14 TRAINING I Vol. 2 I AirRescue I 14

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1 14 TRAINING I Vol. 2 I AirRescue I 14

2 TRAINING 15 Fig. 1: LAA is one out of 18 air ambulance charities in the UK, overall operating around 30 helicopters and flying a total of nearly 20,000 missions per year (Photographs: A. Chesters) Training opportunities in pre-hospital care in the South East of England I Vol. 2 I AirRescue I 15

3 16 TRAINING Fig. 2: The first month of the job is one of the toughest: A whole variety of new skills are learned and the intensive training by experienced pre-hospital care doctors really improves practical skills In the United Kingdom, pre-hospital care is not a recognised specialty in law. There is currently no nationally-agreed structured training programme that trains doctors to a specialty standard in pre-hospital care. Recently, proposals have been developed to designate pre-hospital care as a subspecialty of emergency medicine and anaesthetics, and it is expected that the first cohort of trainees will be recruited and trained in the coming months and years. Many doctors in the UK are active in pre-hospital care. Some work for one of the 12 regional Ambulance Services and some are independent practitioners with voluntary organisations such as the British Association for Immediate Care (BASICS). There are 18 air ambulance charities in the UK, operating around 30 helicopters and flying a total of nearly 20,000 missions per year. Many of these air ambulances are crewed by two paramedics, often seconded by the local ambulance service. Some doctors may volunteer to fly with their local air ambulance, extending the clinical scope of the team. The author joined Essex and Herts Air Ambulance Trust and worked full time with this organisation for a year before spending 6 months as a flight physician at London s Air Ambulance (LAA). This is his firsthand-report. London s Air Ambulance (LAA) was launched in 1989 and provided an opportunity for doctors to work fulltime in pre-hospital care as part of a doctor-paramedic crew responding to major trauma in the London area. Since 1989, many doctors have worked for the service and the model of training, governance, and clinical care has been adopted by a number of other air ambulances in the South East of England, covering a population of around 20 million people. Four charities (London, Essex, Herts, Kent, Surrey and Sussex as well as East Anglia) operate seven aircraft, each with a doctor-paramedic crew, to provide medical cover for the South East of England. Recruitment and selection LAA doctors are senior trainees or consultants, many of whom have already completed specialist training and are looking for a new challenge or to hone their pre-hospital care skills in a busy and well-governed system. Jobs are I Vol. 2 I AirRescue I 16

4 TRAINING 17 advertised annually in professional journals and online, and applicants are interviewed by a panel of senior members of the LAA team. Doctors were previously appointed on a six month full time contract and working exclusively for LAA, but in recent years the post has been linked with full time jobs working for air ambulances in neighbouring counties, so that doctors can now work in pre-hospital care for up to two years. LAA has formed alliances with a number of Helicopter Emergency Medical Service (HEMS) providers in the South East of England. The shared clinical practices, clinical oversight and governance allow clinical staff to work in similar systems but to gain experience in different types of HEMS work. London offers intense exposure to urban trauma (in particular knife and gun crime), whereas the county air ambulance teams are exposed more to high speed road traffic collisions and the challenges of providing pre-hospital care in rural locations that may be some distance from a trauma hospital. In London, a training doctor can expect to see around 140 cases of serious trauma, deliver around 30 pre-hospital anaesthetics and see around 80 lower acuity cases in a 6-month period. Exposure in the county systems is variable but is approximately half that of London, with around 20% of cases being acute medical emergencies rather than major trauma. There are a number of different options as to when in a training programme to apply for a full time job in pre-hospital care. Some doctors choose to apply after completion of specialist training, others take time out from specialist training. For those taking time out, an application must be made to the regional Deanery that is responsible for training. The Deanery will apply to the General Medical Council to get approval for the extension of specialist training and approval will also be sought from the training standards committee of the parent medical college depending on the specialty of the doctor (typically the College of Emergency Medicine, or the Royal College of Anaesthetists). Some posts may be counted towards training in the base specialty (emergency medicine or anaesthesia) and may not extend the total length of specialty training. These posts are designated after inspection by representatives of the medical colleges. Should a post not be accredited, or be only partially accredited, the speciality training of that doctor will be extended and the date of eligibility for certificate of completion of specialist training will be altered. LAA posts have been accredited for training in emergency medicine and anaesthesia for many years, and some of the regional air ambulance posts have also been approved over the last few years. Fig. 3: The HEMS Crew Course (HCC) also includes practical training; London as well as Essex and Herts teams take part in such training, delivered by experienced pre-hospital care doctors and involving simulated patients I Vol. 2 I AirRescue I 17

