Flight Paramedic: The Good, The Bad, The Truth no one talks about!

A closer look at what HEMS is really like:

I hear so many people talk about how they want to go Flight some day, often these are people that aren't even Paramedics yet. The unfortunate reality is that only 1-2% of all Paramedics will ever make that dream a reality(we’ll cover this in the next article).

I get questions daily on the page regarding pretty much everything associated with being a flight medic. Such as: How do I become a flight medic? Is it as cool as it sounds? What are the calls like? What is the scope of practice like? What is the pay like? What can I do to be a better candidate? Which made me realize most First Responders don't actually know what the HEMS world is like. So, I felt it necessary to provide a more in depth look at the world of a Flight Medic and answer all the questions above. Hopefully if you’re interested in being a flight medic, these articles will provide some insight as to what it's actually like, and how to get there some day. 

So, is it actually as cool as it seems?

It seems most people think that being a Flight Paramedic is the coolest thing on the planet, but is it? The easy answer is fuck yes, and conversely …. Absolutely fucking not lol. See, being a flight medic isn’t just hopping out of a helo with night vision goggles on and cutting crics. 

 Unfortunately, the longed after “scene calls” (911 calls) are not usually the bread and butter for most flight porgrams. The fact of the matter is, YOU’RE GOING TO DO TRANSFERS! Yeah, I said what I said. The majority of calls you will have as a flight medic are interfacility. Yes, the percentage of scene calls vs interfacility transfers changes depending on your geographic location, and hospital services available in your area. I know some areas that run 70% scene calls, and some areas that run 98% IFT and 2% 911. But the cold hard truth is that you NEED to find joy in the medicine, not just the “cool 911 shit” to be successful in the world of flight medicine. I’m talking about Paramedicine, Emergency Medicine, ICU medicine and everything in between. It is NOT like being a street medic. You encounter and need to be proficient in all aspects.

Well that sucks, transfers aren’t cool? Now I know doing transfers doesn’t sound sexy, but I assure you that you will run on patients that are sicker than you can even fathom as a street medic. Everyone thinks they’re hot shit until they are faced with a critical access hospital sending a patient on 3 pressors, 5 other drips, a vent that keeps alarming etc. etc. Or you do your first ICU to ICU transfer and everyone around you seems to be speaking a completely different language, talking about conditions and drugs you’ve never even heard of. You will soon be faced with the realization that you didn’t even know what you didn’t know. 

Can IFT’s be critical and bad ass? You bet your ass they can. But you’re going to have to branch out from your original train of thought as to what you know, and what a paramedics role is. You WILL need to learn drips, pumps, ventilator management, and a whole slew of medications you’ve probably never heard of. You will be expected to have similar or identical proficiency in these areas as your RN partner(depending on state and agency). And vice versa for nurses learning paramedic material.

So, your calls and knowledge WILL change. Maybe most of your tubes are in a small hospital at the bedside because the doc was afraid to pull the trigger, instead of on a 911 call. Is that a bad thing? Well… that’s for you to decide. 

Scope of practice:

Flight medics are just glorified transfer medics, right? There’s no difference between a regular medic and a flight medic… I hear this all the time and it cracks me up. These are things only someone who knows nothing about flight medicine would say. The short answer is… I mean… kind of… sometimes, I guess. If you really want to make that big of a generalization. Did you take over and change the entire treatment plan because a rural doc almost killed the patient… yes. But at the end of the day, yes, you’re technically doing a transfer lol.

In every state that I’m aware of, once you become a critical care/ flight medic, you gain a substantial amount of drugs and skills in your scope.  I am not familiar with any states in which a flight paramedic cannot RSI, other than California. Most agencies carry blood, and a plethora of medications not available to ground crews. We’re using beta blockers, calcium channel blockers, hypertonic saline, mannitol, multiple pressor options, ventilators, pumps, multiple paralytic and induction agent options, TXA, managing balloon pumps, impellas, art lines, K+, solumedrol, terbutaline, surgical crics, finger thoracotomy, and even field chest tubes in rural areas. The list goes on and on.  

Autonomy, autonomy, autonomy! Once you make the transition to flight, you will be given more autonomy than you have ever seen on an ambulance or in a hospital. There is no more “calling for orders”. You will likely have standing orders for any and all medications and procedures.  Also, it is very common to have the freedom to follow whatever treatment path is appropriate despite written protocol in your area. ( as long as you’re not doing some wild shit like pericardiosentesis ect.)

