Air ambulance paramedics-a question.
Thread Starter
Air ambulance paramedics-a question.
Hi, hope this is the correct forum.
I was wondering if air ambulance paramedics "do" (ie have skills), that there ground based buddies don't.
Or, indeed, should they (both ground and air crew) have skills, that they haven't, and how would that benefit the patient. - Medical rather than airmanship.
Fact or opinion is ok, if you can distinguish between the two, even better. I thought I may be able to get it straight from the horses mouth here.
It's for a talk I'm doing on extended roles, the audience is made up of paramedics.
Cheers, Ginge.
I was wondering if air ambulance paramedics "do" (ie have skills), that there ground based buddies don't.
Or, indeed, should they (both ground and air crew) have skills, that they haven't, and how would that benefit the patient. - Medical rather than airmanship.
Fact or opinion is ok, if you can distinguish between the two, even better. I thought I may be able to get it straight from the horses mouth here.
It's for a talk I'm doing on extended roles, the audience is made up of paramedics.
Cheers, Ginge.
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What country are you talking about?
In London the HEMS paramedics are chosen & trained specifically for the trauma calls that is the aircrafts primary role. They work as a team with the doctor that is always carried to perform the on-street medical interventions that are not normally carried out.
In London the HEMS paramedics are chosen & trained specifically for the trauma calls that is the aircrafts primary role. They work as a team with the doctor that is always carried to perform the on-street medical interventions that are not normally carried out.
What country are you talking about?
Where I live (California) the (some) air ambulances are staffed by MICN (Mobile Intensive Care Nurses), who are trained to a different level than Paramedics.
Where I live (California) the (some) air ambulances are staffed by MICN (Mobile Intensive Care Nurses), who are trained to a different level than Paramedics.
Thread Starter
Thanks chaps, I'm talking about the UK (and thanks T the Torque for the PM).
These are exactly the sort of things I'm trying to tease out.
A couple of questions,
1) In the UK, what interventions does the doc do that the paramedic doesn't. (And could the paramedic do it if he or she expand his role)?
2) What does the MICN do that the paramedic doesn't?
cheers,
ginge.
These are exactly the sort of things I'm trying to tease out.
A couple of questions,
1) In the UK, what interventions does the doc do that the paramedic doesn't. (And could the paramedic do it if he or she expand his role)?
2) What does the MICN do that the paramedic doesn't?
cheers,
ginge.
Apart from London with its 2 pilot operation, UK helicopter paramedics are qualified HEMS crewmembers and at least one has to be on the helicopter for any HEMs CAA exemptions and permissions to be used by the pilot.
Not a medical skill as you asked, but a point worth noting.
Not a medical skill as you asked, but a point worth noting.
Sorry to harp on but UK air ambulance paramedics (except London) are required to have extended aviation skills, a point worth making to a paramedic audience:
1. When the crew is composed of one pilot and one HEMS crew member, the latter should be seated in the front seat (copilot seat) during the flight, so as to be able to accomplish the tasks that the commander may delegate, as necessary:
a. assistance in navigation;
b. assistance in radio communication/ radio navigation means selection;
c. reading of check-lists ;
d. monitoring of parameters;
e. collision avoidance;
f. assistance in the selection of the landing site;
g. assistance in the detection of obstacles during approach and take-off phases;
2. The commander may also delegate to the HEMS crew member tasks on the ground:
a. assistance in preparing the helicopter and dedicated medical specialist equipment for subsequent HEMS departure;
b. assistance in the application of safety measures during ground operations with rotors turning (including: crowd control, embarking and disembarking of passengers, refuelling etc.).
3. When a HEMS crew member is carried it is his primary task to assist the commander. However, there are occasions when this may not be possible:
a. At a HEMS operating site a commander may be required to fetch additional medical supplies, the HEMS crew member may be left to give assistance to ill or injured persons whilst the commander undertakes this flight. (This is to be regarded as exceptional and is only to be conducted at the discretion of the commander, taking into account the dimensions and environment of the HEMS operating site.)
b. After arriving at the HEMS Operating Site, the installation of the stretcher may preclude the HEMS crew member from occupying the front seat.
c. If the medical passenger requires the assistance of the HEMS crew member in flight.
d. If the alleviations of 3.a, 3.b or 3.c are used, reduction of operating minima contained in Appendix 1 to JAR-OPS 3.005(d), sub-paragraph (c)(4) should not be used.
e. With the exception of 3.a above, a commander should not land at a HEMS operating site without the HEMS crew member assisting from the front seat (copilot seat).
