The practice of crew resource management (CRM) training is now considered essential by those operating in the airborne special missions sector, whether it is for search and rescue or air ambulance operations. 

Whether medical personnel onboard rescue flights should be considered as part of the crew is not always immediately easy to determine from a regulatory point of view. Under European aviation safety regulations, for example, the role of medical personnel is not regulated as that of crew members, unlike the operators of hoist and night vision imaging systems, who are considered crew in all respects. Indeed, medical personnel are referred to as ‘medical passengers’ only. Yet their role often encompasses more than just looking after the health of the casualty or rescue and, because of this, they need to be integrated with the rest of the operating crew in accordance with CRM principles.

The role of medical personnel as crew

According to Carlos Salinas, Chief Executive Officer (CEO) of fixed-wing air ambulance operator Jet Rescue, medical personnel should be considered as crew: “The reason behind this is that they are trained to be a crew member. With Jet Rescue, they perform essential duties related to the safety of the aircraft, such as operating doors and loading and unloading patients, etc.”

The helicopter medical crew of Germany’s air rescue organization DRF Luftrettung consists of a paramedic and an emergency physician. In this arrangement, only the paramedic has an additional flight qualification such as helicopter emergency medical services technical crew member (HEMS-TC), and is therefore officially a cockpit crew member. “The emergency physician is officially classified as a cabin passenger, but s/he is included in the decision-making process of the crew,” explained Christoph Lind, Co-ordinator of Human Factors Training and HEMS-TC at DRF Luftrettung.

Air Methods in the US also designates its clinicians as crew members, as they play a key role in maintaining safe operations through co-ordination with the pilot. “As an example, they do so during the take-off and landing phases, assisting with visual monitoring for obstacles and clearance. In addition, during an in-flight irregularity, they co-ordinate with the procedures or checklists to ensure the safety of all onboard,” said Joseph Resnik, Senior Vice-President of Safety at Air Methods.

Medical personnel at Bristow are integral technical crewmembers who participate in all aspects of the search and rescue programmes, including external rescue hoist operations. “It is not atypical to directly support an offshore medevac via rescue hoist to an underway vessel lacking a suitable helideck, as sometimes the only way out is up. This unique aspect sets our search and rescue (SAR) flight paramedics apart from a typical medical crewmember on an air ambulance aircraft,” said David Jacob, Regional SAR Manager for the US and Caribbean at Bristow.

Bristow’s SAR operations in the US and Caribbean have a full-time critical care paramedic assigned to each duty aircraft. “In the case of our Galliano (Louisiana) base, this means three medics are always on duty. As such, we consider all our medical providers to be part of the operating crew and not merely passengers. Integrating the medical providers into the operating crew environment ensures we train and conduct missions as one team,” explained Martin Kemp, Technical Crew Standards Lead for the US and Caribbean at Bristow. “Everyone on the aircraft has an input into how the task is completed and is free to speak up if anything does not feel right. An extra set of eyes while airborne is also a valuable addition, whether looking for the patient during a search or other aircraft when operating in busy airspace.”

Responsibilities and roles vary in air medical missions

According to Salinas, being a flight medical attendant – i.e., doctor, nurse, or medic – demands extra skills and training when compared to, for example, ground crews. “They fully understand that their responsibilities are way beyond patient care. Patient care is only one component of their duties. Equally important are safety, situational awareness, and customer service. A medical crewmember who only focusses on patient care may be a threat to safety and to the mission itself,” he added.

Lind believes that taking responsibility in a flight mission in general means trusting everyone else in the crew: “Every crewmember can rely on the support of any other crewmember in all kinds of situations. So, it is always a good collective feeling, which is essential for the successful completion of their missions. Providing optimal patient care and safety aspects are the overall goals.”

Indeed, it is important to strike an even balance between patient care and flight safety. “We are fortunate to fly dual pilot, and our SAR aircraft also have two technical crewmembers on board,” noted Kemp. “This crew composition frees up the medics to focus on the patient. Equally important, many of our technical crewmembers are also nationally registered emergency medical technicians (EMT) and paramedics, so they can assist the medics on the more medically challenging calls.”

