Defining the Core Content for Transport Physician Training Programs

Abstract

In many parts of the world, emergency medical services (EMS) clinical care is traditionally delivered by different levels or types of EMS clinicians, such as emergency medical technicians and paramedics. In some areas, physicians are also included among the cadre of professionals administering EMS-based care. This is especially true in the interfacility transport (IFT) setting. Though there is significant overlap between the knowledge and skills necessary to safely and effectively provide care in the IFT and prehospital settings, the IFT care environment requires physicians to develop several additional competencies beyond those that are expected of traditional EMS clinicians. NAEMSP first published recommendations regarding what some of these competencies should be in 1983 and subsequently updated those recommendations in 2002. This document is an updated work, given the evolution of the field.

In many parts of the world, emergency medical services (EMS) clinical care is traditionally delivered by different levels or types of EMS clinicians, such as emergency medical technicians (EMTs) and paramedics. In some areas, physicians are also included among the cadre of professionals administering EMS-based care. This is especially true in the interfacility transport (IFT) setting. Though there is significant overlap between the knowledge and skills necessary to safely and effectively provide care in the IFT and prehospital settings, the IFT care environment requires physicians to develop several additional competencies beyond those that are expected of traditional EMS clinicians. We refer to physicians who are routinely practicing in this environment as transport physicians, who may or may not be the IFT service’s medical director(s). NAEMSP first published recommendations regarding what some of these competencies should be in 1983 and subsequently updated those recommendations in 2002 (1, 2).

The Core Content of EMS Medicine (core content) has since been developed and serves as the basis for the definition of the subspecialty of EMS medicine for physicians (3, 4). This core content is primarily designed to define the competencies that must be demonstrated by candidates for board certification as EMS physicians, and much is also applicable to care delivered in various IFT settings. However, not all physicians providing care in the IFT setting are, or necessarily should be, board certified EMS physicians. Depending on the nature of the IFT service, physicians who are specialists in emergency medicine, pediatric/adult critical care, neonatology, and obstetrics, among other domains, are often well-prepared, integral parts of the IFT team without obtaining board certification in EMS medicine.

NAEMSP believes:

The Physician’s Role on the Transport Team

Individual physicians may serve different roles when functioning as part of transport teams (5). A physician’s role may be to function as a fully integrated crew member, to function as a supplemental clinician present to augment the resources of the crew, or to deploy only intermittently to perform a specific mission. Thus, transport services may choose to vary the transport physician’s training accordingly.

Medical Training of the Transport Physician

Transport programs should ensure that transport physicians have the foundational knowledge, training, and experience regarding patient populations relevant to the IFT service. They should also ensure that transport physicians are ready and able to perform appropriate resuscitative and emergency procedures as defined in the core content. Furthermore, transport physician programs should establish clinical development practices that support transport physicians in attaining and maintaining clinical competency in any other interventions that may be beyond the scope outlined in the core content but that are still appropriate to the transport program’s respective mission(s) (e.g., neonatal medicine, advanced hemodynamic support devices, and high-risk obstetrics). While board certification in EMS medicine may not be needed depending on the role of the transport physician, it is recommended for physicians routinely practicing as part of IFT teams as a component of demonstrating competency in the core content of EMS medicine.

Transport Medicine-Specific Competency Areas

In addition to appropriate portions of the core content, transport physician training and education should also include the following topics as applicable to the transport service’s mission and vehicle deployment model:

History and Purpose of Medical Transport

1. Development of air and surface medical transport in military and civilian settings

   1. Models of program structuring

      1. Hospital vs. non-hospital based

      2. Vendor relationships

      3. Transport brokering

      4. Levels of care

      5. Funding models

2. Purpose of medical transports

   1. Rotary-wing transport

   2. Fixed-wing transport

   3. Ground transport

   4. Special issues of international transport including transport via commercial airlines or military transport

3. Overview of roles for air medical transport

   1. Overview of the relevant literature

   2. Operational indications and contraindications

   3. Advantages and disadvantages

   4. Clinical transport criteria of trauma and non-trauma patients

4. Effectiveness of air and land critical care medical transport programs

   1. Patient safety

   2. Quality-adjusted benefits to life

   3. Cost and economics

5. Overview of medical transport professional associations

   1. Air Medical Physician Association

   2. Air and Surface Transport Nurses Association

   3. International Association of Flight and Critical Care Paramedics

   4. National EMS Pilots Association

   5. National Association of Air Medical Communication Specialists

   6. Association of Air Medical Services

   7. Association of Critical Care Transport

   8. Commission on Accreditation of Medical Transport Systems

   9. National Accreditation Alliance of Medical Transport Applications

   10. European Aeromedical Institute

   11. National Association of EMS Physicians

   12. Others relevant based on site

General Transport Safety

1. Aviation incident/accident statistics, causes, and efforts to improve safety

2. Crew resource management/air medical resource Management

3. Appropriate crew member clothing

4. Personal protective equipment

5. Crew restraints and other safety equipment

6. Vehicle design

7. Vehicle inspection

8. General weather considerations

9. Safe response to the destination (consider an emergency vehicle operator course)

10. Patient and equipment loading and unloading

11. Safe use of equipment during transport (including appropriate securing)

12. Highway and roadside safety

13. Fatigue risk management

14. Just culture and culture of safety

Aviation, Aircraft, and Ground Vehicle Safety

1. Platform Specific Considerations

   1. Rotor-wing aircraft

   2. Fixed-wing aircraft

   3. Ground/surface vehicles

2. Enhanced vision technology (as applicable)

3. Weight restrictions and weight/balance assessments

4. Overview of weather as it relates to air transport, especially with regard to minimum standards for operating safely in different weather conditions (i.e., “weather minimums”)

5. Routine aviation issues

   1. Helipad/hangar safety

   2. Routine aircraft ingress/egress

   3. Routine maintenance and refueling

   4. Aircraft startup/cool-down procedures

6. Landing zone (LZ) criteria and safety

   1. Pre-designated landing zones

   2. Emergency landing zones

   3. LZ approach and assessment

   4. LZ safety (rotor wash, rotor hazards)

7. Routine flight activities

   1. Take-off and landing procedures

   2. Aircraft and obstacle sighting/spotting

8. Emergency procedures/equipment

   1. Battery master switch

   2. Fuel shutoff

   3. Door jettison/emergency egress for land and water settings (consider underwater escape training)

   4. Fire extinguisher

   5. Survival kit and emergency locator beacon operation

   6. Rotor brake (where applicable)

   7. Oxygen shutoff valve

9. In-flight emergencies

10. Precautionary landings

11. Survival techniques

12. Search and rescue operations/techniques

13. Emergency vehicle operations

14. Crew, patient, and equipment harnesses and restraints

Transport Regulations

1. Federal Aviation Administration (FAA) regulations

   1. General knowledge of FAA Part 91 (General Operating and Flight Rules) and Part 135 (Operating Requirements, Commuter and on Demand Operations and Rules Governing Persons on Board Such Aircraft)

   2. Visual and instrument flight rules operations

2. Legislative controversies

3. “Best practices and standards” provided by accrediting bodies for transport services

Medical Transport Equipment

1. Medical equipment

   1. Oxygen supply

   2. Noninvasive positive pressure ventilation

   3. Inhaled gas adjuncts (e.g., nitric oxide)

   4. Mechanical ventilator

   5. Noninvasive monitoring

      1. Cardiac monitor/defibrillator/pacer

      2. End-tidal capnography

      3. Pulse oximetry

      4. Automated blood pressure monitoring

      5. Continuous temperature monitoring

      6. Venous and fetal heart tone doppler

   6. Invasive monitoring

      1. Arterial pressure

      2. Central venous pressure

      3. Pulmonary artery catheters

      4. Intracranial pressure

   7. Intravenous/medication infusion pump

   8. Neonatal isolette

   9. Automated/mechanical chest compression device

   10. Intra-aortic balloon pump

   11. Extracorporeal membrane oxygenation

   12. Ventricular assist device

   13. Other specialty equipment

   14. Security, restraint, and electrical interference issues of medical equipment in the ground and flight settings

2. Communications equipment and procedures

Guidelines for Air and Surface Transport

1. Accessing the system

   1. Interfacility/retrieval transfers

   2. Scene responses

2. Dispatching procedure

   1. Emergent and non-emergent transports

   2. Approval issues (weather, weight/balance considerations, etc.)

   3. Administrative approval

   4. Pilot/crew duty time

3. Guidelines for scene response

   1. Safety issues (extrication, fire, hazmat, landing zone selection, etc.)

   2. On-scene command

   3. Timing of interventions

   4. Collaboration with other ground or air medical units

4. Guidelines for interfacility transfer

   1. Interaction with other care teams

   2. Timing of interventions

5. Patient preparation for transport including safe loading and unloading

6. Receiving facilities and specialty capabilities

7. Coordinating ground transport of the air team if necessary

8. Flight following

Flight Physiology (as applicable to the transport service’s mission and vehicle deployment model)