4. When two pilots are carried, there is no requirement for a HEMS crew member provided that the pilot non-flying (PNF) performs the aviation tasks of a HEMS crew member.
a. assistance in navigation;
b. assistance in radio communication/ radio navigation means selection;
c. reading of check-lists ;
d. monitoring of parameters;
e. collision avoidance;
f. assistance in the selection of the landing site;
g. assistance in the detection of obstacles during approach and take-off phases;
2. The commander may also delegate to the HEMS crew member tasks on the ground:
a. assistance in preparing the helicopter and dedicated medical specialist equipment for subsequent HEMS departure;
b. assistance in the application of safety measures during ground operations with rotors turning (including: crowd control, embarking and disembarking of passengers, refuelling etc.).
3. When a HEMS crew member is carried it is his primary task to assist the commander. However, there are occasions when this may not be possible:
a. At a HEMS operating site a commander may be required to fetch additional medical supplies, the HEMS crew member may be left to give assistance to ill or injured persons whilst the commander undertakes this flight. (This is to be regarded as exceptional and is only to be conducted at the discretion of the commander, taking into account the dimensions and environment of the HEMS operating site.)
b. After arriving at the HEMS Operating Site, the installation of the stretcher may preclude the HEMS crew member from occupying the front seat.
c. If the medical passenger requires the assistance of the HEMS crew member in flight.
d. If the alleviations of 3.a, 3.b or 3.c are used, reduction of operating minima contained in Appendix 1 to JAR-OPS 3.005(d), sub-paragraph (c)(4) should not be used.
e. With the exception of 3.a above, a commander should not land at a HEMS operating site without the HEMS crew member assisting from the front seat (copilot seat).
4. When two pilots are carried, there is no requirement for a HEMS crew member provided that the pilot non-flying (PNF) performs the aviation tasks of a HEMS crew member.
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If you want to know what a paramedic can (or can't) do, then you need to look at the JRCALC guidelines:
http://jrcalc.org.uk/guidelines.html
Essentially this outlines the drugs and procedures UK paramedics are capable of doing (although each ambulance trust will choose to what level their paramedics are trained/can operate).
If paramedics are to use drugs or carry out procedures that are not contained within the above guidelines then a "Patient Group Direction (PGD)" needs formulated. This allows expansion of an individual's remit, usually strictly applicable in specific circumstances.
Patient Group Directions in the NHS : MHRA
This questions is so broad and multifaceted that I don't think there is a simple answer I'm afraid. The medical literature continues to debate the merits of pre-hospital care and what interventions are (or are not) beneficial.
If you want further specifics about what skills/procedures a doctor possesses then I am happy to elaborate...
Simon
http://jrcalc.org.uk/guidelines.html
Essentially this outlines the drugs and procedures UK paramedics are capable of doing (although each ambulance trust will choose to what level their paramedics are trained/can operate).
If paramedics are to use drugs or carry out procedures that are not contained within the above guidelines then a "Patient Group Direction (PGD)" needs formulated. This allows expansion of an individual's remit, usually strictly applicable in specific circumstances.
Patient Group Directions in the NHS : MHRA
Or, indeed, should they (both ground and air crew) have skills, that they haven't, and how would that benefit the patient. - Medical rather than airmanship.
If you want further specifics about what skills/procedures a doctor possesses then I am happy to elaborate...
Simon
Thread Starter
Thanks Simon, useful link.
I'm coming at this, mostly naive of aspects of emergency care. I'm trying to ascertain what gaps there are between the knowledge and skills of a paramedic, and that of, say, a doctor. I've been asked to talk about how Advanced Practice (in my own field of primary care nursing) has helped patient populations.
I'm trying to draw some parallels with that of emergency medicine. Would some of the aspects of Advanced Practice (history taking, clinical examination, prescribing, risk management, critical appraisal etc) be beneficial to casualties? And I guess some paramedics are already operating at, or near this level already. But if it was true Advanced Practice, why have a doc and a paramedic in the chopper/ambulance.
I notice a lot of stuff on the JRCALC site is protocol driven, for example, (not always a bad thing in emergency medicine I expect), but are there times when this constrains paramedics at the expense of the quality of care given to the casualty?
I'm coming at this, mostly naive of aspects of emergency care. I'm trying to ascertain what gaps there are between the knowledge and skills of a paramedic, and that of, say, a doctor. I've been asked to talk about how Advanced Practice (in my own field of primary care nursing) has helped patient populations.
I'm trying to draw some parallels with that of emergency medicine. Would some of the aspects of Advanced Practice (history taking, clinical examination, prescribing, risk management, critical appraisal etc) be beneficial to casualties? And I guess some paramedics are already operating at, or near this level already. But if it was true Advanced Practice, why have a doc and a paramedic in the chopper/ambulance.
I notice a lot of stuff on the JRCALC site is protocol driven, for example, (not always a bad thing in emergency medicine I expect), but are there times when this constrains paramedics at the expense of the quality of care given to the casualty?
