Shaping the flight paramedic program.
After September 11, 2001, the Army transitioned from a peacetime Army to one in continuous wartime operations. As our conflicts have continued, there have been many significant changes and improvements in combat casualty care from the point of injury to rehabilitation of Wounded Warriors to the first ever critical care transport by Army combat medics. This manuscript attempts to capture the observations and decisions that led to the creation of the Army's Critical Care Flight Paramedic (CCFP) Program and how it is being shaped to meet future requirements.
At the initiation of the conflicts after 9/11, Army Aeromedical Evacuation units were staffed with one medical provider for en route care. This provider (flight medic) was trained with the certification level of an Emergency Medical Technician (EMT) Basic. Additionally, the flight medic received training at the Army School of Aviation Medicine on aircrew functions and Advanced Cardiac Life Support, Pediatric Education for Prehospital Professionals, and International Trauma Life Support. This training was 6 weeks long and upon completion the medic became a flight medic with the skill qualification identifier of "F."
The experiences, advice, and decisions that led to the creation of the program occurred over the course of several years. Initially, anecdotal evidence and after action reviews from providers in Iraq and Afghanistan noted that during the course of medical evacuation, postoperative patients transferred from a forward surgical team were critically ill and required significant in-flight medical management, such as ventilator management, provision of multiple medications, and blood administration. The flight medic was not trained to deliver this level of care and although many would learn these skills on the job, it was not a stated requirement to do so. Because medics were not trained in en route care, another medical provider, ie, physician, physician assistant, or critical care nurse, would have to accompany the patient during medical evacuation. This caused several potential problems: new providers were typically not familiar with aircrew procedures which could potentially cause issues while in flight, were unfamiliar with providing care in a nonhospital environment, and most importantly, were lost to the units for a lengthy period of time before they could make their way back.
Medical leaders identified these gaps through various channels and initiated efforts to change the paradigm. One of the Army solutions was the creation of the En route Critical Care Nurse (ECCN) program, which trained critical care nurses to accompany critically ill patients during intrafacility transport. The ECCNs were initially assigned to one of the medical treatment facilities, however, as time progressed, the ECCNs were eventually attached to the air ambulance units where they could develop relationships with the flight medics and aircrews, to great success. This change in assignment contributed greatly to the success of the program because the ECCN became more familiar with the providers and other unit personnel and could assist with point of injury responses.
Although the employment of the ECCN markedly enhanced the level of en route care, a larger issue remained. Because ECCNs were never assigned to air ambulance units, there was no guarantee that ECCNs would be trained and available for deployment in future conflicts. The logical solution to this problem was to ensure that the provider assigned to the unit, the flight medic, has the necessary skills and knowledge to perform the essential en route care, which is standard practice within the US civilian air evacuation community.
Anecdotal evidence from after action reports assessing en route care continued to mount over the course of combat operations. However, there was little evidence to support that staffing evacuation platforms with medical providers who had a level training above that of a flight medic resulted in improved patient outcomes. (1) This changed in 2011, when the Journal of Trauma published the paper "Impact of critical care trained flight paramedics on casualty survival during helicopter evacuation in the current war in Afghanistan". (2) The study showed patient survival at 48 hours was 66% higher when patients were transported by critical care trained crews as compared to patients transported by crews who were not trained in critical care. This strongly supported the recommendation that critical care training should become the standard for MEDEVAC medical providers.
In 2010, the Army Medical Department Center and School (AMEDDC&S) and the US Army School of Aviation Medicine convened a Flight Medic Critical Task selection board which determined that the requisite skill level for a flight medic should be a paramedic with certain additional skills. Shortly thereafter, The Army Surgeon General, based upon a recommendation from the AMEDDC&S Commanding General, decided that the flight medic would be trained as a paramedic with critical care training. The Army codified this series of decisions in ALARACT * 061/2012 which provided notification of the requirement and intent to train 68W Flight Medics to NREMT-P ([dagger]) standards with critical care training. Additionally, the FY13 National Defense Authorization Act (3) (NDAA) directed the Secretary of the Army to implement a requirement to have "all in-flight medical care providers to be critical care flight paramedic (CCFP) certified within the next 3 years."
