Training fixed-wing medical crews

Aviation medicine (and more so critical care medicine undertaken in the air) are both exceedingly complex and highly dynamic, yet remote environments with few backups to call upon should a patient deteriorate mid-flight.

Eva Kluge, Chief Commercial Officer at UNICAIR, says working in such settings demands a high degree of professionalism ‘to yield the output of quality and safety that our clients – here foremost the patients who entrust us with their life and wellbeing – expect of us’.

“To ensure that our medical crews successfully master all medical, logistic-organizational and aviation-related challenges to drive a mission towards success requires an extremely comprehensive yet focused training program,” she added.

One of the great benefits of this system is that every team member has the same training and the ability to operate seamlessly between different regions and retrieval platforms

Kluge says most training programs include a variation of the following:

• Flight environment, altitude physiology, cabin pressurization, advantages and limitations of sea-level cabin pressure operations, biodynamics of movement, limitations of in-flight management of patients
• Clinical considerations with a focus on in-flight management of medical and surgical emergencies. Scenario-based advanced life support simulation training in the aircraft
• Training on the company’s policies, procedures and guidelines, documentation, and AE reporting. Clinical governance. Introduction into flight planning and crew duty times
• Aircraft safety rules and emergency procedures, safety rules on airports and tarmac.

Every team member receives same training

Andrew Donohue, Director of Education and Training at LifeFlight Retrieval Medicine (LRM), tells AMR that twice each year, LRM operates a training course for over 30 doctors, nurses, and paramedics. The four-day course includes a graded sequence of simulated scenarios. One of them mimics a patient becoming acutely disturbed on a fixed-wing aircraft, similar to situations aeromedical crews would face in real life.

“This is the core training for LRM’s medical teams and covers the key skills of pre-hospital and retrieval medicine,” Donohue said. “One of the great benefits of this system is that every team member has the same training and the ability to operate seamlessly between different regions and retrieval platforms.”

The most skillful hospital intensivist might fail when the critical medical equipment onboard suddenly goes into technical shutdown, while a very experienced flight nurse with a high mission exposure could struggle to stay up to date with the rapidly evolving treatment protocols in modern critical care medicine, explains Kluge. Since investing extended time periods in both environments is mutually exclusive, leadership teams at air ambulance companies need to design unique training programs that include regular protocol updates, and, most importantly, they must build effective teams that can integrate diverse skill sets and translate those in measurable outcomes for our patients and their families.

Training has moved away from classroom and whiteboard towards high-fidelity simulation and scenario-based learning. Advanced simulators have been standard in aviation for decades, and are now also used in all areas of medicine, with aeromedical training being one of them.

Donohue tells AMR: “The biggest changes at LifeFlight have been the development from predominantly classroom-style teaching to a mix of highly interactive skills stations and simulated scenarios delivered by a diverse range of practitioners. In recent years, we have started using video chats and online platforms for case discussion and education sessions, and that has meant we can include fixed-wing crews in ongoing education with our rotary crews.”

Integrative, team-focused training

Training has become very team focused and integrative in recent years, according to Kluge. Modern simulation sessions focus not only on individual skills, but on interaction between the various participants and effective team work to utilise all knowledge, resources, and expertise available. The term Crew Resource Management, or CRM, is now an integral part of training medical crews. Finally, good aeromedical training programmes also cover the interaction between medical and flight crew in emergencies as part of their training and integrate both teams into simulation exercises.

The fixed-wing environment can be a dramatic example of the EMS retrieval dilemma, according to Donohue. “The reality is,” adds Donohue, “that a lot of the work is lower acuity interhospital transfers, but the next catastrophic, multi-trauma, or critically ill ICU transfer can be just around the corner. Staying motivated and keeping skills sharpened can be a challenge, as can the demands to rapidly pivot to new and complex tasks such as international Covid retrievals, or multi-stage transfers from remote locations.”

Most reputable air ambulance operators employ a robust system of clinical governance, extensive onboarding, and a continuous medical education program

In contrast to HEMS operations, fixed-wing air ambulances focus less on primary rescue and stabilization of vital functions, but more on continuation and optimization of advanced intensive care therapies since most transports are inter-facility movements of patients. In addition, a substantial number of patients (and crews) spend prolonged periods of time in a very remote, resource limited environments (i.e. up to 20 hours inside a small air ambulance jet, where the next ER is far away), so that contingency plans for equipment failure and prolonged management of critically ill patients become an important part of training. To Kluge, nursing techniques such as supportive bedding and caring for the patient’s personal hygiene are much more relevant compared to a short helicopter ride.

Clinical governance and continuous education

Most reputable air ambulance operators employ a robust system of clinical governance, extensive onboarding, and a continuous medical education program. Medical leadership of each company is responsible to keep such programs up-to-date, innovative and full of transport-relevant content from international, peer reviewed journals and the large intensive care conferences into the air ambulance environment.

All LifeFlight clinical staff participate in weekly case audits and education sessions, including a review of new medical evidence in Journal Club. Making these sessions relevant and accessible is key to keeping teams up to date. Another major source of up-to-date knowledge and innovation is the team’s cohort of Critical Care Registrars: senior trainees in emergency medicine, anesthesia, and intensive care who complete Quality Improvement audits or education projects during their term at LifeFlight.

Kluge says long-distance, international aeromedical transport is generally safe ‘and critical complications enroute occur in less than one per cent of transports based on our own experience’.

“For this reason, we, and others, prefer our medical teams to on fixed but part-time contracts with a mix of air ambulance work and employment in a hospital ICU to keep skill levels up and be exposed to innovative new therapies and procedures,” she adds. “For very advanced therapies, such as ECMO, hospital-based specialists together with well-trained and experienced flight nurses from the respective aeromedical service can build a very powerful and capable team, provided that these mixed teams also undergo simulation training together for optimal crew resource management.”