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I am not precious about it (ask anyone) but I cannot help but think that you are asking the wrong people about the things you want to know. We are (mainly) helicopter pilots here. Anything we know about our walk-on freight is very second hand. I don't now if there is one, but I wonder whether there is not a better place to ask the question you want answered?
From what little I know as a pilot, there seem to be significantly different standards of the medical crews in air ambulances even if we just look at the UK. A major difference is that more and more air ambos carry a doctor and a paramedic. Some of the docs are trauma specialists and some are not.
In my simple (non-medical) way, it may be a response to the different roles that different HEMS units fulfil. The one extreme is the London where jobs attended are limited to serious trauma type incidents: the aim seems to be to get really specialised trauma care to the scene. In more rural areas the HEMS is more akin to a flying ambulance where its speed and ability to go direct A to B at speed and get the patient to hospital is the driving force. Some of the latter are gently moving more to the London model as time goes by.
On that basis your medical crew skill sets are chosen to fit the role selected for the particular air ambulance. Its a response to the demand which varies.
From what little I know as a pilot, there seem to be significantly different standards of the medical crews in air ambulances even if we just look at the UK. A major difference is that more and more air ambos carry a doctor and a paramedic. Some of the docs are trauma specialists and some are not.
In my simple (non-medical) way, it may be a response to the different roles that different HEMS units fulfil. The one extreme is the London where jobs attended are limited to serious trauma type incidents: the aim seems to be to get really specialised trauma care to the scene. In more rural areas the HEMS is more akin to a flying ambulance where its speed and ability to go direct A to B at speed and get the patient to hospital is the driving force. Some of the latter are gently moving more to the London model as time goes by.
On that basis your medical crew skill sets are chosen to fit the role selected for the particular air ambulance. Its a response to the demand which varies.
I suspect a major difference is time available for treatment - the whole point of air ambulances is that you get the trauma patient to hospital as quickly as possible; stabilisation and packaging need to be done swiftly or they may as well go in a land ambulance.
We then come back to the dilemma of 'stay and play' or 'scoop and run'.
We then come back to the dilemma of 'stay and play' or 'scoop and run'.
Don't quote me as I'm not 100% sure of all the facts, but I believe that earlier this year, air ambo paramedics were effectively stopped from administering some classes of drug, that previously they had been able to (my hazy recollection is some of the morphine-based painkillers).
So a properly trained doctor can for example intubate, perform RSI's and administer classes of drug that the paramedics are not trained for or cannot legally do.
It's not (just) a question of skills, but also legality. All of the air ambulance paramedics I have met are highly skilled individuals, but there is a glass ceiling of what they are allowed to do, imposed at national or local ambulance service level. And to a man (or woman) they do not regard the doctor as an inconvenience, they recognise that having a A&E trained registrar (in the case of the charity I know well) adds a whole new dimension to the service.
And Crab, I disagree with you. The point of an air ambulance is to get the patient appropriate treatment as quickly as possible. With the right team and equipment on board, this might be at the scene. Often the stabilised patient is then moved by ground ambulance - but effectively their treatment may have already begun. The doctor often travels with the patient in the land ambulance.
So a properly trained doctor can for example intubate, perform RSI's and administer classes of drug that the paramedics are not trained for or cannot legally do.
It's not (just) a question of skills, but also legality. All of the air ambulance paramedics I have met are highly skilled individuals, but there is a glass ceiling of what they are allowed to do, imposed at national or local ambulance service level. And to a man (or woman) they do not regard the doctor as an inconvenience, they recognise that having a A&E trained registrar (in the case of the charity I know well) adds a whole new dimension to the service.
And Crab, I disagree with you. The point of an air ambulance is to get the patient appropriate treatment as quickly as possible. With the right team and equipment on board, this might be at the scene. Often the stabilised patient is then moved by ground ambulance - but effectively their treatment may have already begun. The doctor often travels with the patient in the land ambulance.
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206 jock
Spot on. The level of drugs that a doctor can administer are completely different than that of an independent paramedic. However when they are working with a doctor they can give them under their strict supervision. Likewise a London HEMS paramedic can do an intubation under supervision.
A doctor can use a scalpel on the street for invasive procedures such as thoracostomy, chest drains, surgical airways, and in extreme cases thoracotomy.
gingernut
If you want to pm me I can put you in touch with an ex London HEMS paramedic who now flies county air ambulance. He will be able to tell you what he is now allowed to do compared to working with a doctor.
Spot on. The level of drugs that a doctor can administer are completely different than that of an independent paramedic. However when they are working with a doctor they can give them under their strict supervision. Likewise a London HEMS paramedic can do an intubation under supervision.
A doctor can use a scalpel on the street for invasive procedures such as thoracostomy, chest drains, surgical airways, and in extreme cases thoracotomy.
gingernut
If you want to pm me I can put you in touch with an ex London HEMS paramedic who now flies county air ambulance. He will be able to tell you what he is now allowed to do compared to working with a doctor.
