking deeply at the situation can we see the truth. The truth is the real necessity to survive.
In the air medical community we often set up territories and go to extreme measures to protect them. It is easy to say, “We need the flights from that area for our base to remain solvent!” and do whatever we can to persuade the hospitals and EMS agencies to use Brand A only. It is easy from a business-only standpoint to crunch the numbers and determine the need for flights.
The missing part of this equation is the customer we are supposed to be helping. Is it truly ethical to gain business at all costs? Is it ethical for a particular service to call only Brand A? Does our budgetary concern authorize us to do anything that is not in the best interest of the patient we are charged with helping? When we look at things from this point of view, the answer is as the Hippocratic Oath suggests and overwhelmingly NO! Still we are able to justify the things we do because we are only keeping our base in service to help the community. Self justification is an art that comes simply to humans.
Interestingly this phenomenon doesn't just occur between opposing companies, but also between bases belonging to the same company. As companies grow larger and larger, this concept will most likely increase. It is hard not to complain when other aircraft come into our area. The thought of my base closing and me becoming a displaced crewmember looking for a new base is frightening, so we justify doing whatever it takes to keep our base intact.
Another human trait that is evident is when the group is threatened by a common enemy is that the group will band together to defeat the enemy. A good representation of this is the recent draft Safety Alert for Operators (SAFO) issued by the FAA. The SAFO threatens the status quo, and therefore the group bands together to defeat it prior to it becoming a published document.
A SAFO is an information tool that alerts, educates, and makes recommendations to the aviation community. This community includes air carrier certificate holders, fractional ownership program managers, and 14 CFR Part 142 training centers. The SAFO was issued to determine the role of medical crewmembers and determine their status as safety sensitive personnel. The wake of the document rippled throughout the community in a very short time, and responses were made and distributed almost instantaneously.
A SAFO contains important safety information and may contain recommended actions. SAFO content should be especially valuable to air carriers in meeting their statutory duty to provide service with the highest possible degree of safety in the public interest. The information and recommendations in a SAFO are often time critical. Many viewed this alert as an attempt to re-regulate the industry, which made it a threat to our operations, and thus the responses were made. The FAA has not issued the SAFO yet and has solicited our input on the wording of the document, which is positive for the community.
The thing we need never lose sight of is that we are here to serve a purpose. That purpose is to aid our patients, and whatever is best for them should be our main concern. Whether we make the flight or a closer unit makes the flight, or whether we are classified as safety sensitive or non-safety sensitive, if that is in the patients best interest', the right decision has been made. We need to strive for that end. Primum Non Nocere.
AAMS
Leadership and Involvement
A community is like a ship; everyone ought to be prepared to take the helm. Henrik Ibsen
The Medical Transport Leadership Institute (MTLI) School held April 28 through May 1 was another huge success, with the first and second year and the graduate school at capacity. I have not attended MTLI since completing my CMTE in 2002, so I had not fully appreciated the growth that has happened over recent years. This not only speaks to the dedication of the regents but also the desire for current and future leaders of our community to attend a unique program that focuses on the many aspects of operations in the critical care transport environment.
I met several first-timers to the MTLI, and when we had the opportunity to check back in at the Thursday evening reception, many spoke of the value in meeting other leaders to bounce off issues they were facing. We all know the importance of networking, and MTLI certainly offers an excellent opportunity for this.
The first day of the graduate program was dedicated to coaching, mentoring, and succession planning. Kris Nelson, Denise Landis, and Robert Frietas did a wonderful job sharing their expertise in these arenas and generated great dialogue among the 60 participants. These three traits sometimes come naturally; hopefully, others recognize there are resources out there to coach their own techniques. A true leader remains humble in knowing there is always room for improvement. This is not a sign of weakness!
By the time this issue is out, voting will be completed for the open 2009 AAMS board of director seats. For the first time in a long time, several regional seats had a contested election. In a previous Forum, I mentioned how the last at-large seats had a slate of 12 nominees. Taking the leap to put your name on a ballot is a significant milestone, one to be congratulated no matter what the outcome of the vote. I spoke with a few people at MTLI and was surprised to learn how many thought only program directors could run for a regional seat. The qualifications do not include that, so this has come about purely from a perception point of view. That still makes it real and means that the AAMS board of directors must improve its own succession planning skill set. As we become more “seasoned” (a nice way of saying getting old, I suppose), I believe it is our responsibility to seek new blood to follow in our footsteps and lead the critical care transport community through the challenges and rewards that lie ahead.
