There has been a considerable growth in recent years in openly accessible and crowd-sourced materials that can be used to supplement and enhance traditional educational methods.

Dr David Denman, writing on Life in the Fast Lane1, believes that although clinical research forms the backbone of medical practice, ‘there is an increasing feeling that our systems of research have not been serving us as well as we think’. Limitations and conflicts of interest are recognized to be a widespread problem in the publication of clinical trial results. “One of the potential solutions,” he said, “is open access publication.” FOAMed could offer a way to fill a gap in ongoing professional development for physicians.

Changing standard operating procedures due to online recommendations

For many air medical and SAR operators, when seeking to change or review practices and standard operating procedures, there are a number of resources that can be utilized while researching best practices among colleagues and peers. Published, peer-reviewed articles used to be the only means of exchanging information. Valuable, for sure, but in many ways, limited. 

For Stuart Cox, Specialist Practitioner Critical Care with the UK’s Dorset & Somerset Air Ambulance (DSAA), social media and the advent of FOAMed has changed the game for emergency clinicians seeking input from fellow medical professionals. “The so-called ‘grey’ resources,” he told AirMed&Rescue, “while unpublished in a technical sense, can be just as useful as evidence-based research and product literature. You just have to evaluate all the information you are being offered from different sources.” 

When asked about a specific example of where social media had aided in the development of a practice or protocol, Cox cited the case of when, in late 2019, DSAA was experiencing issues with a piece of equipment that was not working effectively in sub-zero temperatures. “Despite approaches to the manufacturer for assistance with contact information of other users who may have experienced the same issue and had found a solution, we were unable to make any progress using this route.”

So, instead, Cox and the team turned to social media for help – specifically, Twitter and Instagram. A quick search for the #airambulance hashtag and some direct messages to the doctors who work onboard the aircraft was all it took – one week later, the team had their solution. “Other users had experienced this same issue, and had found a way around it with a product that couldn’t be identified,” said Cox. “We spoke to operators in Sweden, Norway, Canada and the US, and interestingly, they had all come up with the same solution, which was a product not immediately available in the UK market, but appropriately EN ISO marked.”

It was sourced, presented to the equipment governance committee with appropriate clinical datasheets and its approvals, and the problem was resolved. “Is it a backdoor approach?” asked Cox. “Probably. But it is effective, has improved patient safety and has prevented device failure.” What more could you ask for?

While social media certainly has its detractors and its dangers, it is the willingness of people to be open and share information via social media channels that they might not otherwise be willing or able to on other channels that makes the platform so valuable to pre-hospital physicians. “You can sometimes get caught in a corporate or competitive issue if you go through an organization,” said Cox. “Communicating with other healthcare professionals has yielded different results for us. Healthcare professionals don’t go into healthcare for the money, they get into it to improve patient care, and that, ultimately, is their goal. Before social media, getting access to these people would have been almost impossible,” said Cox. “Even if a manufacturer were to be willing to share client information, one has to be mindful that the client could be biased towards that product or business.”

If, by sharing information via social media channels, other patients can be saved, then it’s worth the risk. That’s not to say that every bit of information one receives via social media should be taken as gospel – far from it, said Cox. “We were able to confidently follow the advice we were given regarding the equipment we had an issue with, because every single person we spoke to had actually come up with the same product to fix the problem. But all the information and advice must be carefully considered and weighed against all the evidence and accreditation. Never change a process due to one opinion.”

But all the information and advice must be carefully considered and weighed against all the evidence and accreditation

It’s a brave new world of collaborative working for pre-hospital flight physicians – building a network of trusted professionals online means that there is a strong community of medical professionals who want to share information that improves best practice and ultimately have a positive impact on patient care. 

Knowing which resources are best for particular problems is also important – there was no point, for example, in approaching an operator in Australia for their experience in working in sub-zero temperatures, said Cox. “If, however, I had a problem with an airway device, then I would be onto Sydney HEMS Airway Register as a primary resource.”

Don't believe everything you read online

The danger of believing everything you read online is only too well known – #fakenews is now so prevalent online that it’s scary. You would hope, however, that no-one using the #FOAMed hashtag would purposefully put out something incorrect. However, flawed or incorrect research does happen, and it can be shared online, where it can quickly spread.

