Forum
2007; Elsevier BV; Volume: 26; Issue: 2 Linguagem: Inglês
10.1016/j.amj.2007.01.004
ISSN1532-6497
AutoresGary Sizemore, Edward R. Eroe, Michael W. Brunko, Denise Treadwell, Anthony Pellicone,
Tópico(s)Disaster Response and Management
ResumoOften we look at things and see only a small segment of a much larger picture or situation in which we are involved. There are many coined phrases that illustrate this phenomenon, including, “You missed the forest for the trees,” and “If it were a snake, it would have bitten you.” I'm sure everyone reading this can add to the list. More than likely someone can even establish a physiological reasoning why we don't always see the whole picture. If you have been at any of the meetings facilitated by Ed Eroe and AAMS, you probably heard the adage, “Think globally and act locally.” Why is it important to think globally? In many conversations of late, one of the things that has come up is, “How can global events have an impact on me?” Indeed we see the nightly news airing what has been the big story for a while—the war in Iraq and the number of U.S. military whose lives have been lost in the service of our country. Although the war is a global event, many people think the war has no impact on us, unless someone we know or someone from our hometown is killed. The point can be argued, however, the cost of the war is spread across all of the citizens who pay taxes, and if nothing else, we see those images on the nightly news. While the impact may seem small, it is nonetheless an impact. Elections are also controversial issues, and if your candidate won their races, you feel good about the results. If not, you don't feel so good about the upcoming term and the impact it will have on you. There are many more instances that you may think of that are global events that impact us on a local level. Are there global events in the air medical community? The answer is definitely yes. There are many things that happen on a national level that impact our services in big ways—things like the Medicare reimbursement issues, which may make or break a service. Many finance issues happen on a national level, and often we at a local level don't know what they are or how they impact us. The federal excise tax, although not receiving much press, may appear to have little impact on the pilots and crews flying the missions. Does that mean they are not important to us? Absolutely not! The Federal Excise Tax (FET) involves a great deal of money that would be lost by every program in the country without someone standing up fighting those battles for us. A little closer are the issues that more directly affect us. Nursing issues mean a great deal to the professional nurses on our crew. Paramedical issues are important to the professional paramedics in our crew. Pilot issues should be as important to the professional pilots flying the aircraft as medical issues are to the medical crew. This past year has brought many of the pilot issues to a more public place. The Op Spec issue was one. This was not a local issue, and although it impacted some more than others, it impacted all of us. Issues like the shortage of pilots, regulatory issues such as flight and duty, night vision goggle issues, changes in weather reporting regulations, CRM or AMRM, risk assessments, and many more Handbook Bulletin for Air Transport issues have impacted all of us. If nothing else, your check ride has changed, your training has changed, and the way you fly medical patient flights has changed. How we keep informed about those issues is as important as the issues themselves. I often ask the pilots, nurses, and the paramedics I work with why they chose to become or not become members of their professional organizations. Membership is a means of gaining timely information about national issues. All of the professional organizations are involved with the events that shape the future of the air medical community. If you don't know what your professional organization is doing about the issues, I urge you to ask questions and expect answers. As the president of NEMSPA, I stand ready to discuss any of the issues with anyone who wishes to inquire. The board of directors is also poised to answer any questions you may have. We work hard to serve the pilots flying air medical transports and shape the future of air medical aviation to benefit them. If you only think locally, you are not getting the big picture or the whole picture. I urge you to step back and regain the view. Join your professional organization and get involved with the issues happening on a national level. You can be as involved as you wish, and when you do see the big picture, you will also see we are trying to make it the best picture possible. Gary Sizemore, President The A008 OpSpec, originally scheduled to be released by the end of November 2006, was delayed by the FAA until December 28, 2006. The OpSpec deals with the FAA's concern about the possible transfer of any element of operational control to a non-certificated person or entity by any Part 135 certificate holder. I am pleased to report that the FAA did listen to our community concerns and incorporated many changes from the original draft. For details, please check the AAMS website. The Congressional