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Prehospital Care: An International Comparison of Independently Developed Training Courses

Open AccessPublished:November 23, 2021DOI:https://doi.org/10.1016/j.amj.2021.10.009

      Abstract

      Objective

      Prehospital and retrieval medicine (PHRM) occurs in a complex work environment. Appropriate training is essential to ensure high standards of clinical care and logistic decision making. Before commencing the role, PHRM doctors have varying levels of experience. This narrative review article aims to describe and compare 6 internationally accepted PHRM courses.

      Methods

      Six PHRM course directors were asked to describe their course in terms of education methods used, course content, and assessment processes. Each of the directors contributed to the discussion process.

      Results

      Although developed independently, all 6 courses use a comparable combination of lectures, simulations, and discussion groups. The amount of each pedagogical modality varies between the courses.

      Conclusion

      We have identified significant similarities and some important differences among some well-accepted independently developed PHRM courses worldwide. Differences in content and the methods of delivery appear linked to the background of participants and service case mix. The authors believe that even in the small niche of PHRM, courses need to be tailored to the participants and the “destination of the participants” (ie, where they are going to use their skills).
      Prehospital and retrieval medicine (PHRM) covers a broad range of diseases and patients with additional environmental challenges.
      • Wilson MH
      • Habig K
      • Wright C
      • Hughes A
      • Davies G
      • Imray CH.
      Pre-hospital emergency medicine.
      To deliver targeted clinical and logistical management of these often critical patients safely, prehospital physicians need skills that extend beyond those learned during the initial university degree and subsequent postgraduate specialization.
      • Mazur S
      • Ellis D.
      Right people, right time: prehospital and retrieval medicine.
      A PHRM physician needs to be able to make decisions, often with limited information; rapidly assess patients for life and limb-threatening conditions; and deliver a wide range of critical interventions in a timely manner.
      • Sollid SJ
      • Bredmose PP
      • Nakstad AR
      • Sandberg M.
      A prospective survey of critical care procedures performed by physicians in helicopter emergency medical service: is clinical exposure enough to stay proficient?.
      ,
      • Reid C
      • Clancy M.
      Life, limb and sight-saving procedures—the challenge of competence in the face of rarity.
      Physician-staffed PHRM services are organized and used in various ways; it would seem logical that this would influence the teaching and training within these services.
      • Howie W
      • Scott-Herring M
      • Pollak AN
      • Galvagno Jr., SM
      Advanced prehospital trauma resuscitation with a physician and certified registered nurse anesthetist: The Shock Trauma “Go-Team.
      • Garner AA.
      The role of physician staffing of helicopter emergency medical services in prehospital trauma response.
      • Ohbe H
      • Isogai S
      • Nakajima M
      • et al.
      Physician-manned prehospital emergency care in tertiary emergency centers in Japan.
      During the 1990s, medical courses emerged that introduced a structured and systematic approach to patient assessment and management using the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) algorithm for critically ill or injured patients.
      • Thim T
      • Krarup NHV
      • Grove EL
      • Rohde CV
      • Løfgren B.
      Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach.
      Royal College of Surgeons
      Advanced Trauma Life Support Course.
      • Kopschina C
      • Stangl R.
      [Prehospital trauma care training course. Integration of emergency physician and rescue services].
      Often, these courses focus on managing clinical ABCDE challenges using a standardized algorithmic approach with little emphasis or need for appreciation of the underlying (patho)physiology. Although this approach may benefit the novice clinician in an unfamiliar time-pressured scenario, for skilled clinicians, this simplified approach is less appropriate, particularly for complex patients, and should be abandoned in favor of more holistic and considered practice.
      For physicians involved in PHRM, individual services have developed and evolved numerous courses and training programs to improve the more complex skills and clinical interaction needed to provide an appropriate, genuinely advanced level of care in this environment.
      To address the extensive range of skills required for PHRM physicians who come from a wide variety of clinical backgrounds, these prehospital courses and programs cover a broad array of topics that are delivered in a variety of different ways using many different teaching strategies. It is the belief of the authors that although physician-led PHRM has many similarities throughout the world, the variability of PHRM systems, utilization, and tasking as well as case mix means that one size does not necessarily fit all when it comes to teaching and training.
      In this narrative review of some of the more well-established PHRM services courses and training programs, we describe and compare the organization, the content, and the pedagogical delivery of these educational activities.

