Mario Pierobon investigates the nature and effectiveness of crew resource management training for air medical staff.

From the time it is airborne with a medical crew and a patient on-board, an aircraft is essentially a micro-hospital; it cannot rely on support coming from the outside world and it must be able to operate autonomously, whatever way the medical condition of the patient may develop. The medical team on-board an aircraft operated for medical purposes are effectively part of the crew and there must be a solid co-operation between the aircrew and the medical crew, in order to best manage the clinical aspects of the patient’s condition, as well as the conduct of flight.

Even if there are no thoroughly codified regulatory requirements, crew resource management (CRM) training for medical staff involved in air medical operations is increasingly being delivered. Air operators involved in medical flights are developing these training programmes as it is recognised that there are significant criticalities in air medical transportation which makes it important for medical crews to be trained on CRM-related subjects. Indeed, in both aviation and medicine, incidents and accidents due to human error can have very serious consequences.

Need for CRM Training

“In an ambulance jet the medical professionals work in a small team, operating in a very limited space and in difficult conditions,” said Hanspeter Leemann, head of CRM and jet pilot at Swiss Air-Rescue Rega. “Consequently, it is even more important that, for example, communication within the medical team – but also at an interdisciplinary level such as between the medical and flight crews – is guaranteed at all times, to ensure that the patient receives optimal medical care throughout the entire duration of the transport.”

“Medical personnel are required to be licensed and highly trained professionals, however, many of them are per diem and hold positions at hospitals, fire stations, and ambulance companies,” commented Dawn Cerbone, senior vice president of sales and marketing at REVA Air Ambulance. “The working environment of an aircraft adds the additional stress of space constraints, temperature fluctuations, and noise. Since medical crew members are out of their typical work environments and exposed to additional stress levels, communication can be easily strained. Proper training on communication techniques and decision making skills are essential to properly prepare medical crew members for flight.”

Eileen Frazer, executive director of the Commission on Accreditation of Medical Transport Systems (CAMTS) observed that “Medical transportation requires teamwork between the disciplines - the aircraft or ambulance operator, medical crews, maintenance and communications in order to be effective and safe. Maintenance and communications must be ready and prepared to support the medical team, the pilots and the operators. The transport teams are autonomous and independent and so each part of the mission must be well coordinated and this includes being educated in CRM or air medical crew resource management (AMRM).”

Communication between medical and flight crews is critical because specific clinical requirements may dictate specific operational requirements, such as maintaining a given altitude or the choice of an alternate airport.

“In addition, the medical equipment on-board an aeroplane operated as an air ambulance is powered by the on-board electrical source, this means that in case of failure of the electrical sources there can be limitations on the operation of medical equipment and managing the flight crew and medical crew interface is fundamental in order to best handle any possible emergency or contingency,” said Fabrizio Segrè, director of fixed wing operations at air medical service provider AvioNord. “All these aspects require that there be specific CRM training delivered to the medical crews and this training revolves around two-way communication, between the flight and the medical crew, flight awareness, i.e. fumes and oxygen handling, as well as consideration to personal patient safety.”

Topics for Medical Crews

“Air medical crews work in high risk and high stress environments with very limited resources and many adverse factors,” said Oliver Kreuzer, search and rescue (SAR) flight paramedic at Air Zermatt. “It is absolutely necessary to optimise the crew concept and manage the available resources with training. We cannot perform at such a high performance level without CRM and human factors training.”

Medical crew members typically receive CRM training which is similar to that delivered to aircrews, but there are also some distinctive features. “The primary difference is that many medical crew members are initially unfamiliar with the impact of the aircraft environment on their ability to function, communicate, and make decisions. Because of that, a particular emphasis on the effects of hypoxia is added to ensure crew members can recognize the symptoms in patients, each other, and themselves. Crew members are trained to recognize the effects of dehydration, exhaustion, alcohol, tobacco, and hypoglycaemia during flight,” commented Cerbone.

CRM for medical crews has no legal basis with regard to the development and conduct of training programmes. “Rega endeavours to achieve the greatest possible safety during a mission, and CRM is one of the many ways of increasing safety. In its CRM training for medical crews, Rega addresses the same themes as for the flight crews, which are governed by law, but we adapt them to the requirements of medicine,” said Leemann.

