Time pressure, seriously injured patients and minimal equipment mean that medical crew members onboard air ambulance helicopters have to think fast, adapting to their given mission parameters in seconds. While much can be learnt in a classroom, simulation training is an essential part of ongoing education. Simulation allows participants to practise the non-clinical parts of their jobs in addition to taking care of a patient – so medical procedures, crew communication, situational awareness, and the need for fast decision making under stressful conditions, are all being practised at the same time.
Training courses that provide simulation scenarios are indispensable for air ambulance operators, notes Brad Matheson of US-based Priority1 Air Rescue, as it’s difficult in the commercial HEMS world to provide pilots and helicopter medical personnel with the flight-time experience they need to practise all the skills that enable them to perform as an effective aircrew member, such as crew resource management, situational awareness, confined area landings, scene location/searches, landing zone selection and co-ordination and night vision goggle operations.
recording the in-flight simulations gave faculty the ability to review and debrief scenarios with students
Celeste Alfes is associate professor and director of the Learning Resource Center at the Frances Payne Bolton School of Nursing at the Dorothy Ebersbach Academic Center for Flight Nursing at Case Western University in Cleveland, US. She wrote in Taking Simulation to New Heights: Designing a Flight Simulation Center that simulation scenarios specific to medical transfers allow teams to practise effective communication handoffs, develop a plan of care for a critical ill patient, and implement real-time interventional procedures. The Dorothy Ebersbach Academic Center for Flight Nursing prepares acute care nurse practitioners to work in unstructured environments, organises inter-professional disaster response training during its annual summer camp, and conducts research to build the evidence base for practice in air medical services. Alfes spoke to AMR about why simulation training is essential for HEMS medical crew.:“Flight simulations of critical care air transport differ from other simulation exercises in that noise, light, vibration, time constraints, mission progression, and electronic communication need to be combined with the clinical demise of the patient. High-fidelity simulation can be instrumental in training inter-professional flight teams to improve competency through quality and safe patient care during medical transport.”
Taking pride of place in the Dorothy Ebersach Academic Center’s training facility is a Sikorksy S-76 helicopter fuselage that has been adapted to provide professional education opportunities. Motion, visual and sound effects are all integrated into the fuselage, and the windows were replaced by LCD video monitors to display real-world images of the different phases of flight. A Federal Aviation Administration (FAA)-approved medical interior completes the training environment. During training, the trainer has the ability to observe and evaluate participants’ ability to manage the patient, providing prompts and re-directions as needed, with the aid of two interior-mounted GoPro cameras and aviation headsets. “Recording the in-flight simulations gave faculty the ability to review and debrief scenarios with students, optimising their learning experience,” said Alfes.
Also making use of a full-scale mock up of a helicopter interior is the ADAC HEMS Academy in Germany. While currently the Academy is unable to offer training courses to third parties due to the installation of its third full-flight training simulator (an H145), normally there are mock-ups of an EC135 and BK117 available in which paramedics can train. Thomas Gassman, director of business development and sales for the Academy, said that both helicopters are fully equipped with all the typical gear found on a rescue helicopter. “Both equipment and mannequins are remotely controllable from a hidden directors room,” he added. “In addition, the mock-ups are equipped with video and audio installations; helicopter sounds, control tower noise, etc. is transmitted to the crew helmets.”
Luxembourg Air Rescue (LAR) offers full-scale simulator-based crew resource management training courses for all medical crewmembers, in addition to a medical simulation room in which courses are offered on advanced resuscitation, difficult airway management techniques, major bleeding incidents and paediatric resuscitation.
Crew members also benefit from practising the parts of a mission that occur outside the aircraft, especially treating patients at the scene of an accident. For example, in the UK, the Midlands Air Ambulance Charity has opened an Education and Training Centre, complete with scenario simulation room, at the Tatenhill airbase. Ian Jones, the aircrew supervisor for the charity, said that the simulation room includes medical equipment and props, which enable flight paramedics and doctors to act out various scenarios as part of their advanced medical training; the room allows for the simulation of both indoor and outdoor environments, and is ‘one of a kind’ in the UK’s air ambulance sector, according to Jones. Medics are put through their paces using a Laerdal 3G Trauma SimMan and a Laerdal SimBoy, allowing for cannulation, intubation, and ventilation, among other procedures.
Speaking to the paramedics who have trained using the mannequins in the simulation arena, they say that modern versions are ‘a huge step closer’ to real human patients. Jones said: “For example, with a respiratory examination you would go through the motions on the mannequin and then the simulation driver or trainer would tell you what you found. With SimMan, the simulation driver can change the parameters remotely, and we are able to [match] the findings with our [clinical] assessments. It is currently as close as we can get to being able to create a real patient.”
The sharing of training facilities means that original investment made by one organisation can be recouped when others make use of it. Jones of Midlands Air Ambulance said: “While other organisations have not used the simulation room with SimMan yet, as part of our commitment to fellow members of the Association of Air Ambulances, cross-border training could include the use of SimMan.”
