TY - JOUR
AU - Walrath,, Benjamin
AB - Abstract Introduction En Route Care (ERC) is often an ad hoc mission for the USN. In a review of 428 Navy patient transports, a Flight Surgeon (FS) was the sole provider or a member of crew in 118 of the transports. Naval FSs receive approximately 4 hours of didactic ERC training during their 24-week Naval FS course. Regardless, an FS may be caring for a critically ill patient in a helicopter. We conducted a survey to evaluate FS confidence in their ability to perform ERC and to establish their understanding of the training of Search and Rescue Medical Technicians (SMT). Materials and Methods A convenience sample of FSs completed a needs analysis survey as part of a process improvement project. Flight Surgeons surveyed were actively assigned or had been assigned within the past year to a squadron with Search and Rescue/MEDEVAC capabilities. Results A total of 25 surveys were completed. An average of 13 (range 0–100) patient transport missions were performed by the respondents. Twenty-five percent reported feeling confident in their ability to provide ERC without senior level direction, while 41% stated they would require direction. Nearly 70% of the FSs surveyed expressed “minimal” or less understanding of the training of the SMT. Conclusions Our survey results reveal most FSs are confident in neither their ability to perform ERC nor the ability of their hospital corpsman to provide care during patient movement. INTRODUCTION En Route Care (ERC) is not a program of record in the United States Navy (USN). Thus, there is no formal requirement to guide “man, train and equip” decisions. U.S. Navy patient transport missions are frequently “lifts of opportunity” and can incorporate various vehicles while transiting air, land, or sea. Assignment of medical attendants during patient movement is also often ad hoc and can include Search and Rescue (SAR) medical technicians (SMTs), undesignated corpsmen, rescue swimmers, nurses, or physicians. General medical officers, to include Flight Surgeons (FSs), are included in the ERC provider inventory. Search and Rescue operations frequently result in patient care and transport and have instructions that address ERC.1,2 Many Navy SAR missions are conducted by rotary wing aircraft squadrons, thus the SMTs and FSs assigned to those squadrons are commonly tasked with the ERC missions associated with SAR. Fixed-wing squadrons also engage in patient movement, typically from the sea base to land assets, and their FSs are frequently tasked to perform ERC. Search and Rescue medical technicians complete an 18-month training pipeline to prepare them to provide point of injury assessment and stabilization as well as ERC to the nearest treatment facility. FS training varies significantly. Minimum FS training requirements include an MD or DO degree, completion of 1 year of any ACGME accredited internship, and a 6-month curriculum at the Naval Aerospace Medical Institute. Approximately 8 weeks of the 6-month training bloc is dedicated to aerospace medicine, primarily focused on preventative medical care. Four hours of ERC familiarization are incorporated into the aerospace medicine didactics [H. Casey, personal communication, 22 July 2015]. Other ERC-related topics covered in the FS training pipeline include helicopter egress, rotor arch safety, and fundamentals of aeromedical physiology. A retrospective review of 428 SAR reports dated from January 2012 through January 2015 reported 25% of patient transports included an FS, 6% were staffed by an FS alone. Additionally, 54% of these transports were considered ALS level care with 48% including traumatic injuries.3 With the apparent discordance between training time dedicated to ERC and ERC mission participation for FSs, we surveyed FSs to assess their confidence in their ability to perform ERC as well as provide medical direction for SMTs conducting the ERC mission. MATERIALS AND METHODS Our study is a descriptive summary of responses from an open survey with approval from the local institutional review board. Participants were a convenience sample of active duty U.S. Navy physicians who were currently in an FS billet or had experience as an FS. The survey was announced on a closed group web page on www.facebook.com that included 366 members who were current or former FSs. It was available via a link on the same web page from 13 July 2016 to 13 August 2016. Participation Was Voluntary There was no compensation for participation and selection was self-directed by the participant. The survey consisted of 33 survey questions. All of the questions were on a single page. Question categories included: demographics (current position and duty station), past experience (training, prior military, and ERC), familiarity with current ERC standards (SMT training, regional