Air Medical Caucus met for the third time on December 12, 2006, in Washington, D.C. The purpose of the briefing was to inform congressional staffers on the current issues facing the air medical community so that they can be addressed by the Air Medical Caucus and Congress as a whole. The entire briefing is available on the Government Relations page at www.aams.org. The caucus is an important part of AAMS' public policy agenda so that we can continue to pursue the issues of our air medical community. For more information, contact Christopher Eastlee at (703) 836-8732 in the AAMS office. The new Tax Relief and Health Care Act of 2006 has language that has fixed the FET refund on aviation fuel. This legislation returns the ability of air medical operators to file for their own refunds on aviation fuel or to pass that ability on to the fuel providers as part of an arrangement. The new legislation also provides air medical operators who were not able to receive refunds due to the change in the law to receive those credits. I would like to thank the Gencarelli Group, the volunteers of the AAMS Government Relations Committee, and the many advocacy efforts of AAMS members from around the country in assisting in the drafting of this legislation and its passage. The inaugural meeting of the re-formed Federal Interagency Committee on Emergency Medical Services (FICEMS) meeting, held on December 8, 2006, at the FAA in Washington, DC, was attended by AAMS representatives. The overall purpose was organizational but included a list of issues that the committee would address, including the recommendations of the IOM Report, Emergency Medical Services at the Crossroads, and the prospect of special federal grant funding for EMS, as modeled by the Fire Services Grant Programs. NHTSA also announced, on December 19, 2006, through a listing in the Federal Register, the formation of a National EMS Advisory Council (NEMSAC) to FICEMS. The new NEMSAC will consist of 26 individuals with backgrounds from a variety of EMS areas, including air medical services. The individuals will be chosen by the administrator from nominations received from the EMS community. For more on the NEMSAC, go to the AAMS website. Remember to mark your calendars for the AAMS Spring Conference in Arlington, Virginia, March 21–24. There are a number of great sessions planned, and as we have done for several years now, we are making our presence known on the hill by visiting legislators and having our annual luncheon. With so many new faces on Capitol Hill, it is critical that we get out and meet our new representatives and make them aware of our issues! Each year the president of AAMS works with board members and others in our community to select the chairs for our committees, special interest groups (SIGs), and sections to lead the important work for the upcoming association year. Additionally we have several liaison positions to help us stay current with related organizations. I want to give big thanks for all those who stepped up to help the association move our important agenda forward. Please go to the AAMS website and click on About AAMS and then Committees for an updated listing. The new AAMS Community Service Award is being rolled out this year. The award, sponsored by Omniflight, will recognize an emergency medical transport individual or organization(s) demonstrating broad-based continuing commitment to their referring/receiving agencies and/or the communities they serve. Nominations for the 2007 award closed in January, but check the website for the latest information. The award will be presented at the AAMS Spring Conference in Washington, DC! AAMS, in collaboration with all the associations in the critical care transport community, continues to add value to your individual programs. Be a part of things as we are always looking for volunteers for committees. Contact Dawn Mancuso at the AAMS office; we need your expertise and assistance. Thank you and remember Vision Zero! Edward R. Eroe, President I know I started my last Forum column “complaining” about the 20+ inches of snow we had received in Denver back in October. Well 3 months later, I think I am experiencing what happens if you complain about things you have little control over—it gets worse! About 5 weeks ago, I got to intimately experience our first major blizzard by getting stuck in my car for 4+ hours on a ride between our hospitals that usually takes all of 15 minutes. Naturally, I had plenty of time to complain to myself but also a lot of time to think about the things that I could have been doing that were constructive rather than watching the snow fly and other drivers lose it. A particular area that I thought I could have been spending some quality time on was follow through on some AMPA critical care transport industry issues, topics that we spent some time on and were enthusiastic and energetic in tackling back when we were in Phoenix. I have to admit; I am as bad, if not worse, than most of us in leaving these national meetings with new a outlook and enthusiasm in contributing to the common good we all believe in regarding AMPA and our industry. But I also am more than willing to admit that it usually takes about 72 hours after I return home that I lose that brief