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ASTNA
Live the Mantra
The end of 2008 and the beginning of 2009 have passed. Often this time of year causes us to pause, reflect, and perhaps make resolutions. Gifts, cards, and pithy emails that encourage all to do these things seem to abound.
There were a multitude of reasons for someone to desire 2008 to come to a close, especially within the transport community. I fear there are more storms on the horizon for all of us.
My career as a clinician and nurse has put me in thousands of situations where you see people at their best and at their worst. I believe 2009 will have a similar theme. Enormous disruption will come from the upcoming NTSB hearings, coupled with piercing national media exposure. This disruption will have an effect on all of us: alliances will change, agendas will be altered, and the very core of what we do will be challenged.
As the ASTNA president I try to constantly ask myself what is the typical, average transport nurse thinking? What does he want done? How does she see things? Doing so I attempt to act according to the organization's and our patients' best interests. So what can I do to impact the majority of transport nurses in our community? I can and will be engaged; second and especially at this time of the year, I can urge you to pause and reflect.
During the holidays I received an email that had a personal mantra that someone had written encouraging daily actions, etc. I have such a mantra and would like to share it with the group.
“Survive, do no harm, be nice.”
This encompasses everything we should do every day, every shift, every transport, every patient. First and foremost we must survive and we must fight complacency, speaking up and being a part of a positive safety culture within our organization. Second, we must do no harm to patients, coworkers, and ourselves. Lastly, take a deep breath, smile, look people in the eye, be gentle when you'd like to act otherwise, and take it down a notch.
I believe this mantra is simple, doable, and worthy. As with most simple things in life, it is easier said than done, much like “eat less, move around more.”
In the new year, I urge each of you to see the storm coming, stay engaged, and follow the mantra.
Kevin High, President
IAFP
Hang On, This Is Going To Be a Wild Ride—Embracing Change
Many changes have transpired since the last issue of AMJ. We have seen the inauguration of a new president and a new political party influence in Washington. Imagine the amount of creativity, foresight, and vision that is needed to move an entire country in a new direction. President Obama and his Cabinet have been strategizing to develop an intelligent design to what they believe will be a better America.
As we move into a new era of critical care transport, I reflect on the change over the past years ranging from clinical and didactic patient care training and insurer reimbursement to safety standards and safety training. As the transport industry evolves, we have learned from our history and have seen how research and outcomes have become a standard that has significant influence in the intelligent design of the critical care transport industry.
The NTSB hearing February 3–6, 2009, was the stage where intelligent design became a high priority in the nationwide mitigation of air medical crashes. The IAFP was present to witness and participate in this historic event. The IAFP provided a statement to be included in the NTSB public document that addresses safety, which was taken directly from our membership's point of view. The safety information came directly from a comprehensive internal survey within the IAFP membership last summer. The IAFP brought much attention to the NTSB, emphasizing that paramedics have specialized training in scene safety and prehospital operational safety.
After many hours of testimony, questions, and recommendations brought forth to the NTSB, more time will be needed to deliberate on rational and functional solutions to the current safety problems in the air medical industry. The big question now is how will the NTSB's fact-finding mission affect the intelligent design of future air medical transportation?
How will the IAFP contribute to the future of safety in the critical care transport industry? We are collaborating with fellow professional associations, universities, and industry researchers to provide information and guidance to develop the most intelligent design of safety for the future.
Today the IAFP is looking very hard at our own organization to see where we can improve. We developed a strategic plan and are working from our business plan for 2009. Several areas for opportunity became apparent with the further development of the critical care paramedic, who works in the air and on the ground. The success and longevity of the critical care paramedic will rely on developing a definition, creating standards of care, standardizing the education for critical care, and advocating for our profession with other organizations and government agencies to create an official profession recognized nationwide.
You may say to yourself, “Great. So the IAFP has made promises; where is the return on their promises?” I'm glad you have asked, because we have completed the definition of a critical care paramedic, created recommendations for critical care education, and worked with other professional organizations on standards of care, as well as advocated to government agencies for the creation of a recognized profession.
Speaking of agencies, I would encourage all readers who have an interest in politics within our industry to attend the AAMS spring conference in Washington, March 11–13 as we will be walking the halls of Congress to educate congressional members about our industry and the current needs for safety and professional organization needs. Please take advantage of this great opportunity to become involved in the legislative process!
