What are the key hard skills, soft skills, and core competencies required in Pre-Hospital Emergency Medicine (PHEM)?

Key Skills and Competencies in Pre-Hospital Emergency Medicine (PHEM)

Pre-hospital emergency medicine requires practitioners to have extensive training in both anesthesia and the ability to work safely in challenging pre-hospital environments, with competence defined by these skills rather than by primary specialty. 1

Hard Skills

Clinical Skills

• Advanced Airway Management
  • Pre-hospital emergency anesthesia (PHEA) and rapid sequence induction (RSI)
  • Difficult airway management techniques
  • Failed intubation protocols
  • Pediatric airway management (with higher threshold for intervention) 1

Technical Proficiency

• Procedural Competence
  • Minimum of regular PHEA procedures (suggested at least one per month) 1, 2
  • Trauma resuscitation techniques
  • Vascular access in challenging conditions
  • Thoracic procedures (chest decompression, thoracostomy)

Medical Knowledge

• Broad Clinical Understanding
  • Generalist knowledge across medical, surgical, and trauma pathologies 3
  • Ability to revert to core principles when standard operating procedures aren't applicable
  • Understanding of environmental impacts on patient physiology

Equipment Mastery

• Pre-hospital Equipment
  • Proficiency with portable, robust, and weather-resistant equipment 1
  • Ability to operate monitoring devices in variable lighting conditions
  • Knowledge of battery reserves and equipment limitations

Soft Skills

Decision Making

• Clinical Judgment
  • Risk-benefit analysis under time pressure 1
  • Adaptation to resource-limited settings
  • Decisive action with incomplete information

Communication

• Team Coordination
  • Crew resource management techniques 1
  • Clear communication in challenging environments
  • Effective handover to receiving facilities

Leadership

• Scene Management
  • Command and control in chaotic environments 3
  • Team leadership during critical interventions
  • Ability to coordinate multi-agency responses

Adaptability

• Environmental Awareness
  • Scene safety assessment
  • Adaptability to changing conditions 1
  • Working effectively in physically challenging environments 4

Core Competencies

Training Requirements

• Formal Education
  • Acute Care Common Stem (ACCS) training or equivalent as minimum requirement 1
  • Subspecialty training in pre-hospital emergency medicine (IBTPHEM) 1, 4
  • Regular in-hospital experience to maintain skills 1

Clinical Governance

• Quality Assurance
  • Maintenance of procedure logs 1
  • Participation in case reviews and audits
  • Adverse event reporting 1

Safety Standards

• Patient Care Standards
  • Matching in-hospital standards for monitoring and equipment 1
  • Pre-induction checklists and standardized techniques 1
  • Appropriate assistance from trained healthcare professionals 1

Major Incident Management

• Disaster Response
  • Logistics coordination
  • Triage principles
  • Scene management skills 3

Critical Considerations and Pitfalls

1. Skill Maintenance Challenge: PHEM practitioners must maintain regular practice of critical procedures, particularly airway management. Without regular in-hospital experience supplemented with simulation, competence can deteriorate. 1

2. Environmental Limitations: Pre-hospital environments present unique challenges that can compromise patient care if not properly managed. Practitioners must train specifically for these conditions. 3

3. Pediatric Care Caution: The threshold for anesthesia and intubation in young children should be high, with simple airway techniques often being sufficient. Special training is required for pediatric PHEM. 1, 5

4. Professional Isolation Risk: PHEA should never be undertaken in professional isolation. Access to senior PHEM clinician support is essential. 1

5. Non-physician Limitations: Evidence highlights safety concerns with non-physicians administering neuromuscular blocking drugs. The AAGBI does not support unsupervised administration of anesthesia by non-physicians outside physician-led teams. 1, 2

The development of PHEM as a recognized subspecialty has helped standardize these requirements, but maintaining these diverse skills requires ongoing training, regular practice, and robust clinical governance structures. 4, 3