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Likewise a London HEMS paramedic can do an intubation under supervision.
That said I had heard that the LAS are phasing out paramedic intubation, but that is a separate issue.
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I was wondering if air ambulance paramedics "do" (ie have skills), that there ground based buddies don't.
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And Crab, I disagree with you. The point of an air ambulance is to get the patient appropriate treatment as quickly as possible. With the right team and equipment on board, this might be at the scene. Often the stabilised patient is then moved by ground ambulance - but effectively their treatment may have already begun. The doctor often travels with the patient in the land ambulance.
Having experience of a few HEMS operations around the world I would say that the best model I have seen is one where the medical crew are 2 advanced care (ICU) paramedics who have many years experience as ground based paramedics before moving to HEMS.Their training and expertise includes intubation and infusion of a variety of pain relief drugs. They are also trained in casualty access techniques.
A combination of doctor and paramedic can also work well as each can compliment the other's level of skill and knowledge.
When the medical crew have this level of expertise then they are able to assess, treat and stabilise casualties on scene before loading and transferring them to a hospital or trauma centre.
There should be no such thing as 'swoop and scoop' in HEMS these days.
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Crab, our task in the north west is to get a paramedic to scene. The move to hospital is secondary. True, we normally do carry trauma, but often we leave the follow up to land crews.
Crab has achieved his aim - he loves to stir up the HEMS world with his outsiders views, based on out-dated snapshots seen from a SAR perspective. Don't encourage him!
Ah yes those outdated snapshots where we still see, on a regular basis, casualties spending far longer on the ground than they need to whilst the valuable AA asset is shut down beside them.
As I recall the establishment of AA was predicated on the Golden Hour concept of ops which, if you have an appropriately qualified and experienced doctor on board, may mean just getting the AA to the casualty - but, certainly in this part of the world, there are paramedics, not doctors in the AA and so the cas needs to get to hospital quickly.
It seems to be a case of mission creep where both land and air ambulances pitch up to the same job or is it just to meet NHS response time targets - get the paramedic on scene and the clock stops, regardless of how long it subsequently takes to get the patient to hospital?
I suspect that most AA callouts are not golden hour trauma cases requiring surgical or anaesthetic skills but I am sure the casualties would far prefer to be treated in hospital instead of in a field.
As I recall the establishment of AA was predicated on the Golden Hour concept of ops which, if you have an appropriately qualified and experienced doctor on board, may mean just getting the AA to the casualty - but, certainly in this part of the world, there are paramedics, not doctors in the AA and so the cas needs to get to hospital quickly.
It seems to be a case of mission creep where both land and air ambulances pitch up to the same job or is it just to meet NHS response time targets - get the paramedic on scene and the clock stops, regardless of how long it subsequently takes to get the patient to hospital?
I suspect that most AA callouts are not golden hour trauma cases requiring surgical or anaesthetic skills but I am sure the casualties would far prefer to be treated in hospital instead of in a field.
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"Ah yes those outdated snapshots where we still see, on a regular basis, casualties spending far longer on the ground than they need to whilst the valuable AA asset is shut down beside them"
So now you're a HEMS specialist too, Crab? Just a wild guess on my part but I would imagine that the doctors / paramedics are probably better qualified than your good self to decide when a patient is ready to be moved. It doesn't matter what interventions the doctor or paramedic makes on scene, the aim is simple - stabilise the patient enough to get them to hospital. That may be five minutes or 45 minutes. It takes what it takes.
HEMS isn't about moving the patient ASAP, it's about getting resources on the scene quickly - and that may only be more powerful painkillers than the landcrews have - and then using those resources in whatever way best serves the patient.
As for the valuable asset being shut down on scene, you'd be better focusing on the turn-round times at hospitals where I can often spend an hour waiting for the paras to deliver the patient, get the kit back and try and thumb a lift back to the HLS if we've landed at a secondary site. A lot of time to lose during these short daylight winter days.
FF
So now you're a HEMS specialist too, Crab? Just a wild guess on my part but I would imagine that the doctors / paramedics are probably better qualified than your good self to decide when a patient is ready to be moved. It doesn't matter what interventions the doctor or paramedic makes on scene, the aim is simple - stabilise the patient enough to get them to hospital. That may be five minutes or 45 minutes. It takes what it takes.
HEMS isn't about moving the patient ASAP, it's about getting resources on the scene quickly - and that may only be more powerful painkillers than the landcrews have - and then using those resources in whatever way best serves the patient.
As for the valuable asset being shut down on scene, you'd be better focusing on the turn-round times at hospitals where I can often spend an hour waiting for the paras to deliver the patient, get the kit back and try and thumb a lift back to the HLS if we've landed at a secondary site. A lot of time to lose during these short daylight winter days.
FF