      Methods

      Six larger well-recognized PHRM services worldwide were contacted, and their PHRM courses were selected to be representative for a variety of participants and content combinations. The experienced PHRM providers responsible for these courses and training programs established an informal expert discussion group. This group includes 6 of the authors of this narrative review.
      All participants were asked to give an overall description of their course as well as the pedagogical considerations. In order to more easily compare courses, essential descriptive points are summarized in Tables 1 and 2.
      Table 1Descriptive Factors for 6 Prehospital Care Courses
      SAAS MedSTAR, Emergency Medical Retrieval, Adelaide, AustraliaGothenburg Hospital, Gothenburg, SwedenNSW Ambulance Aeromedical Operations, Sydney, AustraliaLondon's Air Ambulance, London, UKLifeFlight Retrieval Medicine, Queensland, AustraliaAir Ambulance Department, Oslo University Hospital, Oslo, Norway
      No. of participants10-24100321530-3616-24
      Duration (days)10510 (clinical)

      5 (aviation)
      74 (clinical)

      4 (aviation
      3
      Minimum years of postgraduate

      experience
      626668
      Prehospital

      experience
      Not requiredNot requiredNot requiredNot requiredNot requiredRequired
      Prehospital service specificNoNoNoYesNoNo
      Table 2Course Design for 6 Prehospital Care Courses
      SAAS MedSTAR, Emergency Medical Retrieval, Adelaide, AustraliaGothenburg Hospital, Gothenburg, SwedenNSW Ambulance Aeromedical Operations, Sydney, AustraliaLondon's Air Ambulance, London, UKLifeFlight Retrieval Medicine, Queensland, AustraliaAir Ambulance Department, Oslo University Hospital, Oslo, Norway
      Group sizes4-6 people; groups stay together throughout course; mix specialty and experience in group.

      Simulation scenarios run as a 2-person team.
      8-10 people; groups stay together throughout course; mix specialty and experience in group.2-3 people for simulation and examination; workshop groups of 4-8 peopleVaries depending on the type of session; simulation in crew-based teams5-6 people; groups change on a daily basis throughout the course; a 2-person team for simulation4 people; groups stay together throughout the course.
      Lectures (%)20403202025
      Skill stations (%)451041104025
      Simulations (%)354030704050

      Results

      Narrative descriptions of 6 PHRM courses in Australia and Europe are provided.

      SAAS MedSTAR, Emergency Medical Retrieval, Adelaide, Australia

      Participants are senior trainees or consultants generally from a critical care background from emergency medicine, anesthesia, or intensive care medicine and often have no previous PHRM experience. Rescue retrieval paramedics and retrieval flight nurses also attend as key components of the PHRM team. An extensive list of prereading material, as well as online vodcasts and learning modules, is required to be completed by participants before course commencement. The course is delivered using a variety of formats with some didactic lectures or short recaps of precourse learning but a bigger emphasis on hands-on skill stations, simulations, and scenarios. As well as clinical training, manual handling and aircraft safety/crewing are also incorporated. Postcourse participants are required to complete competency sign-off for procedures and undertake a small number of buddy or supervised shifts before independent practice.

      Gothenburg Hospital, Gothenburg, Sweden

      The course was introduced more than 10 years ago as a reaction to what was perceived as a widespread misconception that existing concept courses delivered gold standard knowledge. The course's ideology was to help participants rise above the often quite basic level many of these “life-support” franchises taught at the time.
      Participants are registrars in anesthesia/intensive care and emergency medicine, very few with PHRM experience. Some specialists attend the course before committing to prehospital positions. The course literature that the participants are expected to study and familiarize themselves with is available before the course starts.
      Another course principle is that most specialist physicians taking part in the course will work very little, if at all, in the prehospital environment. On the other hand, all trainees will take part or even lead in-hospital resuscitation efforts. Therefore, 1 course objective is to deliver knowledge and competence that is applicable and usable, not only in the prehospital environment but also in resuscitation situations inside the hospital. This is consistent with course ideology that the quality of care should be equal regardless of where resuscitation takes place, an ambition that raises the challenge of delivering high-quality resuscitation care.
      Originally, the course was aimed at trainees in anesthesia/intensive care. With the introduction of the emergency medicine specialty in Sweden, the course has opened up for trainees from this specialty as well. This has enriched the course in many ways but also posed some challenges with participants with a more varied level of clinical background.