energy and get caught up in the reality of normal job responsibilities, night shifts, etc., with some personal and family demands thrown in just to make things interesting. Let's face it: It is difficult to let the momentum continue after we leave these meetings. By the time this column is published and read by most of you, we will have returned from and experienced what I predict will be another outstanding, successful Critical Care Transport Medical Conference in San Antonio. Between now and then (and after), I recommend that we try to help the momentum. While sitting in my car back in December, I reflected on a few things that I hope we make progress on. For example, part of AMPA's strategic plan, born from our last board retreat, was to develop a Quality Care scorecard that we could introduce to the industry and help in objective clinical quality measurements that programs could use to look at themselves and compare to others. Dr. Robert Falcone volunteered at the AMTC meeting in September to organize a task force of AMPA members to get this initiative off the ground and put it to active use. Naturally, as with a lot of things (refer to my excuses above), it has been slow going in getting this started. I personally think that many of us have intuitive ideas and experience in initiating this plan but have found other things that take priority. I am hoping that by the time everyone reads this in March/April, we (I included) will have made positive progress after some friendly reminders from Pat and some renewed energy that we have experienced from the fiestas near the Riverwalk! One area that has definitely progressed with participation from many AMPA members, influenced and organized by member Stephen Thomas from Boston MedFlight, is the CCT CORE (Air Medical and Critical Care Transport Collaborative Outcome Research Effort). As recently as yesterday, he notified the participants that the Web site is nearly up and running (www.CCTCORE.org) and an IRB protocol summary will be available for those centers to gear up and start collecting data for the first collaborative study, the CCT CORE Airway project. If you are unable to relate to or participate in some of the AMPA goals—look close to home and think of how your own program may improve by what others are doing. I think the majority of us who do rotor transport are actively involved with our colleagues in improving our Acute STEMI and CVA outcomes by being active participants in getting these patients to the right place in the safest, most efficient manner. It also does not take much energy to also look at other areas where we can influence outcomes in the types of patients we transport. For example, I know my surgical, critical care, and pulmonary colleagues are very interested in decreasing the incidence of ventilator acquired pneumonia (VAP) and improving outcomes in the sick sepsis patient. Soon, if not already, our hospitals, colleagues, and reimbursements (yes—pay for performance) will depend on this, and we should be part of the plan in how to best treat these patients from initial contact since we often are the means by which they enter our hospital systems. One way of starting this is to talk to your AMPA colleagues, network at the meetings, send out a group question to the AMPA organization, find out who is doing what and why it is working, and take it to your program for implementation. We may work with different programs, transport different types of patients, and have various time commitments, but I venture a guess we all want to provide the highest quality care with the best outcomes possible for our patients. Be selfish—use AMPA for what you can get out of it and “let the momentum continue”… Michael W. Brunko, President Representation of its members is the most important task of any association. ASTNA is the organization that represents all transport nurses: ground, rotor, and fixed-wing. As you have seen with your membership this past year, ASTNA is committed to giving our members a collective voice within our industry. ASTNA represents the transport nurse by collaborating through invitation with other allied nursing and health care organizations, such as the Emergency Nurses Association, the Nursing Organizations Alliance, and National Teaching Institute & Critical Care Exposition sponsored by the AACN, and the newly formed Technology Informatics Guiding Education Reform, to name a few. Reaching out to other professional associations is instrumental in facilitating unification and advancement of the transport nurse. ASTNA also represents the transport nurse by setting the standards of the profession in our publications and position statements, available through our publication library, and also by working with government agencies to ensure quality patient care in the transport setting. One such example is our continued alliance with the EMS Division of the National Highway Traffic Safety Administration on the recently released Interfacility Transfer Guide. ASTNA is also participating in the National Incident Management System Integration Center's National Emergency Responder Credentialing System, a government initiative driven by requirements of Homeland Security Presidential Directive-5, which addresses the need for