Forum

AMTC Anticipation 

It's hard to believe the 2009 AMTC is around the corner. AMTC is shaping up to be another jam-packed educational experience, along with the networking opportunities that go along with a conference of this magnitude. It will also be one of the toughest economic times many of us have experienced, with many programs facing budget cuts. All the associations have been working hard to promote the value of attending the AMTC, and hopefully this collaboration will pay off with another strong year. The preconferences sponsored by the partner associations are once again informative and timely in their content.

By the time AMTC rolls around, an initiative that was originally launched in 2005 will have become increasingly visible. This initiative is called Vision Zero. Yes, Vision Zero has been noticeable as a sponsor to several safety sessions and posters over the years. However, it never quite established roots to a point of intertwining the many aspects involved in a true safety culture ultimately leading to “zero errors of consequence.” AAMS Jonathan Godfrey is leading the effort to bring Vision Zero back to life and touch those on the line making decisions on a moment's notice that can be the deciding factor in a performing a safe transport, whether by air or ground.

One of the mandates introduced and agreed upon by the original Vision Zero group—which consisted of representation by all the professional associations, AAMS, FARE, and CAMTS—was the creation of a scorecard to monitor progress on new safety initiatives undertaken in our community. It has taken 4 years and the loss of many lives, but we are approaching completion on two projects that will meet this mandate. One is the HEMS Industry Risk Profile, and the other is the Safety Base Camp Project Scorecard. There has been much attention on the HEMS IRP, so I'd like to take a moment to talk about the base camp scorecard.

On July 25, 2008, approximately 120 people met in Dallas/Ft Worth for a 1-day safety base camp to work together as a community to dive deep into the causes of HEMS crashes. At AMTC 2008, a preliminary draft of the notes compiled from that day was distributed. Many hours of hard work by a small group of people have gone into completing the document. The final product is a scorecard listing the seven areas of focus along with objectives, measurements of success, timelines, and the primary association responsible for a specific initiative. Once completed, it will be distributed by each association in the manner by which they have identified as best to accomplish the initiatives identified.

Another important project is drawing to a close and will be presented during AMTC 2009. Dr. Ira Blumen and his multidisciplinary team representing the clinical, aviation, and manufacturing aspects of HEMS operations have reviewed and analyzed over 140 HEMS crashes, following the approach established by the International Helicopter Safety Team (IHST). The presentation will include mitigating factors and recommendations to provide decision-makers with an opportunity to determine how and where to make cost-effective safety-related improvements at their programs.

These are just a few of the focused safety efforts happening in our community, and I know from reading news stories and talking with members that many more are happening at the grassroots levels. One of Vision Zero's goals is to create a repository of safety-related initiatives so that we can learn from each other. On the newly designed web page, a “toolbox” will be accessible for such valuable resources. As we have heard before, “Safety is not proprietary.”

When I sat down to write this issue's Forum, I didn't have a theme in mind, yet it looks to have materialized as safety. AMTC provides a global opportunity to network and focus on the many facets involved in the safe and high quality transport of our patients and teams. I am looking forward to learning more about what my colleagues around the world are doing to ensure the Vision Zero goal of Zero Errors of Consequence.

See you in San Jose, California!

Sandy Kinkade, President

Upcoming Events 

July is here as I write, and maybe a hint of summer is finally showing in the Northeast. Certainly numbers of patients and flights are up, despite some disappointing weather. It's the time of year when it is so easy to put off training and administrative chores to take advantage of the nicer weather when it does occur. I know, however, that as professionals we all make that extra effort not to procrastinate and get all our work done!

The Air Medical Transport Conference is not that far off—October 26-28 in San Jose, California. I hope you all have worked out your travel plans for this event. AMPA has two preconferences planned on Sunday, October 25; the Core Curriculum Part II and the Medical Director Forum will run concurrently. The Medical Director Forum will bring many of AMPA's past presidents together on a panel that will discuss air medical topics, past and present. It is a really unique opportunity to talk with some of the people that helped build the foundation for AMPA and much of the air medical community as we know it today. The setting will be casual and allow for plenty of interaction between panel members and attendees.

Core Curriculum Part II will be updated, have a few new speakers, and should be well enjoyed by those attending that session. Lunch will bring both groups together and allow for some networking. It should be a great day for all who attend. The AMPA board meeting will be on Saturday, October 24, and is open to all members of AMPA and all of you are invited to attend.

I want to take this opportunity to reintroduce your board members:

Current board members at large include:

This board, along with so many of the past officers and current members, are constantly working behind the scenes to keep AMPA's projects and goals moving ahead. They deserve recognition for their time, energy, and the good work they do. They have certainly made the first half of my term less stressful, and I thank them for that!

Pat Petersen, as AMPA's executive director, keeps all of us and AMPA on track and remains the epoxy that holds all the many projects and aspects of AMPA together, and I can never thank her enough for all that she does for AMPA and our membership.