The development of the institutional model started with the creation of the Critical Care Flight Paramedic Program at AMEDDC&S in late 2011. The first pilot course for National Registry Paramedic (NRP) certification was conducted at the University of Texas Health Science Center San Antonio (UTHSCSA) from February to August of 2012. This course follows the National Registry of Emergency Medical Technician guidelines for the medical curriculum taught by the faculty at UTHSCSA. The first time pass rate of the NRP exam was 92% (historical average across the United States in 2012 was 74%), and since inception has always remained above 90%. Upon completion of the NRP course, students transitioned directly to the critical care course, with the didactic portion conducted at UTHSCSA, and critical care clinical rotations at the San Antonio Military Medical Center. Each student completed 240 hours of clinical rotations which significantly exceeded the number of hours in civilian critical care courses for paramedics. The justification for this number of hours was that in the civilian air ambulance community, a paramedic generally will not be considered for hire with less than 3-5 years of experience as a ground paramedic. Given the potential for an Army Medic to not have the clinical patient experience that a full time paramedic would have, the increase in patient encounters during training would provide an equivalent experience that a civilian would accumulate in 3 to 5 years.
The third training course was the integration of medical training in the aviation environment coupled with aircraft crewmember training. Given that the initial paramedic students were already MEDEVAC crewmembers and therefore been to the legacy flight medic course (with the additional skill identifier (ASI) of F3), crewmember training would not be a requirement for them. However, natural attrition of medics required that new medics, who were not trained as MEDEVAC crewmembers, must attend this training. Initially, these students went to the legacy flight medic course until a new course could be created for the flight paramedics.
HOME STATION TRAINING
As the institutional model was created, it became apparent that it would not be possible to meet the throughput necessary to meet the FY13 NDAA directive. Given that the civilian community has many facilities to provide the training necessary to obtain NRP certification and critical care training, the Army created the Home Station Training option. This option, outlined in ALARACT 028/2013 and updated in ALARACT 301/2013, allowed units to send Soldiers to an accredited civilian NRP program as well as civilian critical care programs (with the approval of the director of the CCFP Program). This provides flexibility for units and Soldiers to obtain the training without having to change duty stations. This is extremely beneficial to Soldiers assigned to air ambulance units that may be pending a deployment cycle. Additionally, this option is advantageous for National Guard and Reserve unit Soldiers whose civilian employment would be severely disrupted for an individual training event. This model may become more attractive in the years to come as we try to meet the goal of having every inflight provider be a CCFP.
The current institutional model consists of contracted courses from UTHSCSA. The NRP course is 6 months in length and culminates with the student taking the NRP exam. Upon passing the exam, the student transitions to the critical care course, which is 8 weeks long. The current contracted course differs from the pilot in that the clinical rotations are done with civilian facilities and agencies, broadening the students' experience.
The third course required for those students who have not received the ASI F3 in the past is the new AMEDD Aviation Crewmembers Course. The purpose of this course is twofold: first to "operationalize" the medical knowledge that the students have in the aircraft environment, and second, to introduce the student to the aviation environment and the crewmember skills necessary to become an effective crewmember on an aircraft. The first pilot of this course was conducted in July 2015, and student feedback has been overwhelmingly positive.
As stated earlier, the initial goal of the program was to transition all Army flight medics to CCFP by FY 2017. For a variety of reasons (deployments, funding for pay and allowances for National Guard/Reserve, throughput capability), the likelihood of meeting this goal is low. However, significant progress has been made, and attention is being focused at the highest levels to ensure the program continues to provide for training of this critical skill set.