In 2018, Sarah Edwards and Damian Roland wrote a short report, Learning from mistakes in social media, which used the example of the East Midlands Emergency Medicine Educational Media, a web-based resource that offers emergency medicine learning materials.

The ECG mistake was picked up on Facebook 40 hours after posting by a follower. The infographic mistake was picked up on Reddit, within three hours

Edwards and Roland explained: “In October 2018, we inadvertently shared two sets of incorrect learning materials via social media because of a non-intentional mistake.” Their report then highlighted how the errors were perpetuated, but then corrected. The two posts were made to Facebook, Instagram, Twitter and Reddit. “One was an incorrect ECG where a paced rhythm was published instead of an ECG of hypocalcemia; the other was incorrect information contained within an infographic. We reviewed the analytics of the posts, on each of the social media platforms.” The ECG mistake was picked up on Facebook 40 hours after posting by a follower. The infographic mistake was picked up on Reddit, within three hours. Despite these mistakes, and their correction, they continued to be shared on both Twitter and Facebook. The posts reached over 15,000 people.

Simon Carley, writing in the Emergency Medicine Journal in 2019, wrote about this topic in his paper ‘#FOAMed errors: does the opportunity for speedy resolution outweigh the risk of rapid dissemination?’2. In it, he wrote: “Concerns about the quality and control of #FOAMed-based learning has focused on the risks of early adoption, content bias and dissemination of false information. These concerns have been addressed by #FOAMed creators who have argued that the ability of online publishing to react rapidly is a strength rather than a weakness.”

Sharing best practice and supporting fellow air medical crews

Real-time interaction and discussion is another great way for clinicians to share research and best practice, and onset of Covid-19 has meant that, with no real-world conferences to attend, online became the only option.

Stuart Elms, Clinical Director at Essex & Herts Air Ambulance, told AirMed&Rescue: “Traditionally, air ambulances have been open to helping each other and sharing information and ideas. Joint research occurs regularly and a call for help will often be picked up quickly. But during the initial Covid-19 peak, it became clear that not only was there a need for sharing ideas but also sharing more. Equipment, PPE, PPE stockholders, ideas for staff welfare were all needed. More importantly, the sharing of the burden of leadership was needed.”

Clinicians from air ambulance charities across the UK have shared their experiences of dealing with Covid-19 in a specially arranged webinar. The webinar was developed following a series of video calls involving directors of many of the UK’s air ambulances, held during the pandemic as a way of sharing information, best practice, their experiences and offering mutual support when needed.

The online meetings started during the pandemic by the operations and clinical directors of air ambulances rapidly developed a synergy where experiences and knowledge was shared to the benefit of all air ambulances

During the meeting, nearly 100 delegates from air ambulances across the country heard expert speakers discuss some of the challenges faced by those working in pre-hospital and retrieval medicine during the pandemic, and the learning points that have emerged.

Hosted by Elms, the three-hour online gathering included presentations on Covid-19 and its impact on patients, communicating under pressure, a very challenging case involving a young person, moral injury in Covid-19, and critical care transfers to the NHS Nightingale Hospital in London’s Excel Centre.

Elms commented: “The online meetings started during the pandemic by the operations and clinical directors of air ambulances rapidly developed a synergy where experiences and knowledge was shared to the benefit of all air ambulances. This was an unprecedented, rapidly-developing situation and the mutual support was incredible to witness and has carried on. Discussions included how we could share the learning as widely as possible within the air ambulance community and from this grew the idea of a clinical webinar. Literally every air ambulance in the country helped with ideas and offers of speakers.

“The energy and passion for this was phenomenal, I was incredibly privileged to be able to host this on behalf of colleagues across the UK. We have had very positive feedback and if there is a demand then similar events may be held in the future.”

In a heartwarming conclusion, Elms told AirMed&Rescue: “Help was universally given, nothing in return was asked for, the overwhelming desire was to share, knowing that when you needed something, kit or advice, there would be help waiting. But what was soon realized was that the ability to cognitively offload was hugely therapeutic. The burden of leadership during the early stages of the pandemic was shared. The group allowed welfare checks and sense checks. We were reassured that what we were doing was the right thing, we were not working in isolation and we were all doing the best for our staff and the patients we care for.”

Classroom training shifts online due to Covid-19

Plenty of the training companies have been offering their services online since Covid-19 took the world apart, country by country. ASU has seen success with its online night vision goggle training course; and other organizations – military and civilian – have changed their SOPs to adapt.