Throughout our industry's communities, many safety projects are being worked on as part of our main goal to improve safety in air medicine. AMPA is active in many of these projects while maintaining its own mission commitments by “promoting safe and efficacious patient transportation through quality medical direction, research, education, leadership, and collaboration,” leading to increased safety by continuing education and awareness of the physicians and all others involved in air medical transport. Let's all stay safe!

Upcoming dates to keep aware of:

AMTC in San Jose, October 26-28, 2009

CCTMC in San Antonio, April 12-14, 2010

AirMed World Congress in Brighton, England, May 24-27, 2011

Jack B Davidoff, President

Ownership 

I hear this word thrown around a lot, especially in political circles where one party or individual is trying to take or give ownership of an issue. Having ownership means you take responsibility for something; you own it. Transport nursing is an ownership intensive vocation. We have ownership over our personal safety, personal and professional growth, personal health, and transport nursing at large.

In this day and age, lack of personal ownership and responsibility is becoming more and more the norm; quite pleasantly I find that trend to be the opposite in our profession. One of the things that drove me to become a flight nurse was seeing individuals exhibiting personal ownership, whether it was watching someone do a walk-around prior to a flight, double-checking the security of equipment in an ambulance, or attending a continuing education class on their day off.

It goes without saying that maintaining your personal safety and the safety of your colleagues, the patient, and the public at large is a personal responsibility that requires ownership. To be the best clinically, you have to take personal ownership of maintaining your skill set. Much of the technical skills we perform are perishable and require practice and refinement. The same applies to your career as a whole; no one is going to manage it for you.

The antithesis of ownership is complacency. We all see examples of lowest common denominator behavior in our business. Such behavior gains inertia and can be overwhelming. The same thing goes for those behaviors inside your organization's culture; they are malignant.

ASTNA as an organization owns its mission—advancing the practice of transport nursing, maximizing safety, enhancing education. As ASTNA's president, I encourage each of you to embrace ownership of transport nursing. Own it!

Kevin High, President

Critical Care Paramedic? 

Critical care is not a new concept, yet its definition has eluded us for a decade. For paramedics, the practice of critical care varies from state to state like the color of a calico cat. So what exactly is critical care?

Within the past 5 years, NHTSA and state EMS departments and national organizations have made great strides in an attempt to nationalize EMS through development of the National EMS Scope of Practice Model and the EMS Agenda for the Future. The intent being to create a common vision for the future of EMS and to help guide EMS planning, decision making, and education standards. As an initial stakeholder, the IAFP stands by this initiative and its success for the scope of practice it defines.

Although several national organizations support the growing need for an advanced level of provider care, critical care is beyond the limited scope of the agenda, leaving a significant number of niche paramedic practitioners without a benchmark for education and core competencies. How do we know this? Within the past 2 years, as many national studies have been completed that clearly delineate the advanced role of the critical care paramedic. These studies also revealed a need for consistency in standards. Addressing the expanded scope of practice and the vast difference in quality and competence of critical care paramedics, the IAFP board of directors released a position statement in July that benchmarks eight content areas of critical care and a recommended pathway to certification as a critical care paramedic.

Does the EMS Agenda for the Future conflict with the role of the critical care paramedic? The IAFP does not believe this will have any negative impact on the role of the critical care paramedic. When you look at the National EMS Education Standards, one of the key variables of the didactic curriculum is incorporating critical thinking skills. The new concepts will help develop critical thinking skills at a much earlier point in the clinical provider's career and begin to introduce some concepts that are used daily in the world of critical care medicine. One of the most challenging aspects of creating specialized critical care clinicians is teaching the provider how to analyze and apply critical thinking into appropriate clinical practice. The new enhancements in the EMS Education Agenda for the future, coupled with the IAFP's role of the critical care paramedic, are going to be essential to each other's success.

Now that the IAFP has developed the role of the critical care paramedic and the Board for Critical Care Paramedic Transport Certification (BCCPTC) has developed a valid certifying credential for critical care paramedics, it is essential that we establish a career pathway as a form of mentorship for paramedics aspiring to practice within the realm of critical care. The IAFP is convening a workgroup this fall to develop the career path of a critical care paramedic. The workgroup will be comprised of various members within the critical care industry. We have several other projects on the horizon, and I urge all members who have an interest in working with the board on projects to visit our booth #1829 at AMTC and ask what you can to do to help!

In October, the BCCPTC will be conducting a beta test for the new critical care paramedic certification at AMTC in San Jose and also at EMS Expo in Atlanta. The IAFP is sponsoring the review course at EMS Expo for CCP-C candidates. The BCCTPC reports they are pleased with the show of support and enthusiasm for the new exam. I hope all candidates who are sitting for the FP-C and CC-P exams are studying hard because test day is getting closer; just remember to stay calm, take a deep breath, and good luck!

