Care in the Clouds

When Vanderbilt LifeFlight started 30 years ago, it operated out of a single Bell 206 LongRanger helicopter. Crews realized quickly how difficult it was going to be to manage patients within such a small airframe. My, how times have changed!

Today, LifeFlight—based in Nashville, TN—operates seven aircraft—five primary helicopters, with one backup, to go along with a fixed-wing airplane—as well as four ground ambulances and a event medicine team. “We’ve really evolved from what started as just a simple flight program to very much an integrated critical care transport program,” says Jerry Jones, MPA, EMT-IV, public affairs manager for LifeFlight. “And that was the vision of Dr. John Morris, who was one of our founding physicians when we started 30 years ago.”

In those 30 years Vanderbilt LifeFlight hasn’t just grown by adding apparatus and personnel. It’s also become a model for how air medical transport systems operate and train their flight crews, not to mention the variety of other prehospital providers they work with.

Becoming a Flight Crew Member

It’s not an uncommon question—“How can I become a flight paramedic or flight nurse?”

The answer begins with experience. When LifeFlight began, notes Jones, Morris envisioned bringing the quality care from Vanderbilt University Hospital and its affiliated specialty centers directly to the patient. That meant having flight crews who had gone through some of the toughest training in the country.

According to Lis Henley, RN, EMT, LifeFlight interim program director, LifeFlight’s flight nurses and paramedics must meet minimum state requirements just to get their foot in the door.  For flight nurses those requirements include a minimum of three years of critical care in addition to a host of certifications, including a national accreditation, such as CEN, CCRN or CFRN, as well as ALCS, PALS, NALS/NRP, TNCC or TNATC certifications. That’s on top of being an EMT or paramedic. Henley says flight medics also have minimum expectations of three years as a paramedic, their license as a critical care paramedic in Tennessee, F-PC certification, and BLS, ACLS, PALS, PHTLS or BTLS and NRP certifications.

Once nurses and paramedics have met the minimum requirements, the real training begins.

“There is an orientation to be a flight crew member that is typically about a year long,” Henley explains. “The first part of the process is a hospital orientation that includes clinicals in both the adult and pediatric sides of the hospital, in both the ICUs and emergency departments. They also have clinicals with, for example, poison control. So they will actually spend time—4 hours—with poison control just to see how that works because it is immersed in part of the protocols of the LifeFlight team.

“Along with that we have sim training, so they work with simulated events that are both adult and pediatric/neonate,” Henley continues. “We also have advanced skills labs where they have the ability to train on advanced skills, including intubation, pericardiocentesis, crics—whether it’s surgical or percutaneous—chest tube placement, IOs, and central lines for adults and pediatrics. We also have access to adult and pediatric ORs and cadaver labs, which provides another opportunity to have real-life experience with intubations and other advanced skills.”

Henley says new flight crew members are put on as a third person, typically for about two cycles of six weeks. Then they’re transitioned to partner with their primary preceptor. “It’s done in different phases, so typically by the time they’ve been here about six months they’re partnered with an experienced person because what’s really important for us to provide them the most optimal experience in that first year, and to have the support that they would need to have in this type of environment.”

Flight crew members must also undergo orientation as well as ongoing training with the pilots.

Henley says flight crew members all do one-on-one training with the pilot, who takes them through a variety of aviation-type subjects, such as weather, different airframes, what it means to be a pilot and the regulations that affect them. “Air Methods is our vendor and they provide this training specifically for our medical crew so they are trained the same way as the pilot specific to transport. They talk about minimum expectations, such as how to put the battery booster on, and how to, not necessarily read the gauges, but understand which gauges are important and how crew members can be helpful to the pilot in an emergency situation. They also discuss the different emergencies that can affect an aircraft, the different verbiage and radio communication. And because LifeFlight does instruments-only flights, flight crew members learn about what flying in the clouds is like, as well as participate in night vision goggle training.”

According to Henley, all that training with the pilots is designed to familiarize flight crew members as much as possible with the various airframes LifeFlight uses, as they never know if they’ll need to fly in two different aircraft on a given day. “It needs to be muscle memory; nothing can be a surprise. The crews are also expected to educate and train the patients and the patients’ family members when they come onto that aircraft. That’s part of being on the medical crew, is being able to train other individuals as to what the emergency procedures are in that aircraft.”

Training for Outside Agencies

One benefit to being a part of a university system is the opportunities for education and training never end. LifeFlight opens the doors to its advanced skills and cadaver labs to the EMS agencies, prehospital providers and other emergency departments it works with. LifeFlight’s education and marketing department makes it very easy for these outside agencies to be a part of the same education that flight crews have, Henley says, as well as providing additional information and training to cover core flight crew competencies those providers may not have.

LifeFlight has also put together an ambassador team, which consists of providers from different counties throughout the middle Tennessee region who are partnered with flight crew members and taken through some of the same education components that LifeFlight crews undergo. Additionally, LifeFlight participates in a trauma resuscitation conference led by the emergency department and trauma services team at Vanderbilt University Medical Center, inviting the EMS services it works with to be a part of that so they can see the hand-off that occurs in the emergency department and then the follow-up care that is provided to their patients.