developing a nationwide credentialing system to facilitate identification, dispatch, and appropriate utilization of qualified emergency personnel, including transport nurses, to a major incident. ASTNA represents the transport nurse in our commitment to the promotion of safety in the transport community by actively collaborating with other professional organizations. We are involved in the Air Medical Safety Advisory Council (AMSAC), a community-wide endeavor to remove the barriers created by “competition” so that information is shared with all. Additionally, we have been involved in several industry initiatives and have made raising safety awareness among our members a priority. ASTNA was the first association to develop a position paper, titled “Flight Nurse Safety in the Air Medical Environment,” that addresses safety in the transport arena. ASTNA members received a copy was in the 2006 year-end mailing. Furthermore, ASTNA continues to support the CoOperative Network Call for Emergency Regional Notification (CONCERN) Network, originally used as a mechanism to alert the air medical community of situations in which crewmembers had been injured or killed in helicopter or airplane crashes but now may be used to transmit information on a wide variety of situations without injury or death. In addition, ASTNA implemented the Hazard Awareness Reporting Program (HARP) on our Web site to allow anonymous sharing of issues and concerns from which everyone can learn. ASTNA champions professional transport nursing excellence through professional development and continuing education. Transport nurses are encouraged to demonstrate their commitment to the profession and validate their nursing expertise by becoming certified in their specialty. The certified flight registered nurse (CFRN) and certified transport registered nurse (CTRN) examinations measure the attainment of a defined body of nursing knowledge pertinent to our nursing specialty. This benchmark for our profession is recognized throughout our industry. ASTNA supports continuing education opportunities and advanced training specific to transport nursing through programs such as the Transport Nurse Advanced Trauma Courses, CFRN/CTRN review courses, and the Advanced Stroke Life Support (www.asls.net) course offered this year at AMTC as a pre-conference program by the Florida chapter. Committed to our mission, “Advance the practice of transport nursing and enhance the quality of patient care,” ASTNA will diligently continue our work of defining and promoting the transport nursing profession through educational opportunities, reviewing and revising our position statements to reflect current practice, and defining the practice standards of each mode of transport involved in our profession, such as the Standards for Critical Care and Specialty Ground transports, which will be revised this year, and the new competency-based orientation curriculum. To best represent all the association's members, a number of committees assist the board of directors with their work. Some of these are standing committees, such as the membership, education, safety, military, and research committees. Other resource groups are assembled to link the board to various specialties or subject matter advisors and advise the board on matters related to fixed wing, neonatal and perinatal, maternal/HROB, ground transport, and pediatrics. Any member can participate with the activities of these groups. Member contributions to the ASTNA quarterly newsletter, Wings, Wheels, and Rotors, are also encouraged. ASTNA is the professional transport nurse's link to an expanded network of colleagues, contacts, education, and advocacy of professional issues. Denise Treadwell, President Does it matter if the paramedics in a program are ACLS, CC-EMTP, or are even FP-C certified? Does it matter if they are crossed-trained for the adult and the pediatric patient, for both interfacility and 9-1-1 settings? Does it matter if the pilots of your program have sufficient flying time and are licensed to operate the aircraft? Well, I bet you think that that last statement is ridiculous,… and it is. But the two statements prior to the pilots' hold an equal amount of absurdity. The year is 2007; the patients we treat and transfer are sicker than they have been in the past. The population is growing older, and the older population is continuing to grow. The children of today are somehow figuring out ways to be even sicker than in the past, and everyone else in between is driving faster, going farther from home (or tertiary facilities), and experimenting in ways and with things we never thought we would see, even 10 years ago. The medications that individuals are on are more advanced than ever before, and we have difficulty keeping up with the pharmaceutical trends and the treatment drug of choice. So with all this in mind, I ask you, does it matter if paramedics have all those certifications? Well it should, and if you or I were the patient, wouldn't we choose the paramedic who has them? Some may ask, “Doesn't it cost money for all that training?” The answer is two-fold, both with the same answer, yes. It will cost your program some money for the training and development of these paramedics, or you can choose not to