Hopefully, many of you are gearing up for AMTC at the end of October. The conference promises a lineup of dynamic speakers this year, and I think you will be pleased with the educational content as well. According to the Association of Air Medical Services, the number of vendors and speakers continue to increase every year, and the submissions to lecture were at an all-time high. Also, don't forget to mark your calendars for the IAFP preconference featuring Randolph Mantooth, “Jonny Gage” from TV's “EMERGENCY,” and Drew Dawson, NHTSA EMS Director, on Sunday, October 25, 2009. See the IAFP website www.flightparamedic.org for details. In addition, all members are encouraged to attend our general membership meeting, also on Sunday at 5:30 p.m.

Safe travels and see you in San Jose!

James P. Riley, President

The Scope of Practice for Paramedics in the Critical Care Transport Setting. Completed October 2008.

Job Analysis of the Certified Critical Care Paramedic. Completed February 2009.

The 800-Pound Gorilla 

Here's the scenario: To all of your friends, family, and neighbors, you're living the dream. You've lived here for a little more than a year now. You have a nice home that you would like to stay in indefinitely, and you know deep inside that you couldn't sell it anyway—not in this economy. Your wife is happy and the kids are settled in at school. They have lots of friends, good friends. Things couldn't be better. Other than your wife, no one else knows that this is the third straight month that your program is running low on flight volumes. The rumors are trickling down that your base might close.

It's your last of seven straight night shifts. You haven't flown much, but you still feel tired. The weather tonight is marginal at best, but you know that you need flights. You and your team, who also feel the pressure, somewhat reluctantly accept a 3:30 a.m. flight request. “It doesn't hurt to take a look,” you reason together. As you get closer to the scene, the weather deteriorates, and you get lower and slower to maintain visual contact with the terrain below. “Just a little further on, and this will probably improve,” you think to yourself as you continue to give up a few more feet of altitude and watch your airspeed decay.

A recent survey conducted by NEMSPA among nearly 300 EMS pilots indicated that 1 in 4 feel pressure from outside sources, including pressure from management, medical crews, and competition, to “accept or complete a flight.” Similar surveys have been conducted among other associations with similar results. The NEMSPA survey also showed that 1 in 3 pilots will apply pressure to themselves to accept flights—the “white knight” complex. The pressure to fly syndrome is very real in our industry and certainly has the potential to create scenarios that end in disaster. I have heard it referred to as the “800-pound gorilla” that nobody wants to address.

There are numerous programs in place to educate pilots, managers, and medical crewmembers on the need to isolate flight-related decisions from business or emotional needs. The latter should never influence the former. We believe that good risk-assessment programs are a key component to any flight program. Those programs should require that someone outside of the flight team should be consulted whenever cumulative risk factors become excessive.

NEMSPA has been actively promoting the EDP (enroute decision point) protocol as a simple yet very effective tool in managing the pressure to fly issue. While risk assessment programs are generally designed to keep pilots and flight crewmembers from accepting marginal flights to begin with, the EDP protocols are designed to stop flight teams from continuing into adverse or deteriorating en route weather conditions.

The concept and method are quite basic. When a predetermined airspeed and/or altitude is reached, the pilot has no choice but to land, turn around, or transition to IFR. Continuing on the present course is not an option. Angel One at Arkansas Children's Hospital recently adopted EDP procedures and uses the MECA (Minimum Enroute Cruise Altitude) required by OpSpec A021 as a baseline altitude. When an aircraft gets lower than 800 feet AGL or lower than MECA, whichever is higher, the pilot is required to revert to “plan b” as described above. BJ Raysor, Angel One's director of operations, indicated that they use 60 KIAS as their airspeed limitation.

Intermountain Life Flight, out of Salt Lake City, currently uses 90 KIAS and 300' (day) and 500' (night) as their limitations. When any of those limits are reached during cruise flight, their pilots must turn around, land, or declare an emergency and transition to IFR. The option to continue is not on the table. This program, which employs 14 rotor-wing pilots, conducted its own survey and learned that all of those pilots understand and use the EDP protocol. A full 85% indicated that the EDP system was “very effective” in helping them to “make decisions on whether or not to continue flight into marginal weather conditions.”

An EDP is similar to a DH (decision height) or DA (decision altitude) on an ILS approach. If the DH is reached and the pilot cannot see the runway (or helipad) environment, the only option is to execute a missed approach procedure. The option to continue a little lower in the hopes of picking something up is not an option at all. The DH requirement is a pressure reliever to a pilot. He or she does not need to agonize over whether or not to continue if the prescribed conditions are not met. I spoke with one pilot recently who uses the EDP religiously, and I asked him, “Does it help to take the pressure off of you to complete flights in marginal weather?” His response was, “Absolutely, that is the beauty of this program.” Just as the DH requirement relieves pressure on a pilot executing an ILS, so does the EDP relieve pressure on a pilot facing marginal weather.

NEMSPA is encouraging all flight programs to evaluate and adopt an EDP protocol for their own flight teams and to make those limitations mandatory. You can view and download the basic EDP program definition from www.nemspa.org. If an air medical program is unwilling to establish and enforce formal EDP criteria, an individual pilot could still benefit from complying with a self-imposed EDP.

Kent Johnson, President