Air Zermatt’s Kreuzer stated, “We also incorporate medical considerations into our CRM training with regard to team performance and human factors in order to perform at the best possible level. We also focus on how to prevent situations that would otherwise lead to a possible crisis and how to get the maximum out of human performance with limited resources if the patient becomes unstable. In addition we train on the communication between the medical crew and the aircrew.”

Topics for Aircrews

CRM delivered to flight crews who are involved in air medical operations must also be customised to address the distinctive features and criticalities of air medical transportation, and this is achieved by the inclusion of additional CRM-related subjects.

At REVA Air Ambulance, “Flight crews receive additional CRM training regarding the communication and coordination of patient status with medical crew members. They also receive infectious disease, universal precautions, and respiratory protection training for when medical crew members advise that any additional precautions need to be taken for the flight crew, i.e. wearing masks/gloves, personal protective equipment (PPE),” said Cerbone.

Frazer points out that strictly speaking CRM is an aviation only tool, developed for cockpit crew coordination. The accreditation standards of CAMTS widen the scope of CRM and propose a syllabus for air medical crew resource management (AMRM) which includes all disciplines involved in medical transport.

CAMTS’ AMRM syllabus includes aeronautical decision making (touching on information processing, stress and performance and task complexity), communications processes and decision behaviour (dealing with briefings, inquiry/advocacy/assertion, crew self-critique re: decisions and actions, conflict resolution and communications and decision making), team building and maintenance (focussed on leadership/followership/concern for tasks and interpersonal relationships/group climate), workload management and situation awareness (concerned with preparation/planning/vigilance, workload distribution/distraction avoidance and individual factors/stress reduction). The topics are for delivery for both medical and flight crew, with a different focus depending on the specific responsibilities of training participants.

“CRM topics related to the coordination with the medical crews are addressed as part of flight crew recurrent training as well as during pre-flight briefings. The topics are the same as those constituting CRM training for medical crews but they are delivered with focus on flight crews’ responsibilities,” said Segrè. “Once the topics are treated as part of recurrent flight crew training, they are further considered together with a line training captain during the first air medical flight performed by a flight crew. While classroom training provides a good foundation, the real training is done on-the-job, air medical missions are ever evolving and real learning on how to behave with the rest of the crew is ensured only by accomplishing a wide variety of missions.”

Industry Best Practice

While it is true that there are no legal requirements for CRM training for medical crews being introduced in the foreseeable future, in some areas of medicine, however, CRM is already integrated into other medical training programmes, such as in hospitals with reanimation simulations. Building on such a trend, is an opportunity for air operators who endeavour to promote and further develop measures that increase safety, according to Leemann.

“CRM was introduced in the field of aviation back in the 1970s, so it is now firmly established and tried-and-tested. In contrast however, CRM has only made an appearance in medicine relatively recently, and it will take quite some time and effort before it becomes as widely accepted as it is in the domain of aviation,” he pointed out.

A best practice adopted by REVA is holding a pre-flight discussion with the medical and flight crew. “This discussion is both formal, via a pre-flight safety briefing and passenger medical status, and informal, with a senior medical crew member as point of contact. At the beginning of each flight, the medical crew members will inform the flight crew on who the senior medical crew member point of contact will be. If the point of contact changes, the flight crew will be briefed on who the new point of contact will be. This helps coordination and communication between flight and medical crew members and assigns accountability and responsibility for that communication to the rest of the medical team,” said Cerbone.

Eileen Frazer stated that, “The outline of the training course in terms of topics to address is important. All the involved disciplines should be together when teaching AMRM. The best courses introduce different scenarios to observe teamwork and how each discipline would react and communicate during unanticipated challenges. This cannot be done by taking a computer course.”

The training should be made pragmatic, to the point, and it should incorporate patient crisis into the simulation. “Trainers should not get involved with death by PowerPoint, they should not just talk about theoretical models, but rather be practical and realistic and run simulations. They should video record the simulations and debrief accordingly, and also do it over and over again, as there is never enough practice,” said Kreuzer.

“When implementing a CRM programme for medical crews, it is important to remember the added stress of the aircraft environment on the medical crew members and the impact it may have on their ability to communicate and make decisions. Awareness of this during CRM training, may help reduce confusion while inflight. In addition, training the procedure to assign a senior medical crew member as point of contact, adds consistency and accountability for communication with the flight crew and amongst the medical crew team,” concluded Cerbone.

Published in CAT issue 1/2018