As the program matures, there will likely be a transition of the contracted courses to bring the training into the AMEDDC&S. One advantage of this would be that the instructors will be primarily CCFPs with deployment experience which would bring real world experience to students. Another advantage would be the ability to integrate training in the aircraft cabin environment using the newly constructed Transport Medical Training Lab (TMTL) at AMEDDC&S. The TMTL enables students to integrate all the skills learned using high fidelity patient simulators in a realistic aircraft environment. Instructors are able to record all of the students' interventions with the simulated patient ensuring a thorough evaluation is provided. Additionally, there is a forward surgical team "suite" in which the student will be able to hand over and receive patients from hospital providers, so the first time they conduct such handovers will not be in a deployed environment. This will also allow other providers to rehearse and train in a more realistic environment while at AMEDDC&S. The San Antonio Military Medical Campus, as well as civilian hospitals and other civilian agencies, will still be part of the CCFP training through the use of Medical Training Agreements in order to ensure the students have a breadth of clinical experience prior to seeing a critically ill or injured patient on their own. Finally, the ability to integrate the other agencies at AMEDDC&S, such as the veterinary instructors, allow for integration of military specific training requirements into the program.
One of the main challenges in creating the CCFP is the "tail" of sustainment and recertification training. Army Emergency Medical Service currently has an interim recertification policy that is outlined in ALARACT 071/2014, which meets the requirements of NREMT recertification for NRP. Although it meets the requirements, many of the interventions and much of the knowledge outlined in the policy fail to address the needs for sustainment of the CCFP. Currently the CCFP Program is working on a solution through the creation of a training circular (TC) similar to TC8-800 for 68Ws (combat medics), but focused on the CCFP needs. Additionally, getting sustainment clinical training in a high acuity environment (ICU level care) will be necessary to maintain clinical acumen. This will require medical training agreements (MTA) between units and military treatment facilities (MTF) or civilian hospitals, as many local MTFs do not have the patient level of acuity for the CCFP to maintain clinical knowledge and skills. This will require leaders at separate posts to take the lead in integrating with the outside community, which is already happening at locations like Fort Hood, where the leadership has approved MTAs with civilian agencies, enabling their medics to acquire patient care experience.
As the transition to Critical Care Flight Paramedics continues to progress, other challenges will become evident. Given the successful history of the rapid development of this program, these challenges will likely become opportunities to improve on the program and allow for future success. Early identification of the gaps in en route care, followed by parallel initiatives from multiple sources, have shown that developing a highly skilled en route care provider can be done effectively. Challenges in the future, primarily concerning sustainment of these skills, will likely be met through innovative institutional and organizational solutions in order to maintain the capability to take care of the most critically ill and injured patient.
(1.) Cearnal L. Emergency physicians highlight, "Army-wide emergency medical care deficiency" in training of flight medics. Ann Emerg Med. 2008;52:522-524.
(2.) Mabry RL, Apodaca A, Penrod J, Orman JA, Gerhardt RT, Dorlac WC. Impact of critical care-trained flight paramedics on casualty survival during helicopter evacuation in the current war in Afghanistan. J Trauma Acute Care Surg. 2012;73(2 suppl 1):S32-S37.
(3.) Pub L No. 112-239, National Defense Authorization Act for Fiscal Year 2013; January 2, 2013.
* All Army Activities: a message transmitted to all US Army activities throughout the world, providing announcements, notifications, and other information of import requiring rapid dissemination Army-wide.
([dagger]) National Registry of Emergency Medical Technicians-Paramedic
LTC Davids is Medical Director, Critical Care Flight Paramedic Program, Center for Prehospital Medicine, AMEDD Center & School, Joint Base San Antonio-Fort Sam Houston, San Antonio, Texas.
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|Title Annotation:||PERSONNEL CHANGES THAT IMPACTED CARE AND OUTCOMES|
|Author:||Davids, Neil B.|
|Publication:||U.S. Army Medical Department Journal|
|Date:||Apr 1, 2016|
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