      NSW Ambulance Aeromedical Operations, Sydney, Australia

      Physicians’ specialty background is close to 50% emergency medicine and 50% anesthesia. Some are new to Australia, and many are new to out-of-hospital care. A smaller number of new helicopter emergency medical service critical care paramedics also require training, and some existing critical care paramedics attend for refresher training. The curriculum aims to redress imbalances among these different professional groups in scene management, airway management and anesthesia, critical care, and trauma procedures.
      The focus of training is on team performance rather than individual knowledge. Simulation training and all assessments are consequently performed in teams to foster a collaborative mindset from day 1.
      Interhospital critical care is covered in the first week because this builds on the existing critical care knowledge of the erstwhile hospital-based physicians and allows them to acclimatize to the team structure and systems of governance. Week 2 introduces prehospital care with an emphasis on safety, scene management, mission momentum, and rapid trauma procedures. Human factors and environmental challenges are introduced into simulation training with incremental stress exposure and perturbation training to build team resilience.

      London's Air Ambulance, London, UK

      Flight physicians and paramedics participate in all aspects of the course together. Attendees are from our own and other similar services in the United Kingdom and beyond. Lectures related to core clinical subjects are focused predominantly on prehospital trauma care. “Hands-on” work takes various forms including workshops, facilitated moulages, coached moulages, and full moulages.
      The material builds in a spiral method during the week. Day 6 is a simulated 12-hour shift at work in which teams are activated to different simulated missions but with embedded faculty members in support of the team. Candidates are encouraged to take part in the broadest aspects of a day at work, including conversations with simulated families and technical and nontechnical debriefs. Faculty “windows” allow for key teaching to be delivered.

      LifeFlight Retrieval Medicine, Queensland, Australia

      Trainees are predominately senior emergency trainees (70%) or anesthetic trainees (30%). Most have minimal experience in prehospital care and retrieval. The clinical component focuses on developing new skills in prehospital care and adapting the critical care skills of the candidates to a new environment. Communication, handover, and crew resource management (CRM) skills are reinforced with simulation. Lectures are limited to focus on major concepts (eg, prehospital anesthesia or hemorrhage control); the majority of this is hands-on skill stations and simulation. Local ambulance and fire services are involved in combined extrication training and outdoor simulations at a purpose-built training facility. Trainees have further orientation at individual helicopter bases, sign-off of critical interventions and equipment, and supervised shifts before commencing work for LifeFlight.

      Air Ambulance Department, Oslo University Hospital, Oslo, Norway

      Participants must have prehospital experience, and > 90% are consultant anesthesiologists already working in prehospital care. The participants come from various prehospital services around Scandinavia. The course is designed to take advantage of participants’ previous and extensive experience, which is emphasized at the beginning of the course. The majority of the teaching is conducted using the experience and knowledge from participants. The number of lectures is kept to a minimum. There are 4 hours of simulations on all days, as well as several small group sessions. Participants are encouraged to share experiences, especially during evening sessions like “Wine and Reflections.” The course is organized by the Air Ambulance Department of Oslo University Hospital.
      An overview of the courses is shown in Tables 1 and 2. All courses cover a broad spectrum of PHRM topics. The courses all use a multiprofessional faculty consisting of experienced PHRM providers. The pedagogical methods used have simulation and debriefing as a common teaching technique. Both low- and moderate-fidelity manikins as well as live actors are used in the simulations in all the courses. Group case discussions are used in all courses as well as expert faculty demonstrations. For 5 of the courses, there is an assessment at the end of the course in either a written format and/or a demonstration of skills independently or within simulations. Precourse preparation is a key component in all the courses. This consists of a variety of written or online material including service-specific standard operating procedures (SOPs), relevant readings from the medical literature, and an introduction to specialized PHRM equipment.

      Discussion

      We have described the PHRM courses from 3 services across Australia and 3 countries in Northwest Europe. Despite independent development, the courses described have significant content features and delivery modes in common, although there are important variations. These different services from different parts of the world have independently come to similar conclusions about the essential concepts required for PHRM clinicians and what are good ways of developing and imparting this knowledge. The variation that does exist seems most reflective of the differences in both operating patterns and case mix for the related services as well as the starting point and desired outcome for the attending participants. In the following discussion, we address the importance of acknowledging these differences when looking at PHRM courses.