Whatever changes come about in the critical care transport industry, I encourage all of you to rise above your personal convictions and remember that we place patient advocacy and human safety above all.
As the president of the IAFP, I, too, am trying to create an intelligent design like President Obama for the United States, except I am working to enhance the success and longevity of the critical care paramedic. As we move forward in 2009, I would like to draw your attention to our spring conference. I hope to see many new faces at CCTMC 2009 in San Antonio, Texas, April 5–8. Due to popular demand, we have enhanced the critical care skills lab from half a day to a full day. This year the skills lab will include surgical airways, chest tubes, central lines, ventilators, and i-STAT point of care. The procedure lab will be held at the University of Texas Health Science Center. We have many other great lectures this year, so why not enjoy an early spring in San Antonio? Remember the Alamo!
James P. Riley, President
NEMSPA
That's Not My Decision to Make
While there aren't many authors of “work-related, not-for-fun” books or articles that I can remember, let alone recommend, I do know that when I read something from Dr. James Reason, I normally enjoy it and think I actually learn something. Dr. Reason, who many of us know as the “swiss cheese” model guy, is considered an expert in the field of aviation human factors. In one of his many publications, Dr. Reason discusses decision making in the context of taking some decisions away from the pilot. In the particular chapter that I recall, he uses the MEL (Minimum Equipment List) as an example of a system that removes the decision from the pilot. If a particular broken item is listed in the MEL, you may defer that item and fly. If it's not listed, you have no choice but to ground the aircraft and get the item repaired. The pilot has no decision to make.
Anyone familiar with instrument flying is familiar with the term “decision height” or DH (which has now become “decision altitude” or DA). When flying an ILS approach, the navigation system in the aircraft will take you on a three-dimensional glidepath down to the runway or helipad and will do so with a high degree of accuracy, all without any outside visual cues to the pilot. In practice, the FAA prohibits the average pilot from flying an aircraft to the ground unless that pilot has the runway (or helipad) environment in sight prior to some predetermined point. That predetermined point is the DA, defined as a “specified height or altitude in the precision approach at which a missed approach must be initiated if the required visual reference to continue the approach has not been acquired.”
Note the phrase “must be initiated” in the definition. If the pilot does not have the required visual reference in sight there is no choice but to execute a missed approach procedure. Descending below a DA without the runway or helipad environment in sight is considered at the top of the list of “no-no's” in aviation, and official sanctions can result.
In some respects the term “decision altitude” is a misnomer. As in the case of the MEL, that decision for the most part has already been made for the pilot. Runway environment in sight: you may continue. Runway environment not in sight: you must execute a missed approach. There isn't much gray area here.
Something that our particular program implemented about 2 years ago is a procedure that NEMSPA has recently identified as an enroute decision point (EDP) protocol, which closely parallels the DA concept. Like a DA, the EDP is designed to make the decision for pilots and medical crewmembers in marginal weather conditions. An EDP consists of two decision points, a predetermined airspeed and altitude. In our program that airspeed is set at 90 KIAS and the AGL altitude at 300′ during the day and 500′ at night. If either of those limits is reached, the pilot has no choice but to alter course to find better conditions, abort and return to the departure location, or land immediately and call for assistance. Continuing on the present course with the hope that “maybe things will improve after we get through this pass” or “we only have a few more miles to go” are not options. The decision to continue is not left to the pilot and flight team.
To many, this may sound unnecessarily preemptive. How can you possibly think about taking decisions like this away from the pilot and medical crew? I prefer to look at this as not taking away decision making, but rather as removing pressure. I know that our program's pilots appreciate this protocol for what it really is—a method for taking the burden off of them when unforeseen weather conditions become marginal. When discussing our own EDP policy with our pilots, I continue to hear comments such as “I think its fantastic” and “best thing we have done since night vision goggles.”