5 18 TRAINING Fig. 4: A doctor-paramedic team participates in the scenario and it is run in real time by another member of the aircrew, providing appropriate clinical information at relevant times Starting the job the sign off month The first month of the job is one of the toughest, but it is also the most exciting. A whole variety of new skills are learned and the intensive training by experienced prehospital care doctors really hones practical skills and operational knowledge. My first month was undoubtedly difficult and there was a huge learning curve, but it completely prepared me to do a job that offers a different challenge every day. Doctors appointed to any of the South East of England HEMS services are from a variety of backgrounds. One of the principles of training new doctors to do the job is that everyone goes through the same process in the first month of training. This is the sign off month, a period in which the new doctor is supervised by current prehospital care doctors in the service, or by a consultant in pre-hospital care for every clinical shift. There is an extensive tick list of equipment with which to become completely familiar and standard operating procedures of the service to learn in detail. The members of the team with whom the new doctor works, will have gone through the same process and will devote an enormous amount of time to ensure that the new recruit is completely comfortable and competent to work without direct supervision. This dedicated month of supervised one-to-one training is a huge contrast to many other jobs in medicine and is a hugely beneficial learning opportunity. As well as the clinical aspect of the job, there is a vast amount of operational information to learn. Many doctors will never have worked around helicopters and so this element of the job, including navigation and airmanship, is completely new. Continuing governance and training Clinical governance at LAA is considered to be the cornerstone of the operation. There is a system of clinical governance that allows the duty crews to provide cutting edge pre-hospital care to our patients. Senior consult- ants in pre-hospital care maintain oversight of clinical and operational matters in order to ensure that everyone performs to the highest possible standard. Clinical governance is an ongoing process, but the most visible forms are the weekly death and disability meetings and the monthly clinical governance meeting. Another key part of self-reflection and governance is the debrief system. All missions are debriefed by the duty crew, usually on the same day. This allows an opportunity to identify things that went well, and things that may be changed next time to make things run more smoothly. It is also an opportunity for any deviations from LAA standard operating procedures to be identified and discussed. Training scenarios are debriefed in a similar way. Debriefs offer a chance for constructive comments to be made and I have found that they are one of the most valuable learning tools that we have. Crew resource management (CRM) is a concept that was completely new to me when I began working in prehospital care. CRM focuses on the non-clinical factors that can affect our performance on scene and is now considered to be an essential component of training in the South East HEMS system. Medical decision-making is often based on facts and medical procedures are performed on the basis of the technical ability that all our clinicians have. It is CRM that forms the backbone to our interactions on scene and ultimately dictates our ability to provide excellent trauma care to our seriously injured patients in high-pressure situations. There is special emphasis on CRM throughout HEMS training (on scene, in scenario and in mission debriefs) and it is undoubtedly one of the most important concepts that I have learned during this job. Checklists and new perspectives on trauma in the South East HEMS-system Despite the variable and unpredictable nature of pre-hospital care, there is a structure to the day. As well as the overarching governance structure and regular training, the system is made safe by a series of checklists that are conducted by challenge and response with both members of the team taking part. These checklists are used for procedural issues such as checking that all necessary equipment is loaded into the aircraft and rapid response car, and also for certain critical clinical interventions on scene, such as prior to rapid sequence intubation. The introduction of checklists into my clinical practice was a new concept for me, but it was soon clear that their use minimises the chance of mistakes being made under pressure. Even familiar tasks can become difficult when there is so much going on and the use of a well-rehearsed checklist helps to regain control of the situation and ensure that the patient receives the best possible care. I now consider the use of these checklists to be an essential part of clinical practice. The team in London responds to major trauma following a well-defined set of activation criteria. The county systems are also set up to respond to medical emergencies. As an emergency physician, I have been used to receiving these patients into the department but being on I Vol. 2 I AirRescue I 18