guidelines), confidence in ERC performance (of the participant, an SMT, and a nurse), and perceived training needs for the participant. Answer choices were either qualitative or quantitative. Ten quantitative choices offered a Likert scale to rate level of confidence in a specific ERC dynamic (0–10, with zero being no confidence and 10 being the most confident). Two questions offered descriptors for the possible answer choices. The question asking confidence level of the respondents’ ability to perform pre-hospital medical care offered, “never performed pre-hospital care, does clinic time count?, exposure but no experience, hands-on but as directed, directed care.” The question asking the respondents’ familiarity of their SMT’s training pipeline included possible answers of, “What’s an SMT?, minimally, somewhat, I help teach the PQS (personnel qualification standard).” RESULTS Of the 366 members of the www.facebook.com closed group, 25 responded to the questionnaire, 21 of whom were current or former FSs (6.8% response rate). Four respondents were never FSs and were excluded from our analysis. Of the 21 FSs, 14 were serving in FS billets and seven had completed their FS tour of duty and were enrolled in graduate medical education programs. Of the 14 active FSs, seven were assigned to USN squadrons (four fixed-wing, three rotary wing) and seven were assigned to USMC squadrons (four fixed-wing, three rotary wing). The seven respondents who had completed their FS tours did not report type of squadron with which they served. The four excluded respondents included one Hospital Corpsman, one General Medical Officer, and two interns. A summary of survey responses describing respondent experience, associated certifications, comfort level with performing prehospital medical care, and perceived role and comfort as a prehospital medical director, are detailed in Tables I–III and Figures 1 and 2. TABLE I. Participant Training/Certifications Training/Certification Yes No Naval Aeromedical Officer Course 21 0 SAR Training 9 12 Tactical Combat Casualty Care 8 13 Combat Casualty Care Course/Bushmaster 19 2 Advanced Trauma Life Support 20 1 Fleet Marine Force Officer 4 17 Emergency Medical Technician 4 17 Paramedic 2 19 SMT PQS 1 20 Military Cold Weather Medicine 1 20 Training/Certification Yes No Naval Aeromedical Officer Course 21 0 SAR Training 9 12 Tactical Combat Casualty Care 8 13 Combat Casualty Care Course/Bushmaster 19 2 Advanced Trauma Life Support 20 1 Fleet Marine Force Officer 4 17 Emergency Medical Technician 4 17 Paramedic 2 19 SMT PQS 1 20 Military Cold Weather Medicine 1 20 TABLE I. Participant Training/Certifications Training/Certification Yes No Naval Aeromedical Officer Course 21 0 SAR Training 9 12 Tactical Combat Casualty Care 8 13 Combat Casualty Care Course/Bushmaster 19 2 Advanced Trauma Life Support 20 1 Fleet Marine Force Officer 4 17 Emergency Medical Technician 4 17 Paramedic 2 19 SMT PQS 1 20 Military Cold Weather Medicine 1 20 Training/Certification Yes No Naval Aeromedical Officer Course 21 0 SAR Training 9 12 Tactical Combat Casualty Care 8 13 Combat Casualty Care Course/Bushmaster 19 2 Advanced Trauma Life Support 20 1 Fleet Marine Force Officer 4 17 Emergency Medical Technician 4 17 Paramedic 2 19 SMT PQS 1 20 Military Cold Weather Medicine 1 20 TABLE II. FS Confidence in Ability Question Number of Participants Range Mean Median Mode Number of transports performed 17 0–100 15.3 3 0,3 Confident in pre-flight patient and cabin preparations 21 0–10 3.2 3 0 Comfort with patient evacuation during Combat SAR operations 21 0–10 2.6 1 0 Comfort with point of injury patient evaluation, stabilization, and extraction during SAR 21 0–10 4.2 3 3 Comfort managing an unstable patient during flight 21 0–10 3.0 3 3 Comfort with in-flight patient care and equipment utilization 20 0–10 3.1 2.5 3 Question Number of Participants Range Mean Median Mode Number of transports performed 17 0–100 15.3 3 0,3 Confident in pre-flight patient and cabin preparations 21 0–10 3.2 3 0 Comfort with patient evacuation during Combat SAR operations 21 0–10 2.6 1 0 Comfort with point of injury patient evaluation, stabilization, and extraction during SAR 21 0–10 4.2 3 3 Comfort managing an unstable patient during flight 21 0–10 3.0 3 3 Comfort with in-flight patient care and equipment utilization 20 0–10 3.1 2.5 3 TABLE II. FS Confidence in Ability Question Number of Participants Range Mean Median Mode Number of transports performed 17 0–100 15.3 3 0,3 Confident in pre-flight patient and cabin preparations 21 0–10 3.2 3 0 Comfort with patient evacuation during Combat SAR operations 21 0–10 2.6 1 0 Comfort with point of injury patient evaluation, stabilization, and extraction during SAR 21 0–10 4.2 3 3 Comfort managing an unstable patient during flight 21 0–10 3.0 3 3 Comfort with