and it will cost you in lack of reimbursement dollars from insurance companies or, even worse, in legal fees for your “inability to properly care for the intensive care/critical care patient.” The future, which starts now, is in the development of a real critical care paramedic. The reason I choose to use the definition “development” is because it takes time, organization, money, and of course a vision to develop not only a critical care program but also the individuals who will hold the responsibility and opportunity to be a critical care paramedic. This vision must be set to uphold the highest values that your program, hospital, or health system believes in. Administration, both operational and clinical, must buy in completely because the reputation of both parties is in the public eye during the developmental and roll-out period. One must ask, “Why do we need to have a critical care program? What will critical care education do for our program? What will it do for my staff?” Well, we all got into EMS one way or the other to help ill individuals (some sicker than others), so that means we want to create the best environment to treat those under our care by raising the bar a few notches. We can enhance our performance improvement initiatives, as well as increase our paramedics' overall knowledge base. Your marketability for business and recruitment/retention of staff will definitely be affected, both in a positive manner. Also, now in 2007 hospitals will be reimbursed based on the performance and meeting the measures that the Centers for Medicare and Medicaid Services have set. Medicare has an assortment of initiatives to improve quality of care in all health care settings where Medicare recipients receive services, including physicians' offices and ambulatory care facilities, hospitals, nursing homes, home health care agencies, and dialysis facilities. The foundation of effective pay-for-performance initiatives is to ensure that valid quality measures are used, providers aren't being pulled in conflicting directions, and providers have support for achieving actual improvement. With these measures in place, now is the time to concentrate on the quality services that we offer, for our patients' sake and the future viability of our service A few years ago I had a vision to create a paramedic program that would supersede any others at that time. The vision was embraced my administration and my medical director. We created a medical advisory board of specialists in all areas that we were looking to venture into. Pediatrics, anesthesia, neurology, emergency medicine, cardiology, trauma, and respiratory were around the table during the developmental stages and the creation of the Critical Care Paramedic Program. The ultimate foundation of this was and still holds true today: education. The education of these select individuals was to surpass any conventional paramedic training, through formal classes, research, training through the methodology of formal educational offerings, clinical hands-on experience and observation, as well as working closely with physician and nursing staff. The integration with the nursing and physician staff broadens the mentality and thought process of the paramedic into the hospital itself. Most paramedics training in the treatment of patients stop once they hit the hospital door. In order to break through this barrier one must open the door to their eyes and minds to the reality of the patients that lie before them. With the addition of mandatory clinical rotations in the hospital setting, from the ED to the cardiac cath lab, and pediatric/neonatal ICU's to the SICU/CCU/MICU and much more, all enhances the development and growth of these paramedics. A critical care patient, whether she is on the ground or in the air, may need one or all of the following: invasive monitoring (eg, Swan Ganz or CVP), intra aortic balloon (IABP), advanced airway management with the use of paralytics, a vented patient or even a patient on a ventricular assist device. These patients require the paramedic to expand their skills and education. Caring for these patients takes a great deal of dedication, education, and experience. This is why credentials and the certifications need to include advanced training in hemodynamic monitoring, IABP, airway management, neurovascular/neurosurgical patients, pharmacology, lab values and interpretation, and cardiology. In this rapidly changing world of medicine, it has become imperative to adjust to the standards that drive us. The weakest link in a transfer is the amount of time that the patient is out of the hospital, whether it is in an airplane, a helicopter, or the back of an ambulance. Paramedics need to realize they should never become complacent with their skills; now it is time to recognize the necessity of education. The program and the individual who strives for excellence in advanced credentialing exemplifies what it means and takes to become a critical care paramedic. Not all programs are created equally, not all paramedics are equal; however, we as an organization must advocate for and support advanced training and education for those who strive to be the best. Anthony J. Pellicone, President
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