But, with the increased scope and skills… comes an increased knowledge base requirement. You’re going to be expected to learn and understand things you’ve never thought about before. A&P and pathophysiology that is well above what you likely learned in medic school. You’ll be interpreting ABG’s and managing the ventilator accordingly, managing pressors and sedation infusions etc. You will have to learn this stuff, stay competent on this stuff, and continually train and take courses on this stuff. To some of you this may be “living the dream,” but some of you will hate this. Most days you’ll likely feel more like an ICU nurse than a paramedic, this could be a good or bad thing for some.  

The good parts of the job:

NVG’s! Honestly, I never get tired of night vision lol. That, and the sound the turbine engine makes when it’s spooling up… best damn sound in the world. If that doesn’t do it for you, the job does have some good perks. For many people, just the increase in knowledge and scope is one of the best parts of the job and worth its weight in gold.

As listed in the previous section, the scope of practice and autonomy are a huge plus for most providers. This is the job where it's cool to be smart, where learning things above your standard knowledge base pays off. It can feel like you’re finally allowed to function at your true potential without restriction, and for many people this alone is the best part of the job. 

The views, OMG the views! Every day you go to work is like a private helicopter tour. You will see sunsets and sunrises that take your breath away. You will get views of geography in your area that most  of humanity will never experience. It can be surreal at times. His to me, never gets old!

For some, just being a member of the 1-2% that gets to drop in on a whirly bird is payment enough.

Pay: Yes, in most areas other than Texas (Texas you’re fucking weird) becoming a Flight Paramedic does come with a pay increase. The national average yearly income for a Flight Paramedic is $71,000 vs the average ground medic salary of 41-50K. With that being said, some areas are as low as the 50K range, and some are in the 100K range. Like anything, it depends on your location and service.

Most flight programs provide pretty solid benefits packages, in comparison to their ground counterparts. Including good life insurance, because you know… you might fucking die in a helicopter crash lol.

Like anything, some of the “perks” may be a downfall to some. And some “downfalls” may be perks to others. This all depends on what you enjoy, and what your expectation of the job is.

The bad parts of the job:

Ahh, what you’re all curious about. There aren’t any negatives to being a flight medic right? Yes, you bet your ass there are. Things that most non-flight medics haven’t even thought about yet. To some these will be a minor inconvenience, and yet to others these will be deal breakers. For many, just the time on the ground and dedication it takes to get hired may be a deal breaker (we'll cover that in the next article).

Fixed wing aircraft: Maybe you’re lucky and get hired at a service that only does rotor transports. However, most agencies have both fixed and rotor wing aircraft.  Taking a transfer by airplane can DRAIN time you didn’t even know was possible!  Let’s say you have a 2-hour transport by plane somewhere. You’re likely going to have to fly there, load ALL your shit into an ambulance, drive to the hospital, transfer the patient to all of your own equipment (a complex patient can take over an hour at bedside transferring and stabilizing), drive back to the airport, load them in the plane, fly your two hours to the receiving facility, then do that whole rodeo again and fly a few hours back to base. Boom, that ONE transport just took 6-8 hours.

Paperwork: Air medical documentation is much different than ground paperwork. It’s much more thorough and similar to nursing documentation than it is traditional medic paperwork. So that call from above, if they were critical… could be 2+ hours just in charting alone. Then you do three of these in a row? You’ve got 5+ hours in charting once you’re done with calls.

Hold Overs: If you’re an EMT or Paramedic… you ARE familiar with being held over at the end of your shift. Getting that late call that puts you an hour past your end of shift sucks huh? But let this sink in, imagine getting one of these 6-hour calls an hour before you’re off, and you’ve been up all night! Then needing to do 2+ hours of paperwork when you were supposed to be off 5 hours ago. The OT pay is cool and all, but it gets old… really old.  You probably shouldn’t make plans for the entire day after your shift. You may be getting off half a day late.

Pilot Time-outs: Oh, didn’t think of this one did ya? The FAA has strict guidelines as to how long a pilot’s shift can be. So, you might do one of these long transfers, and your pilot times out in another state. Meaning they cannot fly you home until they have another pilot, or they have had adequate rest and time in between shifts. Congrats! You aren’t getting off today… hopefully you brought spare toiletries and a credit card.

Commuting/relocating: The likelihood of getting a flight job where you live is highly unlikely. The majority of people will have to either relocate or commute significant distances to make their dream of flying a reality. This is a common trend nearly everywhere in the United States.