in-flight patient care and equipment utilization 20 0–10 3.1 2.5 3 Question Number of Participants Range Mean Median Mode Number of transports performed 17 0–100 15.3 3 0,3 Confident in pre-flight patient and cabin preparations 21 0–10 3.2 3 0 Comfort with patient evacuation during Combat SAR operations 21 0–10 2.6 1 0 Comfort with point of injury patient evaluation, stabilization, and extraction during SAR 21 0–10 4.2 3 3 Comfort managing an unstable patient during flight 21 0–10 3.0 3 3 Comfort with in-flight patient care and equipment utilization 20 0–10 3.1 2.5 3 Table III. FSs as Medical Directors Question Number of -Participants Range Mean Median Mode Comfort with HM’s managing a critical trauma patient 18 0–6 1.8 2 0 Comfort with HMs managing a critical medical patient 18 0–6 1.8 2 0 Confidence in HM or RN prehospital care capability 15 0–6 2.6 2 2,3 Level of involvement with HM training for ERC missions 15 1–10 4.8 5 1 Question Number of -Participants Range Mean Median Mode Comfort with HM’s managing a critical trauma patient 18 0–6 1.8 2 0 Comfort with HMs managing a critical medical patient 18 0–6 1.8 2 0 Confidence in HM or RN prehospital care capability 15 0–6 2.6 2 2,3 Level of involvement with HM training for ERC missions 15 1–10 4.8 5 1 Table III. FSs as Medical Directors Question Number of -Participants Range Mean Median Mode Comfort with HM’s managing a critical trauma patient 18 0–6 1.8 2 0 Comfort with HMs managing a critical medical patient 18 0–6 1.8 2 0 Confidence in HM or RN prehospital care capability 15 0–6 2.6 2 2,3 Level of involvement with HM training for ERC missions 15 1–10 4.8 5 1 Question Number of -Participants Range Mean Median Mode Comfort with HM’s managing a critical trauma patient 18 0–6 1.8 2 0 Comfort with HMs managing a critical medical patient 18 0–6 1.8 2 0 Confidence in HM or RN prehospital care capability 15 0–6 2.6 2 2,3 Level of involvement with HM training for ERC missions 15 1–10 4.8 5 1 FIGURE 1. View largeDownload slide Number of participant’s that ranked their ability (0–10 scale) in managing critical medical and critical trauma patients. FIGURE 1. View largeDownload slide Number of participant’s that ranked their ability (0–10 scale) in managing critical medical and critical trauma patients. FIGURE 2. View largeDownload slide Number of participant’s who ranked their hospital corpsman’s ability (0–10 scale) in managing critical medical and critical trauma patients. FIGURE 2. View largeDownload slide Number of participant’s who ranked their hospital corpsman’s ability (0–10 scale) in managing critical medical and critical trauma patients. Participants were also asked how many patients they have prepared for transport and how many patients they have received from an ERC provider. Many said that they have neither prepared (48%) nor received a medical evacuation patient (44%). Eight percent prepared more than 10 patients and 20% received more than 10 patients. Participants were asked about their familiarity with the SMT training pipeline. Respondents selected “What’s an SMT?” (17%), “Minimally” (52%), “Somewhat” (22%), and “I help teach the PQS” (9%). DISCUSSION Our survey of a convenience sample of 21 active duty Navy FSs identified most respondents lacked confidence in performing ERC, and most were uncomfortable serving as an ERC medical director. Despite a median of 3 transports per respondent, only 4 FSs scored their comfort with in-flight patient care and equipment utilization as greater than 5 out of 10. The FSs expressed some involvement with hospital corpsman (HM) ERC training, yet communicated minimal confidence in their HM or registered nurse prehospital care capability. For questions related to FS performance of ERC, the responses ranged from 0 to 10, with the two FSs with prior experience as paramedics expressing greater comfort in all prehospital care scenarios. With only four hours of didactic instruction devoted to ERC during the Naval Aeromedical Course, this finding is not unexpected. The confidence to perform ERC for paramedic respondents, as contrasted by the lack of confidence in those FS without paramedic training, suggests paramedic training, not the FS curriculum, best prepared them for the ERC mission. FSs were also uncomfortable with HMs performing ERC, leaving most squadrons with little confidence from their FS in the ability of the medical staff to provide ERC. Physicians do not typically serve as care providers during prehospital transport in the USA.4 In the USN, however, FSs are tasked as ERC providers. In Australia, Norway, England5 and in Japan,6 prehospital care is provided by emergency physicians and anesthesiologists who also complete aeromedical training.7 The incongruence between FS performance of patient transports and their minimal training and experience highlights a patient