For those of you who know me, you know that my passion is critical care transport. I could care less if I did it by helicopter, ambulance or “Red Rider” wagon. I have two jobs that I absolutely love: Flight nurse for The University of Michigan Survival Flight in Ann Arbor and West Michigan AirCare in Kalamazoo (yes, it does exist). For this, I consider myself incredibly fortunate.
There is, however, one dark side to air medical transport that I have no stomach for: competition. From a safety aspect, it causes smart people to do dumb things6. From a business aspect, it causes my colleagues to lose sleep at night.
Whether you believe it or not, the landscape of this industry is changing. Flight volumes have been on the decline for the past several years. Utilization of our services has come under much scrutiny, and rightfully so4. Many ground services insist that they can transport patients “better, faster, cheaper” and most importantly, “safer.” Don’t be mad; they have done an excellent job providing the evidence while we in the air medical industry have done little to challenge this.
Critical care transport is always evolving. Your organization needs to be dynamic to stay relevant. The days where primary call volumes included trauma and cardiac patients are quickly diminishing. More hospitals once viewed as “referring” centers are attaining ACS trauma verification7.
More diagnostic and interventional cardiology suites are being established within a specified region. More prehospital providers are safely providing Rapid Sequence Intubation (RSI), a skill once exclusively afforded to air medical transport providers3. Those patients that do need our services have a higher acuity and tend to be more challenging from a management perspective.
We in the air medical industry have a couple of choices. We can jump up and down and scream that someone is playing in what has been traditionally “our sandbox”, or we can show why we are the best option for expert care and safe transport to definitive care. My colleagues and I on both sides of Michigan have chosen the latter option with a great deal of success.
With the cooperation of local emergency service agencies, local referring hospitals in the region and regional tertiary care centers, we have established new management practices, revised existing protocols based upon current evidence and standards of care within the region, and introduced new equipment and procedures to care for a sicker patient population and to ensure continuity of care1,2,5. In my meager experience, the transport system that is able to accomplish this needs not to worry about what its competitors are doing, what kind of aircraft they have or how many free t-shirts that they hand out (although personally, I would do quite a bit for a free t-shirt).
Another concept that unfortunately escapes many transport programs is to partner with the referral and receiving institutions. Aligning your practice to be consistent with the receiving physician alleviates confusion and delay on both ends of transport, allowing you to initiate definitive care that will continue upon arrival at your destination.
For instance, let’s say that the neuroscience interventional radiology suite at your regional referral center has expanded. Your ability to appropriately manage patients with cerebral vascular accidents according to current evidence-based guidelines will be essential, thereby instilling confidence in the referral process and your place in it5.
An actual opportunity presented itself last fall when the H1N1 pandemic hit Michigan with all of its fury. The University of Michigan became a regional referral center for the sickest of these patients. Partnering with the intensivists and respiratory care staff of the Surgical Intensive Care Unit (the primary receiving unit), the Survival Flight transport team established very progressive management strategies in order to reverse the profound hypoxia and hemodynamic instability often seen with these patients at the referring center and safely transport them to definitive care.
Establishing clear lines of communication, sweat equity in research and literature review, and a solid team effort are often all that are needed in order to foster change and establish a “culture of clinical standards.” Here are some of its tangible cornerstones:
- Updated, evidence-based protocols and procedures
- A well-run training program
- Know what your receiving physicians want
- Shared vision and among team members
By establishing such elements of clinical standards and making it part of your company’s core values, you set a precedent with those that you serve, communicating to them that “your needs are important.”
I still remember my mother telling me to “stop worrying about what everyone else is doing and start worrying about Paul.” When you cultivate excellence and become essential, the competition fades away.
References
1. Fenton AC and Leslie A. Who Should Staff Neonatal Transport Teams? Early Human Development 85 (2009) 487–490.
2. Gerritse BM et. al. Advanced Medical Life Support Procedures in Vitally Compromised Children by a Helicopter Emergency Medical Service. BMC Emergency Medicine 2010, 10:6
3. James DN et. al. Emergency Airway Management in Critically Injured Patients: A Survey of US Aero-medical Transport Programs. Resuscitation 80 (2009) 650–657.
4. Judge T. Breathing Easier: Good News From Air Medicine. Critical Care 2008, 12:164.
5. Knobloch K et. al. HEMS vs. EMS Transfer of Acute Aortic Dissection Type A. Air Medical Journal 28(3). May-June 2009. 146-149.
6. MacDonald E. What Would Mom Say? Air Medical Journal 28(5). 2009. 214.
7. McVey J et. al. Air versus Ground Transport of the Major Trauma Patient: A Natural Experiment. Prehospital Emergency Care 2010; 14: 45-50.
