When looking at HEMS models in the US and the UK, it’s important to note the differing training and background of the professions. “In the US, nurses are more highly trained and experienced to conduct interfacility transports than paramedics and therefore, critical care nurses are found on most critical care teams,” Frazer explains. “Physicians, unless they are in an Emergency Department Residency (and air medical transports are part of their rotations) are rarely part of the team with nurses operating under medical protocols from the medical director. We encounter physician-led teams in most other parts of the world where the culture has developed with physician/ paramedic teams and where nurses may not have the same level or scope of practice as paramedics.”
But should having a doctor onboard HEMS be seen as a gold standard rather than a necessity? Chief executive of Wiltshire Air Ambulance (WAA) David Philpott, who is responsible for a paramedic-led service funded solely by charitable donations, thinks so: “It is the platinum standard and very expensive. If the NHS funded doctors on helicopters, one would be a fool not to want them. However, doctors don’t come cheap – costs ranging from £500 to £1,000 a shift.” As with many services in the UK, WAA has access to paramedics seconded from the state-funded National Health Service (six of its 11 paramedics are funded by South Western Ambulance Service).
Philpott continued: “Charitably funded air ambulances have a duty to their donors to ensure that donations are being properly spent. A few air ambulance charities (including Wiltshire) have a small cohort of doctors who work onboard the helicopter from time to time as unpaid volunteers.” Using doctors onboard could also damage the reputation of Wiltshire Air Ambulance, explains Philpott, if allegations of clinicians profiteering from charities were ever upheld.
As for the medical limitations posed by a paramedic-only service, there are some impediments, Philpott says, but they are rarely seen. This is backed by NHS tasking data, he said: “From the data, we see that in 2016, Wiltshire Air Ambulance with a [critical care paramedic]/paramedic team were deployed to traumas on 361 occasions, whereas another air ambulance in the region using the physician/paramedic model was deployed to 260.”
Rick Sherlock, president and CEO of the Association of Air Medical Services (AAMS) in the US, explains that fielding a physician onboard every HEMS flight is not pragmatic or feasible in every situation in the US. “As an example, the state of Minnesota has about six million people and is roughly two-thirds the size of Germany, which has about 81 million people,” he says. “The US has vast distances and many areas with low population densities. There are not enough doctors to have one onboard every helicopter or critical care ground ambulance transport under these circumstances.”
Should HEMS be doctor-led ideally, though? “Actually, HEMS services in the US are ‘doctor-led’,” Sherlock explains, “the clinical guidance is simply done remotely during transport of the patient. Medical control is always available and involved for any issues that are encountered by the crews when caring for the patient on the flight.” He goes on: “AAMS does not believe that there must be a doctor as part of the flight crew, but does believe that programmes need doctor-led medical direction and oversight. The most common HEMS crew in the US consists of a nurse and a paramedic. Only about five per cent of US programmes have a physician onboard. Given the scope-of-practice for nurses and paramedics, proper training and with good medical oversight, it has not been shown that a crew with a physician has better outcomes.”
Eileen Frazer, executive director of the accreditation body Commission on Accreditation of Medical Transport Systems (CAMTS) based in South Carolina, US, refers to a study backing this: “The University of Wisconsin (physician-led flight teams) and Mayo Medical Transport (nurse/paramedic teams) compared transports events and hospital outcomes of 398 STEMI [ST-Elevation Myocardial Infarction] patients. This study found that both had zero-per-cent deaths in transport, and no statistical difference in the rate of in-hospital deaths or length of stay. There were higher rates of nitro-glycerine and opioid administrations in the nurse-paramedic teams, which could have led to a higher rate of adjusted in-hospital events. But more study is needed.”