At a recent workshop I attended, a section was dedicated to the younger workforce. This is the first time there are four generations in the workforce. I have certainly seen this at my company and hear about some of the “Gen Y” frustrations they are facing. Not being employed in the health care arena anymore, I am not sure how prevalent these same issues are (but plan on doing some research). With that being said, I think it is important for everyone to take stock of your program and make sure the generation gaps are being addressed. We “oldies but goodies” can learn a lot by keeping ourselves open and listening to the next generation.
Calls go out frequently to get involved in a committee, yet there is still a huge gap of volunteers. There are committees with over 50 names, yet only a handfull are truly engaged. There are committees with less than 10 who are all engaged, but they are reaching the saturation level in trying to balance their full-time position with the volunteer work. Getting involved with an association is a huge commitment, yet the rewards truly make it well worth the challenge of trying to maintain some sort of balance in our lives.
I am asking once again, please consider getting involved! It's a great way to network with others who have your same passion and an opportunity to give back to your profession, which serves such an important role in communities around the world. Speaking of the world, this same request applies to our international members. We share many of the same challenges across borders (safety, communication barriers, utilization, etc). Information is powerful; the more we share, the stronger we will become.
I'll close with another quote, this one from John Quincy Adams: If your actions inspire others to dream more, learn more, do more, and become more, you are a leader.
AMPA
The Patient's Best Interest
Unfortunately, this past May 10, our community lost three members from the University of Wisconsin Med Flight program: Darren Bean, MD, Mark Coyne, RN, and pilot Steve Lipperer. I am sure we all share the same sorrow and prayers for the friends, families, and coworkers of these individuals, who met their untimely deaths doing something they truly loved and believed in. The next day, after the accident, I also unfortunately began to get confronted with questions from both EMS and physician colleagues regarding my knowledge of the details of the transport and patient illness/injury that led to the transport. This is not the first time this has happened to me and likely will not be the last. I even have a couple of partners who are quick to give me feedback when my program flies a patient to our hospital and, after a thorough Level 1 Trauma Center evaluation, is found to not have any significant injuries—usually ending with “the crew should not have been put at risk to fly this patient.”
The common premise with these questions is that the patient being transported likely did not require “risky” air transport and the crewmembers should have never been placed in a situation where they could potentially risk their lives in doing such a transport. Just last week, “Ask AMPA” was queried by an international colleague regarding any information that we may be aware of that looks at the incidence of accidents that occur doing transports where air medical (specifically rotor) transport was not indicated.
I doubt I am the only one who hears these questions and opinions from our colleagues. I also doubt I am the only one who gets a “little” defensive when I respond to these conversations. I do not want to attempt to give a critical care transport utilization review dissertation here, but I do feel the need to both vent and defend my values and opinion and those of what I feel are AMPA's values and opinions.
As I mentioned above, many of the criticisms are based on retrospective reviews of a patient's diagnosis after arrival and evaluation at a tertiary center. I will admit that I myself sometimes find it difficult to do utilization review and try to “blind” my knowledge of the ultimate diagnosis and disposition. This is even more difficult for our non-transport colleagues to understand when you attempt to explain it to them. I have been successful, although in a minority of cases, to suggest the critics try to visit some of the rural, small community referral hospitals and EMS systems to personally witness the capabilities of expertise of the health caregivers. At other times, I find it helpful for the critics to personally speak to the referring physician or EMS professional and listen to how the patient presented and what their concerns were.
For some of our surgical colleagues, I remind them of the early days of their training when they had to get up in front of their entire department at an M and M conference and explain why they took out a normal appendix. (As a surgery intern, I personally had a 35% normal appendix rate on the appendectomies I performed—having no control over the how the patients presented and especially ZERO control over the senior surgical residents telling me to “get my butt downstairs to the ED if I wanted a case”!)
For our EMS colleagues, especially in urban 9-1-1 systems, it helps to remind them of the high number of Code 10 (lights and siren) responses that their dispatch triage criteria require and the low number who actually require that after arrival. From what I am aware (and I am very open to be corrected on this), there is little if any evidence that lights and siren responses to a call and from call to the hospital add any measurable value to the patients in urban systems, where transport times are relatively short at normal speed limits. We do know that when these vehicles are in an accident, the safety of the occupants is at great risk.
Finally (and you are welcome to use this comparison if you wish), if I have a patient come into the ED with an acute severe vomiting and diarrhea illness with uncontrollable expulsion of body fluids in the room they are in and I know there has been a recent Norwalk virus outbreak where this patient is from, I could consider not walking into the room at all, giving some IV and medication orders to the nurse and hoping the patient gets better and discharging them. There may be a < 5% chance that by not examining the patient, I could potentially miss a more severe or complicating diagnosis but a ∼10% chance that I be exposed to the virus by inhalation of viral droplets in the room, and then I would get ill 1-2 days later. So for my safety, I would be best suited to not enter the room, examine the patient, and potentially discover some other condition other than acute gastroenteritis. I don't feel any of us would do this (although most of us have considered it) because that is not what we do when we try to provide the most efficacious, safest care for our patients.