In an environment where weather reporting is spotty at best and where both internal and external pressures to the pilot and medical crew may result in flights being launched into marginal conditions, programs should consider procedures and tools that alleviate such pressures from those flight teams. The EDP is one of the tools that I personally endorse. Does it take away the flight team's ability to make a decision? Yes, I suppose you can look at it that way. Will your flight teams look at it as a safety policy that will relieve pressure? Based upon my own experiences, I believe they will. Will you have a safer program as a result? There is no question about it. I also believe that such a policy, with buy-in from all members of the flight crew and unequivocal support from all levels of management, can provide a means to be a significant deterrent to CFIT accidents.
Kent Johnson, President
AAMS
Scrutiny and Advocacy
As I'm writing this Forum submission, there is a flurry of activity going on around the industry in preparation for the NTSB public hearings. There will be an incredible amount of scrutiny thrust upon us for those 4 days, and everyone involved has been working diligently to gather data to support their roles in the hearings. Plenty will be written about the events as they unfold and certainly for a while afterward, as there will definitely be changes as a result.
There is that word that some dread and others embrace: change. I'm sure everyone has seen one model or another of the change curve, but all of these models have one element in common in terms of the acceptance of change: those that are on the leading edge of implementing change have a jumpstart on those that are not part of the process.
There is no doubt change is coming. We have a new administration that will be focusing on healthcare reform. What does this mean to the air medical industry in the United States? It remains to be seen, but I've always been more comfortable being a part of the process than taking a “wait and see” attitude. It will be important that our industry look into the future and find ways how we can integrate the role of transporting patients into the overall healthcare system while ensuring those transports are done safely, with high standards and cost effectiveness.
Several groups are working on promoting what they feel is the optimal approach. Each of these groups firmly believes they are promoting safe and high quality patient transport systems and are going to great lengths to educate the lawmakers. I am not going to delve into the differences of these approaches, as this is not the forum for this discussion. What does strikes me is how confusing and possibly even unsettling the different approaches must appear to those with whom we strive to instill the highest level of confidence in our capabilities.
Chaos is a natural part of evolution, and truly our industry is undergoing such an evolution. This is not the first time we've gone through a significant period of change, nor will it be the last. While you or I may feel like the community is following a path of total chaos for awhile, the outcome of this period will be a system that will be stronger, not only from a safety aspect, but also from an integration and funding aspect as well.
Be sure to attend the AAMS Spring Conference March 11–13 at the Melrose Hotel in Washington, D.C. This conference focuses on legislative and regulatory issues related to the air and critical care ground transport services we provide and includes updates on the results of the NTSB hearings, a discussion by FAA officials on their plans, and educational programs on reimbursement and corporate compliance plans.
The program also includes a day of visits to lawmakers on Capitol Hill; this activity has continued to gain momentum, with more attendees doing more visits each year. Participation in this industry-critical event is more important than ever. We have a new Congress that needs introduction to critical care transport and education about our interests. With such serious issues facing the new administration that will garner significant national resources and attention, such as the economy, healthcare reform, tension in the Middle East, and, of course, the Iraq/Afghanistan wars, it will be more important than ever to ensure your voice is heard. Each and every day the AAMS staff works to make sure your messages are carried to the halls of Congress, but lawmakers listen much more intently to constituents like you. Please make your plans to join us in March!
The NTSB hearings will be behind us by the time of the Spring Conference, but the ramifications will only just be beginning. It is obvious the NTSB was intent on doing a deep dive into our industry, based on the number of panels and the diverse backgrounds of witnesses. I would like to thank everyone who will have represented their profession during the hearings and am confident we will ultimately regain the confidence of those that have wavered. I encourage you to go to the AAMS web page (www.aams.org) for the latest information about the hearings and other timely public policy issues.
Sandy Kinkade, President
AMPA
Air Medical Transport and Care a Necessity
By the time you read this, the National Transportation Safety Board's 4-day public hearing on the safety of helicopter emergency medical services (EMS) operations will have come and gone. At this time I do not know when the material collected from that hearing will be available or in what form, but I am anxious to see this material, as are so many others. The NTSB worked enthusiastically to obtain as much resource material as possible and to invite members of all parts of the EMS and healthcare communities involved with air medical transport and critical care to make sure this hearing was as inclusive as possible. The schedule looks as though people who really are involved every day with air medical transport are going to be asked to testify and present the real facts about air medical transport and utilization.