      Participant/Students

      The difference in knowledge, skills, and attitudes expected from novices attending an introductory course compared with an experienced practitioner can be immense. It is a matter of debate if this needs to be considered during individual simulations, but the authors agree that it is vital to understand this when designing a PHRM course. Standardized courses deliver standardized training, whereas these courses try to adapt to learner needs by supporting mastery learning.
      • Barsness KA.
      Achieving expert performance through simulation-based education and application of mastery learning principles.
      Although receiving both pre- and postgraduate teaching in similar ways, PHRM course participants come from various clinical backgrounds and incorporated within this are the different learning traits of individual students.
      • Reed S
      • Shell R
      • Kassis K
      • et al.
      Applying adult learning practices in medical education.
      • Jones R.
      Learning and teaching in small groups: characteristics, benefits, problems and approaches.
      • Jones RW.
      Problem-based learning: description, advantages, disadvantages, scenarios and facilitation.
      • Ryan E
      • Poole C.
      Impact of virtual learning environment on students’ satisfaction, engagement, recall, and retention.
      The background of the students on a course is a critical consideration during course planning.
      It is important to remember that although students on many of the courses may be PHRM novices, they are usually experienced physicians that have a good understanding of and experience with critical care patients and procedures. The challenge is the application of this knowledge and procedures to the PHRM environment. For the novice in PHRM, considerable emphasis needs to be placed on the variation and change in the working environment and how managing it or adapting to it is a critical part of overall patient management. Within PHRM training, this is done with an emphasis on both rapid-cycle deliberate practice as well as including additional environmental and psychological stressors in the teaching environment.
      • Lauria MJ
      • Gallo IA
      • Rush S
      • Brooks J
      • Spiegel R
      • Weingart SD.
      Psychological skills to improve emergency care providers' performance under stress.
      • Cory MJ
      • Colman N
      • McCracken CE
      • Hebbar KB.
      Rapid cycle deliberate practice versus reflective debriefing for pediatric septic shock training.
      • Yan DH
      • Slidell MB
      • McQueen A.
      Using rapid cycle deliberate practice to improve primary and secondary survey in pediatric trauma.

      Destination of the Students

      In the described courses, the destination of the students varies. For courses organized by the PHRM service that the students are joining, interprofessional team training, including paramedics and PHRM nurses, is an essential part of the training. Such interprofessional training is well recognized for providing positive outcomes on both team behavior and patient outcomes.
      • Reeves S
      • Fletcher S
      • Barr H
      • et al.
      A BEME systematic review of the effects of interprofessional education: BEME Guide No. 39.
      By training with the team and within the organization that the students are going to be working in, familiarization is optimized, CRM is enhanced, and service-specific SOPs can be used. If the services focus is on a specific medical population subset (ie, a trauma population or neonates and pediatrics), then this is reflected in the course.
      In contrast, when the student's destination could be any number of different services, the simulation training is of a more generic/broad nature. These courses have either non–service-specific students or are specific for services attending the broader population of PHRM medicine. Such issues need to be considered when planning the course content. Some service-specific courses may expand their content and course participants to include non–service-specific training to facilitate network building among other services in a region or internationally and for sharing of SOPs and experiences. However, initial curriculum development must always begin with assessing the needs of the organization and the individual learner.
      • Kern DE.
      A six-step approach to curriculum development.

      Simulation and Group Training

      All the described courses use simulation training as an integral part of the teaching, although this is used in different ways. All the authors agreed that for novice PHRM participants, a clear progression in the simulation stations’ complexity should be ensured because overwhelming a learner with a complex scenario initially, although realistic, may have a negative impact. Many of the programs progress scenarios along simple scenario–simple environment, complex scenario–simple environment, simple scenario–complex environment, and complex scenario–complex environment pathways. The use of skills stations or deliberate rapid-cycle practice is used in some courses in which experienced providers may need optimization of a specific skill for prehospital use.
      • Bucklin BA
      • Asdigian NL
      • Hawkins JL
      • Klein U.
      Making it stick: use of active learning strategies in continuing medical education.
      Examples of this are training for emergency cricothyroidotomy or prehospital treatment of pneumothoraces or handling a patient during extrication. This may be undertaken before inserting the specific skills within a scenario to place the skills into context.

      Background of Lectures

      Traditional lecture-based teaching has been used for centuries.
      Osler
      An Introductory Address ON EXAMINATIONS, EXAMINERS, AND EXAMINEES.
      ,
      • Nandi P
      • Chan J
      • Chan C
      • Chan P
      • Chan L.
      Undergraduate medical education: comparison of problem-based learning and conventional teaching.
      However, the number of lectures vary from 3% to 80% (as shown in Table 2), with a median of 20%. In the last few decades, the previous emphasis on lecture-based teaching has been questioned and is increasingly replaced by other teaching methods such as focus groups, discussion groups, simulation, and flipped classroom-based teaching.
      • Rotellar C
      • Cain J.
      Research, perspectives, and recommendations on implementing the flipped classroom.
      Although there is a smaller proportion of the teaching that is delivered as lectures, these still have some benefits and a role for general introduction and information about a topic, particularly when a consistent core principle needs to be delivered to a large group and when teaching resources may be limited.

