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Competence and Credentialing in Pre-Hospital and Retrieval Medicine: A Suggested Framework


Toby Fogg
Medical Director - CareFlight
Samantha Bendall

Co-Director of Education and Retrieval Specialist - CareFlight


Dr Toby Fogg is the National Medical Director of CareFlight and an Emergency Physician at the Royal North Shore Hospital in Sydney.


Dr. Sam Bendall is the Co-Director of Education and a Retrieval Specialist at CareFlight. She is responsible for registrar training and is passionate about ensuring clinicians are able to excel in the pre-hospital environment through realistic simulation and the honing of critical decision-making skills.  She is also an Emergency Physician at Royal Prince Alfred Hospital where she is also involved in multi-disciplinary education and training. She developed and teaches on the HETI ED Masterclass program for the Rural and Remote clinicians, as well as clinical and mission specific training for a variety of organisations including the Australian Defence Force.



Pre-Hospital and Retrieval Medicine (PHARM) presents a number of challenges with regard to training doctors in procedures that they may have to perform.

  • It is possible that if a life, limb or sight saving procedure has to be carried out by a Registrar, it will be the first time they have performed it on a patient.
  • Registrars come from differing critical-care specialities and have varying skill gaps.
  • Senior supervision is rarely possible in this environment, so the Registrar needs to be able to practice independently.
  • There are not limitless resources with respect to time or personnel to exhaustively prove competence in every procedure for every clinician.

A training model is therefore required that is tailored to the PHARM environment.

We propose that more weighting in terms of resources and training rigor be given to those procedures that are more likely to be conducted in a retrieval setting and/or carry the highest risks.

The risk associated with any given procedure was estimated using an online survey of 15 experienced retrieval specialists. Historical data on the frequency that each procedure was performed within a retrieval service was obtained from review of the retrieval database.
These values were combined to generate a risk-frequency score.

A risk-frequency matrix was then used to assign a validated level of competence required for each procedure: advanced beginner, proficient or expert. Each level has pre-defined requirements for theoretical knowledge, practical application and familiarity/comfort

We have therefore developed a framework that is realistic in terms of its expectations and delivery, yet adequately reflects the job we do. The framework accepts that the training for any given procedures cannot mitigate all risk: risk should be lowered to a level as low as reasonably practicable (ALARP) given the finite resources available.



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