I have personally had the opportunity to be involved with air medical transport from many angles. I started in EMS when air medical transport was something I saw only on the 6 o'clock news as US troops in Viet Nam were rushed off in Hueys for urgent care. I have been the receiving physician at the tertiary care centers who occasionally commented about why air medical services were used to transport a particular patient, perhaps implying that it wasn't necessary. I have been at many a scene call, working up a patient and wondering why the helicopter hadn't arrived 5 minutes ago because I really needed some extra hands to help me and time was running out for this patient. Worse was the knowledge at some scenes that, because of weather or limited resources, no helicopter was going to arrive. I most recently have worked in community hospital emergency departments with very limited hospital resources and have been the sending physician requesting the air medical transportation knowing that it was the only chance the patient had to survive. I would not be surprised if some physician at the receiving hospital made some comments regarding my choice of transportation on some flights.
Depending on where in the system you are at any given time, the view is quite different. I know that we try to think we are aware of all that is going on around us, but the reality is that a few miles away things can be very different. Within the same city, from one hospital to another, resources may vary greatly. From one community to another, the differences may be even greater. At one hospital ALS/MICU ambulances may be lined up to care for patients, yet in the next community there may only be one ALS ambulance, if any at all, to cover a larger area.
Geography, weather, and staffing are some of the variables that we know affect how we use all our resources, especially air medical services. A single incident with multiple victims can wipe out a rural community's resources and therefore require air medical services, yet the same incident in another location would not make the 911 system flinch. Hospitals in many regions are downsizing or losing specialty care availability locally. This requires long transports of patients who need such services. Utilization criteria vary for so many reasons that most of us can only speculate what is involved in regions other than those best known to us.
Air medical services play a key role in providing critical care transport for many patients that would have delays in their care if such services were delayed or not available. As not just a member of the air medical community, but also a consumer of air medical services, i do not want to see restrictions that would adversely affect the availability of such services.
On the other hand, I have lost friends, colleagues, and patients to crashes and want to see that we do everything possible to prevent such recurrences. SAFETY is first and most important, but we must continue to take care of our patients with the highest quality of care available too.
As we put forth this additional effort to review what it is that we do and how we do it looking to make our system safer, we must also continue to provide critical care and air medical services. We must continue to maintain the level of care that has come to be expected by those that utilize our services. Education must continue. Research needs to be promoted.
I urge those of you that are AMPA members to be active; those that are not I urge you to join and become active and be heard. An educated system is more efficient and, hopefully, safer for our patients and crews. As I said earlier, each one of you is the expert in your region and can teach the rest of us, but only if you are active and vocal.
As the change of leadership for most of the air medical associations occurs in October, it has been challenging that so many activities have been taking place so early in our terms. I want to acknowledge and thank my colleagues from the other organizations. There was an almost seamless turnover, and communication has been great. I look forward to a collegial and productive few years.
AMPA's Mission—promoting safe and efficacious patient transportation through quality medical direction, research, education, leadership, and collaboration—continues to be followed effectively due to the diligence of our Executive Director Pat Petersen and the members of AMPA's board. Please contact any of us through the AMPA website (www.ampa.org) if you have any concerns, questions or just want to discuss something.
April 6–9, 2009, is the Critical Care Transport Medical Conference in San Antonio, Texas. CCTMC will once again feature a Scientific Forum with poster presentations of original scientific research. Poster presentations will be formally judged during the conference on April 6 and an Outstanding Research Award bestowed. Accepted abstracts will be published in the Air Medical Journal. Dr. Reed Brozen, AMPA board member at large, will organize the Scientific Forum. Please look at the AMPA website for details on how to make your abstract submission.
AMPA will again facilitate Skills Day at CCTMC. Dr. John Pakiela, AMPA's Education Committee Chair, has added even more clinical skills, including point of care testing and ventilator management. If you cannot attend CCTMC, please try to make sure members of your flight crews can be there.
Planning ahead: AMTC2009 is scheduled for October 26–28 in San Jose, CA, with the AMPA pre-conferences tentatively scheduled for Sunday, October 25, immediately followed by the AMPA General Membership meeting. There have been many discussions regarding how to make the scheduled meetings easier for attendees, so stay tuned should there be changes.
Stay SAFE!
Jack Davidoff, President
PII: S1067-991X(09)00002-9
doi:10.1016/j.amj.2009.01.001
