Pre-Hospital Emergency Medicine (PHEM)
While immediate medical care in one form or another has existed for many hundreds if not thousands of years, more recent history in the UK has seen immediate care provided by motivated volunteers. Over the last few decades the scope and spread of immediate care has evolved significantly .
Increasing opinion that formal training and speciality accreditation was desirable led to Pre-Hospital Emergency Medicine (PHEM) coming into being as an accredited sub-speciality training option in 2011. Since 2013 it has been recognised as a sub-speciality of Anaesthetics, Emergency Medicine, Intensive Care Medicine and Acute Medicine and training is the responsibility of The Intercollegiate Board for Training in Pre-Hospital Emergency Medicine (IBTPHEM).
What exactly is it?
PHEM involves provision of enhanced and critical care for seriously ill or injured patients before they reach hospital (on-scene) or during emergency transfer to or between hospitals (in-transit) in what is often a resource limited and both physically and psychologically challenging setting.
Sub-specialist PHEM practice relates to the Emergency Response, Primary Scene Transfer and Secondary Emergency Transfer at the level of the Consultant (Level 8) practitioner. It represents a unique area of medical practice which requires the focused application of a defined range of knowledge and skills to a level not normally available outside hospital .
Who can apply?
Trainees in Anaesthesia, Emergency Medicine, Intensive Care Medicine & Acute Medicine with a successful ST4 ARCP who meet the person specification and have the support of their Head of School (HoS) and Training Program Director (TPD).
Note that there is currently a requirement for a minimum of 6 months training in an approved training post at 'CT1 or equivalent in Emergency Medicine'. This means those Anaesthetic candidates who have not completed the ACCS Core Training Route will also need to obtain a 6 month long OOPE in a recognised training post in Emergency Medicine. The TPD can facilitate this for those committed to undertaking sub-speciality training in PHEM.
There is also an important change coming to the person specification for posts from August 2021, in that programmes starting in August 2021 and beyond will require: "Minimum 6 months training in each of Anaesthesia, Emergency Medicine, Intensive Care Medicine and Acute Internal Medicine in posts approved for training at or above CT1 level or equivalent by intended start date.
This will be an 'essential' requirement and applications will need to ensure they meet this in order for their application to be considered."
For those applying for posts commencing in August 2021 or after the recommendation will to be complete ACCS core training or discuss early their requirements to fulfil the additional EM and Acute Medicine training with the TPD.
When can you apply?
Requirement exists for a successful ST4 ARCP is to permit trainees to commence their post, therefore the earliest you can apply is in the beginning of your ST4 year. I would strongly advocate that completion of the Final FRCA examinations should also be considered as a higher priority than applying for PHEM training, if this had net been completed at the end of ST4. Indeed, it would seem unlikely that you would obtain the required HoS/TPD support required to apply prior to this being achieved.
Adverts normally appear in late September with applications opening a few weeks later, closing in late October and successfully shortlisted candidates are invited to a selection centre in November. Final offers are then made in December.
Where can you do it?
There are training locations throughout the UK. Over the last few years trainees from Wales across the parent specialities have taken posts in Wales, West Midlands and the South West. The nature of the training means training is typically delivered by an Air Ambulance service, although the IBTPHEM curriculum covers the full spectrum of PHEM practice.
You should try to speak to PHEM trainees who have completed training within deaneries you are keen to work in, and bear in mind that you may have to move away to complete your training.
How does the training work?
The extensive curriculum covers 6 domains of PHEM with a number of cross-cutting themes. The training begins with a week long national induction course (the best NHS induction you will ever do!) and local formative assessments culminating in NSA1 at 6 months (the Diploma in Immediate Medical Care) and NSA 2 (Fellowship in Immediate Medical Care) in the last month of training.
In terms of work place based assessments there currently are a mere 15 CEX, 30 CBD, 10 SIM, 30 DOPS, 2 MSF, 25 ACAT and 5 TO for completion - which doesn't make any anaesthetic unit of training you have ever done seem that bad now does it?! Fortunately there is ample provision for supervision and WPBA completion, and this does not usually give cause for concern. An e-portfolio solution, PHEMnet has been developed and from 2018 onwards will be used as the sole method of submission of evidence to the TAP (training assessment panel) at the end of the training program.
The year is based around full time working in the Pre-Hospital environment, generally delivered between a mix of HEMS and Land based Critical Care team deployments. As trainee experience and competence increases, the amount of direct supervision can decrease to allow "solo" deployment - typically as part of a team with remote "top cover" support.
