Right or wrong, it seems that every facet of health care and, for that matter, every public safety entity is being challenged to justify its necessity. I welcome the opportunity to explain to those that I serve why I am important. I feel that it will help establish our community as a specialty. This prompts another interesting question: are we a specialty? To me, the answer is not so obvious. This has often been the topic of rather colorful debate both within and outside of the air medical community. There are rather compelling arguments on either side of the fence. I suppose that in order to make a determination, it would be important to define what a specialty is. According to Merriam-Webster, a “specialty” is defined as:
1: a distinctive mark or quality
2: a special object or class of objects: as (1): a legal agreement embodied in a sealed instrument (2): a: product of a special kind or of a special excellence b: the state of being special, distinctive, or peculiar
3: something in which one specializes.
While definition (3) provides little assistance, the other two definitions begin to get to the core as it relates to health care. The way that I and many of my colleagues in air medical transport, emergency medicine, EMS, critical care medicine, and nursing view the question of what makes up a specialty is consistent with the above definition(s). Common threads include:
- A “subgroup” within health care
- A collection of individuals
- A “unique” and “specific” area of expertise
- A “shared body” of knowledge, ideas, and experience
- Specific, identifiable standards of care
- Evidence-based
I will reserve my opinions for a later date because quite frankly, the heated discussions in the hangar break rooms and communication centers are rather entertaining. I will say that if the air medical community is not yet a specialty, it is continually getting closer. Our body of evidence and research is growing. Our treatment modalities continue to be based on “what is best for the patient as we move them from point A to point B” rather than “if it works at the bedside, it will work in the air.” I must also admit that I am constantly impressed with the critical care transport provider’s ability to quickly formulate a “plan B” (improvising, adapting and overcoming if you are a Clint Eastwood fan), something that we can proudly place in the category of “unique and specific area of expertise.”
Regardless of which side of the fence you stand, it is an important question to ponder. There are economic and logistic advantages to placing a patient on a balloon pump in the back of an ALS ambulance accompanied by a CCU or cardiac catheterization lab nurse. The question to ask is: what is the safest way to complete this transport? There is a difference between a highly skilled bedside provider and a provider who is trained not only in expert ICU care, but safe patient transport as well.
I have no doubt that there exist many clinicians who could do my job from a clinical perspective. The difference is that I have to do it at altitude, while also ensuring the safety of myself, my crew, and my patient. I have to understand how the stresses of flight and altitude affect my patient’s clinical condition. I have to do it in the dark, in a multitude of environments, and without much support. From this perspective, I can make a strong argument for why my occupation constitutes a specialty.
The question of “why air medical transport” always surfaces, and it is a question that I welcome. The day that a small, community ambulance service is not overwhelmed by the thought of a two-hour ground transport to the closest tertiary center with a profoundly septic patient requiring multiple drips, advanced hemodynamic support and ventilatory management will be a great day because that means that education and training are expanding for all care levels. As an educator, my goal is to always train my replacement to be a better clinician than I was. Until that day comes, however, being part of a “tiered response system” is a necessity. How a transport occurs will depend on the level of training required for a particular clinical situation and crew comfort level. I will never be ok with hearing that a crew was “pushed into” a transport when it was secretly uncomfortable doing so.