In June 2020, for example, 20 members of the Honduran Air Force graduated from a Basic Aeromedical Evacuation Training Course run by the US Army, under its Joint Task Force-Bravo banner. The training was supposed to take place in person, but with Covid-19 wreaking havoc around the world, the course occurred entirely online. “We discussed the strengths and weaknesses of their program and asked how JTF-B could help them improve. They expressed a desire to establish a partner medical training program and provided us with a list of requested lecture topics based on areas where they felt they were lacking knowledge and experience,” said US Army Sgt Julie Sargent, Critical Care Flight Paramedic, 1-228 Air Ambulance Detachment. “We then structured the course curriculum to meet their requests.”

Technology has its challenges, but I am thankful that it exists and that we were able to use it

“The course has been very interactive. We haven’t had any issues and our staff are learning a lot,” said Honduran Air Force Lt Obed Antonio Contreras, General Physician and Chief of Medical Services for Soto Cano Air Base, who was the point of contact for students participating from the base. “They share opinions, chat and debate on the subjects, so there are lots of opportunities for interaction, even if it is online.”

“Technology has its challenges, but I am thankful that it exists and that we were able to use it,” said US Army Reserve Lt Col Kathleen Flocke, JTF-Bravo Surgeon. “It was a great experience because we got to build it from zero and create what we wanted and make it really customized to what the Honduran Air Force needed.”

Immediate Medicine Action, Inc. (IA MED) is a disabled veteran-owned small business founded by Chris Smetana and Jonathan Reed that provides specialty medical training ranging from pre-hospital emergency medicine, in-hospital emergency or critical care medicine, aeromedical critical care, austere remote and tactical medicine, conference management, and program and content accreditation. Chris Smetana, one of the program’s Directors, explained that when IA MED was founded, it was solely an in-person training company. “While in the jungles of Guatemala teaching survival and aircrewman with one of our training partners last March, Covid-19 really took hold and I had to pull out to redesign and open up our livestream options due to mass gatherings and in-person training being shut down,” he said. “In 96 hours, the IA MED team was able to convert 100 per cent of our training model from in-person to online, which was then followed with our online medical conference (ICON) and our all-new online and on-demand courses. It has pushed the IA MED team to innovate more creative ways to deliver online learning with a new spike for online and on-demand training. We have grown our educational offerings, training, and development by almost 400 per cent since Covid-19.”

AirMed&Rescue spoke to Dr Terry Martin, who runs the Clinical Considerations in Aeromedical Transport (CCAT) suite of courses around the world. He managed to hold a Foundation Level course in March 2020, just before the UK went into lockdown, and he made sure that all the attendees adhered to social distancing rules before most of us knew what they even were. “Since then,” he said to AirMed&Rescue, “I’ve seen a very high number of enquiries, particularly from nurses, about when the courses will be running again, whether face-to-face or as distance learning, online versions.” He mused that this increased interest in aeromedical transport training is, perhaps, because nurses and doctors working on the frontline of the Covid-19 response in hospitals have been hit harder than most sectors of society, and some are looking for alternative ways of using their skills. It appears that flight medicine and nursing is one option they have not previously considered.

In the early 2000s, Martin was responsible for putting together a package of online distance learning patient air transport courses in partnership with the University of Otago. He is currently working to find a British university that will accredit similar courses in the UK, but has hit a financial stumbling block – £12,000 to accredit a single short course is a difficult upfront cost to absorb in these challenging times.

“Distance learning is the future – certainly at least until we are free of this pandemic, and undoubtedly there will be more anyway. The way we learn and teach will change forever as a result,” Martin told AirMed&Rescue. For medics, this is hardly a new proposition though, as he pointed out. Most have full-time jobs, and are also expected to find time to take part in training courses and complete medical currency training as well. The challenging part of medical training, though, is the more practical aspect. In former times, the old adage ‘see one, do one, teach one’ was the accepted method of training for new procedures, and this is a lot more difficult to accomplish in a distance-learning environment. Martin is currently investigating new methods of teaching practical competencies and other skill types that are difficult to assess using traditional methods.

 So, challenges remain in the field of medical training, whether online or in person. What is without doubt, however, is that innovations will be made, and solutions will be found.