safety concern. To optimize patient care and avoid preventable deaths, further review of FS ability to provide safe and effective ERC is needed. The Navy Tactics, Techniques and Procedures Manual 3–50.1, Search and Rescue Manual, designate FSs as the medical directors for patient transport operations.2 The National Association of Emergency Medical Services Physicians state “EMS systems require knowledgeable physician participation and supervision at every level.”4 FS responses to questions regarding involvement with HM training and familiarization with the SMT training pipeline reveal FSs have limited knowledge and involvement in SMT preparation to perform ERC. It is thus understandable why FSs have little confidence in the ability of their HMs to perform ERC, especially for critically ill or injured patients. As the medical director, it is the responsibility of the FS to train their ERC providers, provide treatment protocols, and perform quality assurance reviews. With no formal training in medical direction and a lack of confidence in their own ability to perform patient movement, the FS responses regarding their role as the medical director for ERC operations are consistent with our expectations. Our study has limitations. First, the responses of our small convenience sample may not reflect the general consensus of all Navy FSs. A larger number of respondents might more reliably reflect the FS community as a whole. Second, as with any survey-based research, recall bias is a concern. By enrolling only current FSs or those FSs who recently completed their tour of duty we hoped to minimize this bias. Third, our study is not linked to patient outcome data. An objective, clinically relevant metric would enhance the results of our research. Finally, this project was initiated as a process improvement project to inform the development of an ERC course for FSs. The survey questions, while informative, were not always structured to provide easily analyzed data. Generating a survey with the intention to evaluate FS ability to perform ERC and provide medical direction through a pre-conceived plan of research and statistical analysis would be beneficial. CONCLUSION Our survey results reveal most FSs are confident in neither their ability to perform ERC nor the ability of their HMs to provide care during patient movement. Funding This supplement was sponsored by the Office of the Secretary of Defense for Health Affairs. References 1 Naval Search and Rescue Standardization Program . OPNAVINST 3130.6E. Available at https://doni.daps.dla.mil/Directives/03000%20Naval%20Operations%20and%20Readiness/03-100%20Naval%20Operations%20Support/3130.6E.pdf; accessed February 18, 2018 . 2 Navy Tactics, Techniques, and Procedures 3 – 50.1 Search and Rescue Manual . Available at http://www.public.navy.mil/surfor/Documents/3-50-1_SAR.pdf; accessed February 8, 2018 . 3 Walrath B , Mora A , Ganem V , et al. : Navy en route care: a three-year review of 428 navy air evacuations . J Mil Med 2017 ; 182 : 162 – 6 . Google Scholar Crossref Search ADS 4 Hector A , Blanton D , O’Connor RE : Physician medical direction in EMS . Prehosp Emerg Care 1998 ; 2 ( 2 ): 153 – 7 . Available at http://tandfonline.com/doi/abs/10.1080/10903129808958861; accessed January 22, 2018. Google Scholar Crossref Search ADS PubMed 5 Sunde GA , Heltne JK , Lockey D , et al. ; Airport Study Group : Airway management by physician-staffed Helicopter Emergency Medical Services - a prospective, multicentre, observational study of 2,327 patients . Scand J Trauma Resusc Emerg Med 2015 ; 23 : 57 . doi:10.1186/s13049-015-0136-9 . Google Scholar Crossref Search ADS PubMed 6 Abe T , Takahashi O , Saitoh D , Tokuda Y : Association between helicopter with physician versus ground emergency medical services and survival of adults with major trauma in Japan . Crit Care 2014 ; 18 ( 4 ): R146 . doi:10.1186/cc13981 . Google Scholar Crossref Search ADS PubMed 7 Baker T , Kumar K , Kennedy M : Learning on the fly: how rural junior doctors learn during consultations with retrieval physicians . Emerg Med Australas 2017 ; 29 ( 3 ): 342 – 7 . doi:10.1111/1742-6723.12754 . Google Scholar Crossref Search ADS PubMed Author notes The views expressed are solely those of the authors and do not reflect the official policy or position of the U.S. Army, U.S. Navy, U.S. Air Force, the Department of Defense, or the U.S. Government. © Association of Military Surgeons of the United States 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - An Assessment of Flight Surgeon Confidence to Perform En Route Care
JF - Military Medicine
DO - 10.1093/milmed/usy281
DA - 2019-03-01
UR - https://www.deepdyve.com/lp/oxford-university-press/an-assessment-of-flight-surgeon-confidence-to-perform-en-route-care-N0RGMCEY0f
SP - 306
VL - 184
IS - Supplement_1
DP - DeepDyve
ER -