Resnik says that Air Methods’ clinicians take great pride in their role as members of the crew. “During normal operations in cruise, the medical crew can stay focussed on the patient, but when necessary, the safe return of all onboard always takes precedent, and our medical crews do an excellent job of maintaining the balance to ensure our patients get the highest level of care possible,” he observed.

The role of CRM training

To ensure safety and effective patient care onboard air rescue missions, all crewmembers should be trained and re-trained periodically in all aspects of the mission profile, aircraft safety, crew co-ordination, and decision making. “CRM training is an essential component designed to enhance the air medical industry’s safety culture by promoting group cohesiveness and adaptation during change. Patient safety, like aviation safety, is a complex interaction of systems, human factors, and technology. The aviation and medical fields know that without a continuous effort and focus on safety, preventable mistakes can easily go unnoticed,” Salinas told AirMed&Rescue.

The practice of CRM training, and of the related procedures, drive proficiency in an air rescue environment, and is doubtless considered essential by those operating in the sector. “We deliver CRM training both during initial and recurrent training sessions as well as during practice at the bases with the pilots at the local level,” confirmed Resnik. “CRM creates the avenue and the mindset to ensure the practice is just as real as the daily routine, both for normal operations and irregular ops.”

According to Lind, CRM training plays an important role in professional development, since knowledge of human factors is essential to deal with workload, stress, and fatigue: “CRM training sharpens situational awareness, which is necessary for a successful mission. In the end, the process consists of mental training and its implementation into the entire team,” he said. “In parallel with CRM training, medical personnel can be made more proficient with regard to their air mission responsibilities through daily briefings and debriefings, learning and training in a combination of flight operations and medicine and continuous simulation and skill training.”

According to Kemp, the proficiency of medical crews is maintained when there is ongoing training, both in the air and on the ground. “Since we do not use constituted crews, regular training flights allow medical crewmembers to interact with a variety of pilots and technical crew. CRM plays a huge role in the search and rescue mission,” he told AirMed&Rescue. “Crews must communicate efficiently and effectively to ensure the safety of the aircraft, rescue personnel and, ultimately, the patient. Although the ultimate responsibility for the aircraft lies with the pilot in command, each crewmember has stop work authority and can call off a mission or aspect of a mission at any time.

Peculiarities of CRM for medical personnel

A defining feature of CRM training for medical personnel is that the best practices that have led to the reduction of errors and incidents in aviation, must be transferred into the practice of medicine. “The main peculiarity is that CRM for medical crews encompasses both flight safety and patient safety. The CRM concept evolved after a fatal accident of two 747 jumbo jets back in 1977,” noted Salinas. “In the early 1980s, airlines started training their flight crews. By 1990, it had become a global standard. The air medical resource management (AMRM) concept was conceived from the roots of CRM.”

Kemp observes that often, medical providers enter the SAR and HEMS arena with little or no experience working in the airborne environment. “Not only must they provide ongoing medical care for some of the most critically injured or sick patients, but they now must also contend with a barrage of other factors such as busy air traffic frequencies, crowded airspace, and possibly hostile weather conditions,” he pointed out.

Many ground EMS systems have incorporated CRM into the way they operate, so the concept may not be completely alien to these new providers, continues Kemp. “Adapting their knowledge to the aircraft environment, however, can be challenging. Solid training and mentoring programs can assist with the transition. In the case of Bristow, yearly CRM training and the willingness of leadership to be open to crew recommendations ensures all our crew members, no matter what position they hold, have a voice,” he told AirMed&Rescue.

An important requirement is that medical personnel recognise the essence of CRM. “Only then, CRM will be properly implemented. Overall, the medical sector is increasingly realising that it is a high-sensitive system in which CRM should be a dogmatic component. CRM must evolve in all areas to new events, newly discovered sources of error, new psychological studies and findings and cases. Building on these, concepts have to be rethought, rebuilt and re-trained,” concluded Lind.

Indeed, CRM is an area of continuous improvement. “We are always looking for avenues to improve the co-ordination within the crews and create a more realistic experience for both flight and medical crew members,” said Resnik.

The evolution of CRM as a concept, and now as a real-life training opportunity, in the airborne special missions sector has brought increasing levels of safety and cohesion to air medical and SAR operations. The fact that operators around the world have embraced the concept wholeheartedly demonstrates the importance of it as a means of enhancing the safety of everyone onboard the aircraft.