Pay: But wait, I thought the pay was a positive? Let’s hold on a second. Is it really that good? Yes and no. Most agencies will give you a several dollar-per-hour raise to become a flight paramedic. Which seems great at first, until you realize your nurse partner has the same scope and responsibilities as you and makes double your salary lol…. to do the exact same job and paperwork. Side note- go to nursing school, then get a flight job! When you think about what is actually required of you in terms of knowledge, skills and time working on the ground prior to getting a flight job… a few bucks an hour might not seem like adequate compensation.

IFT’s: Ya, I know I said they can be bad ass, and they can. But we also went to school to deal with acute emergency situations. And you’ll likely want to pick up a side gig on your days off if you still want that 911 adrenaline fix. You’re not going to be IC or doing the initial assessment and treatments the majority of the time on the helo.

Its not all critical: Unfortunately, even once you put on that bad ass helmet and onesie, you’re still going to transport bullshit. Bullshit that doesn’t need to fly and could go by BLS. Yep, I said it… we don’t always do critical calls. I’ve walked people onto a plane, transported people that didn’t even have an IV in. Just like anything, its not all what you wish it were. Just like Firefighters don’t often actually get to fight fire,  flight doesn’t only do critical medicine. Most of the time when we encounter this, it’s quite simply some doc that doesn’t have any beds open, or the patient needs a service that isn’t available there. And don’t forget the BLS ground agencies and lazy medics that either don’t know who should fly, or are too lazy to drive them where they need to go.

 You will VERY often transport patients by CCT/ Flight that have one or two meds going. Easy meds, things that don’t really need a critical care team… but because of local ground protocols… a regular 911 ambulance isn’t allowed to transport it, such as Heparin, blood or beta blockers ect.

It’s still like private EMS: Sad, but true. The majority of flight programs in the United States are privately owned.  And just like private ground EMS, monetary gain is the bottom line for all these agencies.

GMR, that’s the owner of AMR, owns AirMed, Guardian Flight, Reach, and Air Evac Lifeteam.

Air Methods, who is notorious for being… umm… just like GMR. They own: Mercy Air, Omniflight, Rocky Mountain Holdings Air Transport, and LifeNet.

PHI, or Petroleum Helicopters International was founded for providing helicopter services to offshore oil drilling operations and didn’t become involved in medical transport until they had been in business for 32 years. They were founded on making money in the oil business. I think that’s really al that needs to be said about that.

There are a plethora of hospital based/owned flight services around the nation as well. Which at the end of the day, are still “for profit” programs just like their owning hospitals are.

Unless you work for ACTEMS or a handful of other tax-based services that operate their own air program, you are still in private EMS at the end of the day. And as expected, you WILL still encounter many of the issues you didn’t like about private EMS.

It can feel isolating at times: Flight crews are kind of like Batman, no one sees them or even really knows where they come from until you call. They come in, do work, and are gone before you know it. Which is fun, don’t get me wrong. But with that said, you’re not hanging out in the ER bay for an hour BS-ing with the boys. It can feel like you see less people and have less connection with your first responder counterparts at times.

ITS HARD WORK: I cannot emphasize this one enough. You think you’ve been tired from a 24 or 48 on the ground? Ha, doesn’t even hold a candle to the bird. People underestimate the physiologic stressors of flight, and how they wear you down. Just flying all day makes you tired... it’s a thing.  Loading people and working on people in a helicopter or plane is significantly harder than an ambulance. The angles are more awkward, you’re twisting more, and have little to no room to stretch out and be comfortable. You’re exposed to the elements more than you are on the ground. That AC sucks in the bus? Well, the AC in a helo is worse. If its 110 outside, you’re wearing a long sleeve death suit and sweating from places you didn’t know were possible. And conversely in the winter, you get colder.  They’ve somehow managed to find flight suits that ensure you’re hot as balls in the summer, and cold as fuck in the winter.

These things aren’t that bad by themselves, however, combined they make for a type of fatigue you are likely not used to on an ambulance. And make no mistake, you WILL put in more hours than you anticipate. 

So, should you become a Flight Medic?

That is a question only you can answer for yourself. If you think all you’re going to do is hot load traumas, do crics and kiss babies, this job isn’t for you.   If this all sounds like a challenge you’d enjoy, then yes, maybe it is a viable option for you. The biggest take away I want you to get from this, is that it’s not all grandeur. You may only see us on the terrible wrecks. But its not all guts and glory in between. It’s hard work, and dedication to continued training and proficiency. I hope this helped shed some light on what its really like. Let me know what you think in the comments. Is it for you?

The next few articles will be focused on how to become a competitive candidate, and how to get hired.