      Lectures Versus Skill Stations

      The described courses have a small total percentage of lectures versus skill stations, discussion groups, or simulation (Table 2). This likely reflects the focus of the courses on team-based learning and CRM, equipment and environmental challenges, and the understanding that the background knowledge base of clinicians coming into PHRM is quite high with more time and effort required on the skills and attitude required. It is the experience of the authors that the hands-on nature of the role of the PHRM specialist suits this style of teaching. Traditional lectures on specific topics can still add value but in some of the courses have been entirely replaced by extensive precourse material. The flipped classroom concept using vodcasts and podcasts as prerecorded lectures so course participants can review them before course attendance is used. This maximizes the use of course time with practical sessions and small group contact and has proven popular with some of the programs described. For specialist topics with an external speaker delivering a lecture, this may be more economically feasible and time efficient than small group learning.

      Specific Teaching Methods

      Rapid-cycle deliberate practice is a simulation-based teaching model in which the student rapidly cycles between deliberate practice and direct feedback until mastery is achieved.
      • Hunt EA
      • Duval-Arnould JM
      • Nelson-McMillan KL
      • et al.
      Pediatric resident resuscitation skills improve after "rapid cycle deliberate practice" training.
      This form of teaching is beneficial for novices entering PHRM and in role-focused training helps to reinforce SOPs.
      The PHRM simulation training programs incorporate both postsimulation debriefing and debriefing on demand. Postsimulation debriefing is commonly used in group-based training.
      • Sawyer T
      • Eppich W
      • Brett-Fleegler M
      • Grant V
      • Cheng A.
      More than one way to debrief: a critical review of healthcare simulation debriefing methods.
      This form of debriefing and the dedicated time it requires for in-depth discussions and exchange of experiences of all participants and observers is in contrast to the debriefing on-demand method.
      • McMullen M
      • Wilson R
      • Fleming M
      • et al.
      Debriefing-on-demand: a pilot assessment of using a "pause button" in medical simulation.
      Here, a “pause button” is used, which facilitates immediate reflection and correction if needed. In this way, there are fewer chances of obtaining bad habits/learning and retaining poor performance that might lead to poor performance at a later stage and poor patient outcome. Within the previously described programs, both types of debriefing are incorporated. Debriefing on demand is generally used earlier in the course programs as more of a teaching tool when students are less familiar with PHRM processes; as they progress, the debriefs tend toward postsimulation debriefing, which is often less of a teaching process (although this still occurs) and more of an assessment process. All the courses use a broad spectrum of teaching and debriefing modalities.

      Faculty

      All the courses use experienced PHRM consultants as faculty. This has several benefits, including credibility, experience, knowledge of a service or a region, availability, and sustainability. Some programs also use experienced paramedic and nursing staff, which has the benefits of developing team CRM, showing the value of interprofessional education, using the experience and unique skill sets with this group, and helping develop the flatter hierarchical structure that is often of benefit in PHRM. The use of other professions with PHRM experience helps broaden students’ perspectives as well as strengthening teamwork.
      Some courses also invite in-hospital specialists. They can contribute to narrow subspecialty topics (ie, toxicology or other niche topics/in-depth cardiology). A beneficial aspect of using in-hospital teachers is that it streamlines mutual expectation in the interface between in-hospital medicine and PHRM.

      Assessment

      Assessment is achieved by various tools reflecting the differing nature of the courses and the varying assessment cultures between countries. Courses in which the participants are about to start a PHRM rotation within a specific service often have higher scrutiny levels with a mix of observation/feedback by faculty, participation in simulated patient scenarios, or procedural assessment. Little is known about the right way to assess students. Scenarios with or without formal assessment are used, and some PHRM courses use continuous assessment as a more formal process throughout the course. The authors all agree that some form of observed practical assessment is an important part of the overall assessment process in helping decide on a candidate's ability to work effectively in the PHRM environment.

      Limitations

      This article is a comparative description only and is limited in its qualitative scientific methods, but it is hoped this may form a base for more rigorous qualitative research in the education field. The services discussed are confined to Northwest Europe and Australasia.

      Conclusions

      We have identified similarities and differences among some well-recognized PHRM courses worldwide. Although independently developed, a similar pattern of course content and teaching methodology has evolved. In many instances, course directors and teachers independently came to the same conclusions about what training is needed for the PHRM clinician and what is an effective format for delivering that education with a higher degree of sophistication. Differences that do exist relate to some aspects of content as well as the background of participants and in some cases the method of delivery. The authors believe that even in the small niche of PHRM, courses should be tailored not only to the participants but also to the destination of the participants (ie, in which organization and context they will use their skills).

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