1. Effect of altitude on:

   1. Gas pressure, volume, temperature, and humidity

   2. Liquid/gas interfaces

   3. Patient oxygenation

   4. Medical equipment

2. Noise, vibration, G-forces, and light/flicker

3. Acceleration/deceleration forces

4. Disease specific medical considerations

Human Factors and Clinical Logistics

1. Metacognition and visualization

2. Cognitive resilience and self-talk

3. Tactical breathing

4. Optimizing the out-of-hospital workspace

5. Team communications

   1. Sharing mental models

   2. Team leader: directive, yet flexible and encouraging of input from others

   3. Handoffs

   4. Post-mission debriefs

Legal and Ethical Issues

1. Non-transport

2. Utilization

3. Regionalization and system integration

4. Changes in mode of transport

5. Termination of resuscitation on scene or during transport

6. Licensure and practice when crossing state lines

7. Flight prioritization

8. EMTALA

Local Program-specific content

1. History of the transport program

2. Administrative policies and procedures

3. Clinical guidelines and protocols

4. Integration of transport program into regional disaster/mass casualty incident planning

5. Incident action plan for responding to a crash of a transport vehicle or serious duty-related injury/death of a transport team member

   1. Search and rescue procedures, where applicable

   2. Infection control

6. Documentation (medical charting and other documentation)

7. Logistics

   1. Staffing/scheduling

   2. Stocking/cleaning

   3. Equipment maintenance

8. Quality assurance/quality improvement/utilization review

9. Public relations—services/team composition

10. Outreach programs

    1. Community

    2. Collaboration

       1. EMS partners and landing zone safety

       2. Hospital partners

    3. Utilization

11. Team Members/Roles

    1. Communications specialist

    2. Flight follower

    3. Flight crew (pilot in command, multiple pilots, air crewman)

    4. Aircraft maintenance technician

    5. Medical director

    6. Direct medical oversight

    7. Indirect medical oversight

    8. Medical crew

       1. Transport physician

       2. Transport nurse practitioner/physician assistant

       3. Transport nurse

       4. Transport paramedic

    9. Special medical crew members

       1. Respiratory therapist

       2. Neonatal personnel

       3. Perfusionist/bioengineers

       4. Physician specialist (i.e., subject matter expert)

       5. Others

12. Crew member medical fitness for duty (for flight and/or ground)

Practical Orientation

A practical, hands-on orientation is critical to the training of any physician joining any transport team, regardless of his or her prior medical or transport experience. All members of the transport team should be involved in conducting this practical orientation. The practical orientation should be performed systematically, be overseen by dedicated training personnel, and should include experience with transports during an orientation period. Competency testing specific to the transport environment is a best practice. An interfacility transport agency’s practical orientation must address, at minimum:

1. Aircraft/ambulance operations

2. Safety

3. Communications

4. Equipment

5. Clinical guidelines and protocols

6. Review of an agency’s checklists and quality assurance practices

7. Case scenarios

Transport team physicians must be subject to at least the same level of rigor during competency verification and local credentialing required of other clinicians on the transport team. Additional physician-specific competency verification and credentialing may be necessary for clinical activities that exceed the scope of practice of other transport team members.

Ongoing Skill Maintenance and Verification

Transport team physicians must also be subject to at least the same level of rigor during recurring skill maintenance and competency verification standards as other clinicians on the transport team. Ensuring that a process to ensure ongoing competency exists is the responsibility of the medical direction team. It is reasonable for such a plan to include (i.e., for many requirements to be satisfied by) clinical activities outside of transport medicine.

Acknowledgments

The authors of this document gratefully acknowledge the work of the first edition’s authors: Jon R. Krohmer, Richard C. Hunt, Nicholas Benson, and Russell B. Bieniek. The authors also gratefully acknowledge the second edition’s authors: Stephen H. Thomas and Kenneth A. Williams.

Disclosure statement

No potential conflict of interest was reported by the author(s).