As a PHEM trainee you will see and so things you could never entertain within your hospital practice. Working often in dangerous, cold, wet and unpleasant environments you will be treating patients of all ages - it will be a challenge, and it will be hard physically and emotionally. It will also be once of the most rewarding experiences of your career. Find a current or completed PHEM trainee and chat to them to find out more about the day to day realities, and if possible speak to someone who has completed training in each of the services to which you intend to apply.
Advice to aspirant PHEM trainees
PHEM training has become incredibly popular, as such it has become incredibly competitive. This is great for the speciality, as it can select the best candidates, but can be very frustrating if you work to apply and don't get shortlisted.
So how do you make sure you get shortlisted when you apply? Well, firstly work out what you are going to need to have done before you even apply. National recruitment to PHEM is currently hosted by Health Education East of England and you should review the current person specification and recruitment timelines on their website well in advance of your application (https://heeoe.hee.nhs.uk/recruitment_phem).
By well in advance I mean at least 2 years before you are due to apply, as unless you already meet all the essential and desirable criteria; it is likely to take you this long to put in the many, many hours of work required to do this. Remember the aim of producing the best application you can is to get you to the selection centre, on the day at the selection centre its everybody's job to loose.
- Speak to current and recent trainees about the job and how they went about securing a post, if possible try and get a current PHEM practitioner or recent trainee to mentor you and help guide you in the years and months before you apply.
- Get involved in PHEM at a basic level. Arrange Foundation Year tasters in PHEM, do ACCS rather than Core Anaesthesia, try to include some PHEM in that year out you are planning after Core Training - maybe even consider planning a year out in a PHEM fellowship.
- Arrange some observer shifts with the Ambulance service or a Community based PHEM service such as the Royal Gwent Emergency Department's Physician Response Unit, and attend your local Air Ambulance Clinical Governance days (EMRTS Cymru run these regularly in Wales) if you are eligible to do so. What ever you manage to do - log it and generate some reflections, it all builds up evidence of your suitability to apply.
The mandatory life support courses listed in the person specification offer opportunities to be selected to instruct. Be open with your mentors on these courses about your desire to achieve IP status, and your motivations for doing so: plan when you will revalidate these courses, remember they need to be in date when you apply for (and start) PHEM training. Consider also the more difficult to evidence areas of the person specification, things like personal skills and training in Team Resource Management may be best evidenced by a niche course, study day or self-directed learning.
There are several excellent annual conferences (e.g. Trauma Care, Retrieval & the BASICS/FPHC Conference) that offer the opportunity to meet the PHEM community across the UK, and also provide excellent forums to display posters or present on PHEM related scholarly activity. Again, your regional air ambulance or mentor may be able to help with this or you can apply to join the newly developed Pre-Hospital Trainee Operated Research Network (PHOTON - https://fphc.rcsed.ac.uk/my-fphc/about-us/sub-committees-groups/photon-group) to support this aspect of your development.
It feels hard to get a PHEM training job as an anaesthetist. The nature of funding of many jobs currently means that only emergency physicians can apply which leads to steep competition for those jobs that those from other base specialities are able to apply for. You need to make sure that you work to produce the best application you can, shortlisting for interview has to be your first target. While you are doing this you should also be producing a PHEM portfolio that is well structured, neat and can be used to evidence everything you put on your electronic application.
Think about how far you are able and prepared to move for a job, and bear in mind that may mean committing to two years in a different location for a blended job - this will impact on the jobs you can potentially apply for.
Finally, keep fit, stay keen and be enthusiastic about PHEM and one day you may well be fortunate enough to be able to stop describing yourself as "an aspirant PHEM trainee".
Points of contact
- Matt Creed (Consultant in Anaesthetics & Pre-Hospital Emergency Medicine)
- Wales PHEM TPD: Dr Syed Masud firstname.lastname@example.org
- EMRTS Cymru (https://www.emrts.cymru/) @EMRTSCymu
- BASICS Wales is the umbrella organisation that links the following charity organisations:
- MEDSERVE Wales (South Wales BASICS Scheme) email@example.com @MEDSERVEWales
- MEDS (Mid Wales BASICS Scheme) http://emergencydoctors.org.uk/
- NWEDS (North Wales BASICS Scheme) https://www.nweds.org.uk/
- Welsh Ambulance Service NHS Trust: Dr Jonathan Whelan (Consultant in Anaesthesia & PHEM, Assistant Medical Director WAST) firstname.lastname@example.org