Now I know that there may be some criticisms of my examples, and some may suggest that they are “apples to oranges” comparisons to accident rates and patient diagnosis in critical care transport. But that also is part of my point—how can you be critical of a system where the variables you have to work with depend on imperfect information, human nature, and the ultimate goal of doing the best for what the patient is perceived to require at that point in time? Don't get me wrong—we cannot become complacent in tracking our utilization and sharing this information with our referring EMS agencies, physicians, and hospitals. We owe it to our colleagues who have suffered or lost their lives doing what they were trained and skilled to do to not forget that part of our mission is “to share expertise so that patients may receive the best care possible in the safest operating environment.”
ASTNA
The Value of Networking
Since I personally value education and networking opportunities, I encourage you to attend this year's Air Medical Transport Conference (AMTC), to be held in Minneapolis, October 20-22, 2008. Looking ahead to next year, pencil in the Critical Care Transport Medical Conference (CCTMC), scheduled for April 2009, in San Antonio. Both of these transport-related conferences provide many educational and insightful presentations.
This spring has been a very busy time for me (keep in mind I'm writing this article in May but it won't print until July). The ASTNA board met in San Antonio March 31-April 2 at CCTMC, and I'm happy to report we had a very well-attended and successful conference. I really enjoy this conference because of its close, personal feel and the primary clinical focus. Because of its smaller size, CCTMC offers vast opportunities for networking and developing lasting relationships.
At the end of April, I was off to Wheeling, West Virginia, to complete my second year of the Medical Transport Leadership Institute (MTLI). I can honestly say this was a very intense week as our group put in long hours working on our assigned project. The value of learning from experts in the transport community and those in the assigned work groups was immeasurable. Study time in the “library” provided ample networking opportunities as well!
During the first week of May, Chicago hosted the American Association of Critical-Care Nurses' National Teaching Institute & Critical Care Exposition (NTI). For the past few years, ASTNA has been invited by AACN to present transport nursing related topics on the ASTNA Transport Nursing Stage. ASTNA Board member Kyle Madigan was instrumental in lining up this year's expert panel presenters. Along with Kyle, Becky Pusateri, Teri Campbell, Allan Wolfe, and Scott DeBoer offered various transport nursing topics, including safety in the transport environment. With over 9600 critical care nurses attending the NTI, I was fortunate to meet many nurses who are interested in getting into the transport nursing environment.
I was also disheartened to meet critical care nurses from across the country who routinely put themselves in the back of an ambulance with critical patients but have no formal transport nursing education. I realize that in some parts of the country there are limited resources to provide critical care transport, and there is no choice but to put an ICU nurse in an ambulance with the patient. That being said, I believe ASTNA was able to effectively convey our association's commitment to safety and educate our nursing colleagues about safety recourses such as the ASTNA Position Paper “Transport Nurse Safety in the Transport Environment.”
Each day of the conference, NTI published a newspaper highlighting conference activities and key presentations. One article in particular caught my interest. The following is a brief overview of a session presented by Joyce L. Fitzpatrick, Elizabeth Brooks Ford professor of nursing at Case Western Reserve, called “Empowerment Among Certified and Non-Certified Critical Care Nurses: A National Survey of AACN Members.” AACN distributed a web-based survey to their membership measuring the following six components: opportunity, information, support, resources, formal and informal power. Significant differences were found in total empowerment scores between AACN specialty certified nurses versus non-certified nurses.
“Specialty certification of registered nurses is significant for every institution,” Fitzpatrick said. “Nurses who are more empowered are more connected and less likely to leave, which is why institutions should invest in certification. We should further research the effect of specialty certified nurses on clinical patient outcomes, safety initiatives, and patient and family satisfaction.”
I'm a proponent of nursing certification, so I found Ms. Fitzpatrick's article thought provoking and pondered the similarities between critical care nurses and transport nurses. I found it interesting that critical care nurses feel more empowered and satisfied if they are certified and wonder if the results would be similar if transport nurses were surveyed in the same manner. Perhaps this could be an idea for a research project. Hint!
To close, I encourage all transport nurses to stay connected with other professional associations paying particular attention to research data and recommendations for best practices. Become certified in your specialty, whether that is CFRN or CTRN. Obtaining certification helps nurses become more assertive and feel more competent, and our patients will be better for it.
PII: S1067-991X(08)00106-5
doi:10.1016/j.amj.2008.05.012
© 2008 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