Jones notes one area LifeFlight has really extended its training opportunities is through a 9-1-1 communicator course.

“It’s such a different environment for a 9-1-1 operator to have to call for a helicopter,” he explains. “So what we do is go into the agency and talk about a lot of helicopter specifics. We talk about ETAs and how they’re different for different helicopter programs; the weather and the impact that it has, because a lot of times when they’re calling for a helicopter it might be clear but then we’re telling them we can’t fly because of weather. So we talk about why that is in different parts of Tennessee. And we also look at it as a great opportunity to have input from them things we’re doing that they either don’t understand or that we can improve on.

“We made, based on their input a couple years ago, some significant changes in how we dispatch,” Jones says. “Our 9-1-1 operators felt like they were being left out of the loop. So now we try to keep them on the phone and we’re dispatching helicopters via radio traffic, whereas before we would hang up and actually call the bases by telephone.”

Henley also says LifeFlight personnel noticed a few years ago that there weren’t many EMS courses available for management. So it created its own dynamic curriculum related to prehospital management and leadership, which it extends to the services it works with.

Another program LifeFlight developed is Operation Tail Watch, it’s helicopter use and safety class. But because LifeFlight crews couldn’t physically go out to every agency that asked for the training, Henley says one of LifeFlight’s team members developed a program where agencies can do it online. “So now you have two options. You can do the online stuff annually, and still have the ability to have us do fly-ins for all the other training. We find we can capture a wider audience now, so it’s really helped with that.”

Through these extended training opportunities and others, LifeFlight trains 3,000 field providers each year, in addition to the ongoing training of its own flight crews.

Research and Other Projects

LifeFlight has particularly excelled in research. It is one of six air medical programs involved in the Prehospital Air Medical Plasma (PAMPer) Trial, scheduled to begin this month. Vanderbilt LifeFlight already carries blood on its aircraft, and Henley says this opportunity will enable it to provide one more service to the patients it serves.

LifeFlight also conducted its own research into 24 hours shifts, after other research questioned the effectiveness of providers working round the clock. LifeFlight crew members do have the option to work 24 hours shifts, but they are not required to do so. Nevertheless, LifeFlight took it upon itself to investigate how effective its own crews are, looking at intubations performed at different times throughout the day based on how many hours crew members worked.

What they found was there was no appreciable difference in their flight crew performance, regardless of the time of day or the point in the shift, which spoke volumes about the way they were managing flights and shifts, Henley says. Part of that is because of protocols LifeFlight already had in place.

“We have a fatigue database where the crews sign in first thing in the morning and answer a host of questions,” explains Henley. “It kind of sets you up at the beginning of a shift as to how much rest you’ve already had and then they reassess the situation with every transport. It gives you additional information during a shift to be able to assess whether you’re fatigued or not. We also support our team in being able to call a time-out. It’s a piece of information; it’s not the only thing that drives you going out of service, but it does encourage people to start asking questions—do you need to take a time-out to go have a quick dinner?

“Along with that is our capability for serving our patients,” she adds, “so we also have staggered shift start and end times so there isn’t really an impact to our patients if a crew is out of service.”

One project those at LifeFlight are especially proud of is its nurse residency program, which provides flight paramedics who want to transition to being a flight nurse with a clear path to do so.

Henley says LifeFlight’s flight paramedics are initially trained just as they would be if they were flight nurses. “There are a few variations because the core background of a flight medic is different than a nurse, but we take that into consideration in the orientation process. In the end we don’t want you to be able to see the difference in the individual who takes care of a patient in the back of an aircraft.”

But, Henley says, LifeFlight discovered a barrier to its flight paramedics who were working to become flight nurses and also wanted to remain on the aircraft. A state regulation requires individuals to be a nurse for at least three years before they can be eligible to be a flight nurse. So LifeFlight worked with the state to alter the requirement. Now, as long as the individual has already been a flight paramedic for several years, they have the ability to transition into being a flight nurse after just one year of being a nurse.

LifeFlight’s Tony Smith spearheaded the project, Henley says, and Shala Horton was its first flight nurse who went through the process. Horton got her nursing license and then went through a nurse residency program within Vanderbilt.

“What that entailed is she went to a variety of different units for a certain amount of time and LifeFlight paid for the orientation,” Henley explains, “and then once she was oriented the unit paid her to work on their unit. It was a give and take, but in the end after one year between working in ICUs and EDs on the adult and pediatric side, she was able to transition back to an orientation at LifeFlight and become a flight nurse. It’s been a phenomenal project and we‘re just now finishing up with our second individual who’s going through it, and we already have another individual lined up in another year who’s going to be able to be a part of this nurse residency program.”

Conclusion

A lot of education and training goes into staffing and operating an air medical service, but Vanderbilt LifeFlight is proof that training pays.

“Safety has always been our No. 1 product and it will always continue to be,” Jones says. “For 30 years we’ve had a program without any accidents and it’s because from the minute someone’s hired here we practice and preach safety. That’s not to say something won’t happen tomorrow, but …”

“This isn’t something that we just created overnight,” Henley points out, continuing Jones’ train of thought. “Safety has just been ingrained within our program, and that’s because of our training. We don’t take patient care lightly.”