6 TRAINING 19 scene offers an entirely new perspective. Special attention is paid to mechanism of injury and predicting patterns of injury in order to anticipate disease processes that have yet to declare themselves. The skill of being able to predict injuries and provide appropriate treatment and triage has been something unique to pre-hospital care training and is something that I intend to develop in my future career. Unique opportunities There are a number of unique opportunities that come with a job as a pre-hospital care doctor in the South East HEMS-system. During my first month, I was entered onto the HEMS Crew Course (HCC), a three-module training programme accredited by the University of Teesside as a Post-graduate Certificate of Professional Development. This amazing course consisted of three modules, a medical, an aviation- and a multi-agency practice module. The medical module was an intensive week of theoretical and practical training delivered by experienced pre-hospital care doctors and involving simulated patients. The simulated scenario is set up to be as realistic as possible and they are almost always based on a real case seen and managed by one of the team. A doctor-paramedic team participates in the scenario and it is run (in real time) by another member of the aircrew, who provides appropriate clinical information at relevant times. The crew participating in the scenario are expected to do everything as if it was for real and we pay particular attention to ensure that the clinical condition of the patient is feasible and realistic. Some of the scenarios are difficult and we will try to recreate some of the stresses of a real job in order to enhance the training experience. The debrief for our training scenarios is the same as for live missions and key learning points can be drawn out and discussed in detail. The aviation module was an incredible opportunity to learn something completely new. A week-long residential course combined theoretical teaching on the concept of flight, airmanship, meteorology, map-reading with practical sessions on board a helicopter to practice navigation and communication in flight. Underwater rescue and escape as well as issues of flight safety were practiced during the week. The final module was an introduction to multi-agency working with the other emergency services. The Fire and Rescue Service demonstrated and taught extrication techniques and the Police discussed the tactics of firearms situations. Media awareness is another new skill to learn. The air ambulances in the South East of England are heavily reliant on charitable donations in order to continue to provide a year-round service. The costs to the charity can be around 250,000 a month and in order to generate income, the helicopter, the team and the brand must be as visible as possible. The jobs to which the air ambulance is tasked, are high profile and often are featured in local and national media. In addition, part of the duties of the crew is to take part in charity events such as cheque presentations and sponsorship events, which can also generate media interest. It is an important skill to learn to be able to interact with the media, deliver a corporate message, maintain a professional appearance and still remain aware of important issues such as patient confidentiality. Pre-hospital care in the UK is still in development and there is much to learn by sharing experience of national and international teams. During my time in the job, there have been a number of opportunities to attend and speak at high quality national and international conferences and this has been of immense educational value. In London, in particular, there is a 24-hour response by LAA teams to major trauma. At night and when the aircraft is offline, the doctor-paramedic team response is by car. The paramedic is typically responsible for emergency response driving while the doctor navigates. The ability to plot a route in a very short space of time and with no advanced notice, and to navigate from a map through busy and unfamiliar Fig. 5: A week-long residential course combined theoretical teaching on the concept of flight, airmanship, meteorology, map-reading with practical sessions on board a helicopter Fig. 6: In London in particular there is a 24-hour response by the Essex and Herts Air Ambulance doctor-paramedic team and response car to major trauma: at night and when the aircraft is offline, the response is by car I Vol. 2 I AirRescue I 19

7 20 TRAINING Fig. 7: Skills have been honed in forming cohesive teams and getting the best out of that team and this is something that is also critical for effective work in a hospital setting roads is honed and many of the doctors find this amongst the most challenging aspects of the job. Preparation for the future Pre-hospital care is developing in the United Kingdom. There is a move towards the introduction of regional trauma networks with major trauma centres receiving seriously injured patients from a wider area. As these systems go live, the role of specialist pre-hospital care teams will become even more important as these patients must be identified, stabilised as necessary by a clinical team and transported to the most appropriate hospital. Doctors who have been trained in the South East of England HEMS systems, will be well placed to play a significant role in this reorganisation of services in the future. There are a number of things I will take back to the emergency department as I continue my specialist training alongside my continuing work in pre-hospital care. Teamwork has been a large focus of the last 18 months. Skills have been honed in forming cohesive teams and getting the best out of that team and this is something that is also critical for effective work in a hospital setting. Decision making under pressure and the importance of the concepts of crew resource management as well as forward planning and anticipation are skills that have been practiced on a daily basis. Making sure the system is safe through ongoing governance and review, continuous training, checklists and drills have been invaluable and are something that will be invaluable in hospital service development. Final words The last 18 months have been full of challenges for me. I have enjoyed every minute of the job and learned something new every day. It has been easy to remain motivated whilst working with some of the most experienced and passionate clinicians in the business and I feel proud and privileged to have had the opportunity to work with a dynamic team of doctors, paramedics and pilots in Essex and Herts and in London. It has been a thrill to be part of such a professional crew that brings life-saving interventions to seriously ill and injured people and I have received some of the best training of my career. I have been utterly astounded by the tireless work of the charity and volunteer staff who promote the cause and rally the donations in order to keep the aircraft flying and I would recommend this job to anyone. Author: Adam Chesters Specialist Registrar in Emergency Medicine and Pre-Hospital Care at London s Air Ambulance I Vol. 2 I AirRescue I 20

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