According to LAR, flight medics find that the most important aspect of the company’s courses is ‘the combination of a strong theoretical element with regular practice/recurrent training in a realistic environment’. The courses were developed by LAR when it found a lack of adequate courses available elsewhere for its staff. Over time, said Schomaker, the courses have been adjusted and enhanced, with trainers from both the medical and aviation sides of the business, allowing them to offer ‘true aeromedical courses’. “Having put so much time, effort, money and resources into developing these training courses,” concluded Schomaker, “we are confident enough to offer these courses to external organisations to share our knowledge and help to save more lives by training others to increase their aeromedical skills.”
helicopter sounds, control tower noise, etc. is transmitted to the crew helmets
Another UK HEMS charity that has developed a similar set-up is Hampshire and Isle of Wight Air Ambulance, which recently opened a new simulation training facility that has the ability to project a series of mock incidents, complete with movements and sound. The crew members are currently able to simulate a multitude of different training environments, from a busy nightclub to a Hampshire forest. HIOWAA hopes to add more scenes, with proposed locations including the New Forest, the helipad at St Mary’s Hospital Newport and the resuscitation room in University Hospital Southampton.
“This exciting piece of equipment allows us to safely practise many of the technical and non-technical skills that are required of a critical care team,” said HIOWAA consultant paramedic Els Freshwater. “At a recent training day, we were able to simulate a number of scenarios, including a patient who had fallen in a forest, a cyclist who had been knocked off a bicycle on a busy road and a pedestrian who had been hit by a van in a residential area.”
HIOWAA CEO Alex Lochrane commented: “Hampshire and Isle of Wight Air Ambulance is one of the few air ambulance services in the country to benefit from this pioneering technology. The new immersive training suite is an example of our commitment to remain at the forefront of pre-hospital emergency care, continually improving the service that we are able to provide to our patients.”
Even as digital solutions develop, traditional analogue simulation – for example mock vehicle crash scenes using real cars and actors as patients – remain a useful tool. The Pre-Hospital Emergency Medicine Crew Course provided by the UK’s Great North Air Ambulance Service offers participants the opportunity to take part in a large-scale tactical multi-agency exercise involving the fire service, police, ground ambulance service and traffic officers. Another element of the course gives medics the chance to practise their skills in low-light conditions, with a night-time scenario with multiple casualties involved in a car accident, which tests situational awareness, crew resource management and critical care skills.
HEMS missions are not just about the medical crew treating a patient – taking off and landing helicopters can be a dangerous business, and keeping the whole air crew up to date with the latest safety techniques is an essential part of training. Brad Matheson of Priority1 Air Rescue offers simulation training that addresses this aspect of operations. He said: “For us, this component is essential, as probably the most dangerous job in HEMS is getting there (especially landing) and returning, and to provide the maximum level of safety, the entire crew should be contributing, not just the pilot(s). With our helicopter simulator we can provide our own EMT/paramedics and customer with helicopter simulation and incorporate our Helicopter Emergency Medical Responder (H/EMR) course which includes our ground school training into the synthetic flight training environments.”
With its simulator, Priority1 has the ability to replicate 20 different types of helicopters, incorporating realistic synthetic modelling specific to airframe, internal/external communications, weather conditions, day/night (aided/unaided). Matheson went on to say: “Something as simple as spotting [an] air traffic collision course, rotor obstacle clearances, spotting land marks en route, CRM and [tasks that] people often learn reactively in the field, we can proactively input into the synthetic learning environment for our customers and provide an ‘actual’ HEMS mission scenario and practise situational awareness that can keep a HEMS crew safe.”
flight students become efficient in managing time-sensitive critical conditions
Matheson of Priority1 Air Rescue summed up the real value that simulation training has for the entire crew of an air ambulance helicopter: “Using simulation, we can put crews in high-risk situations, and purposely set them on a course to having a tail rotor strike during a confined area landing, or radio tower collision and night to see if they identify and act accordingly, or set up other scenarios that we would never replicate with live flight training. The next [benefit] is cost savings, [because] commercial (and military for that matter) operators do not have the budget to provide all the hours required to conduct the optimal amount of flight hours to perform all these training modules, however with simulation, we can accomplish the training in a shorter amount of time and without all the associated helicopter flight time, maintenance, scheduling, and possibly having an aircraft out of service that would be on an alert/in service type status.”
Alfes of the Frances Payne Bolton School of Nursing concluded: “[Our] simulator has been a tremendous learning tool, providing faculty with a structured environment for training related to stressors of flight, patient packaging, radio communication, crew resource management and situational awareness. Flight students become efficient in managing time-sensitive critical conditions and performing advanced procedures with limited clinical resources while in motion.”
There is little doubt that mission simulation training for flight medics is of huge benefit to all crewmembers. Whether it is the use of a full-scale mock-up of a helicopter, or a room in which a situation is projected on the walls and a mannequin with simulated injuries, the myriad of options available to flight medics is impressive and essential to their continued professional development.