Monday, March 31, 2014

Pressure to Fly...

We operate under pressure. It's a fact of life. Recently I discussed a tragic result of succumbing to pressure to fly and you can read by clicking here

Is it "good" or "bad" pressure?

Click here for an excellent video concerning pressure to fly.

Thanks and credit to PHI Air Medical for this excellent video. May we all benefit from it.

Sunday, March 30, 2014

WATCH OUT! (update 4/15)

courtesy Reuters

For more about drones and HEMS click here.

A Huge Opportunity... Missed!

We got an update from the Association of Air Medical Services yesterday, concerning their efforts to maintain prior-level government funding for HEMS transports for persons covered by TRICARE, the medical insurance used by various classes of persons associated with the military - including retired service members like me. Here is what they had to say...

AAMS Member Alert - AAMS Provides TRICARE Update
March 25, 2014
This morning, AAMS President and CEO Rick Sherlock, AAMS Chairman Marty Arkus, and a number of top executives from AAMS’ member programs met with the Department of Defense Office of Health Affairs to discuss the sudden and unexpected drop of TRICARE reimbursement rates last October. As of October 1, 2013, TRICARE lowered its air medical transport reimbursement rates from to Medicare rates, resulting in an average 62% reduction in payment for TRICARE flights.
After working with AAMS for the past two months to identify the issues and the effects on the medical transport industry, the Defense Health Agency told AAMS, at this morning’s meeting, they will be reinstating the pre-October reimbursement levels retroactively, enabling programs to re-process medical transport bills from October 1, 2013 to now, and receive payments at the pre-October rates. They also said they will create a tri-service working group to work with AAMS to develop a reimbursement structure moving forward that recognizes the critical services air medical transport programs provide for military personnel, military retirees, and their families and create an action plan to implement that structure.
This morning’s outcomes will have an immediate and positive effect on the entire air medical transport industry and AAMS sincerely thanks the DOD Office of Health Affairs for their prompt actions to address our concerns. We look forward to an ongoing partnership with them in the future. AAMS will also continue to work with our friends on Capitol Hill to address the rapidly growing inadequacies of Medicare payments.

While the return to prior-level funding is good news for the HEMS companies, a chance to move HEMS in the right direction regarding safety has been missed, and if the people in charge of TRICARE did a little research, we might still create a win-win situation. 

Keep in mind, the TRICARE managers are supposed to do everything in their power to ensure that the best level of care - provided safely and cost-effectively  - is what folks covered by TRICARE receive. Against that we have the federal government looking to pay for expanded entitlement programs by cutting costs associated with military healthcare. That is rational if not appropriate. So they decided to reimburse TRICARE-covered HEMS flights the same way they do Medicare flights - Medicare pays "on average 62% less than TRICARE", but all HEMS companies participate in Medicare and accept "assignment." 

The return to prior level funding may have something to do with the AAMS choice for CEO, retired Major General (two stars) Rick Sherlock. The general was a great choice for communicating with the military on reimbursement issues as he speaks from decades of experience and may have even known some of the government folks involved. 

It's a shame though, that the Association of Air Medical Services (AAMS) doesn't live up to it's full mandate as the voice - not only of the HEMS industry where it is today - but also of where HEMS should be going in the future. AAMS could have sought to tie increased (or more properly "reinstated") reimbursements from TRICARE to improvements in the HEMS industry, the improvements called for by the NTSB and others familiar with our industry.

Click here to see what the NTSB has to say about the current state of affairs in HEMS

I suppose Mark Twain was right, It's difficult to get a man to understand something when his paycheck depends on his not understanding it. General Sherlock is influenced by the HEMS companies who get the same level of reimbursement from insurance companies (including Medicare and TRICARE) regardless of what features their aircraft don't have. But wouldn't it be tragic if some relative of General Sherlock's was flown in a single-engine, single-pilot helicopter with no autopilot that that suffered a mishap due to lack of these readily available features. (In case you haven't been paying attention, this happens fairly regularly - when it happens to someone you know and care about you see the issue differently). AAMS represents "Cadillac" flight programs who do everything right, as well as the other type of operator, and it is interesting that these first-class operators didn't sound off about getting something for the extra money they spend to be the best.

The only reason this is permitted today by the FAA is that safety requirements are predicated on how many people we will hurt if something goes wrong. If we are only going to hurt a few the rules are more lax. This ignores the fact that the person we fly usually isn't in any condition to comment on what we have or don't have regarding safety and redundancy. Australia recently dealt with this and mandated IFR twins for HEMS. ( IFR "instrument flight rules" capable - able to fly legally in the clouds which stops a pilot from getting progressively lower in bad weather until he finds the ground and, in the words of Ben Springer, takes a 40 g nap)  Imagine the U.S. being second to Australia! I remember when we were first in all things.

For Randy Mains' article on Australian HEMS click here...

SideBar: We miss you Ben Springer. You fly with angels now, for these last ten years. You showed us the way forward. We have goggles, and it is just as you said ten years back...Damn you were smart!

 Here's hoping that someday we will remember the "VFR-only" days and wonder why...

(from Flightweb, 10 years ago) We share the position: the right application of technology can reduce our accident rate.
Damn the barriers!
One reason I posted on this topic is I'm convinced one way to break through barriers is to stay stubbornly on message. I've decided to beat the drum on the issues I feel are most relevant, that is, can have the greatest impact on our accident rate. NVG & IFR or bust.
NVG is breakthrough technology. In 10 years, we'll be looking back wondering how we ever got along without them. Every year we delay, more people die--tragically stupid. I don't care how much they cost. The good news is the costs are in the ballpark of that $25-50K, "very affordable."
I'd like to see a collective unified outcry and see if we could break down the barriers on this one thing. There is other technology that can help too, but I don't want do diffuse the drumbeat. NVG-IFR-NVG-IFR. Stay focused--stay loud.
ALNW Pilot - Ben Springer

If you got a hundred HEMS pilots in a room and put this question to them, "should we operate twins with autopilots or the current crop of singles with no autopilots?" the answer would be unanimous, let's go for safety! But as we don't want to lose our jobs - us pilots -  we keep our mouths shut and hope that one motor doesn't quit.

How many commercial airplanes have you flown on in your life that had one engine?

Here is what TRICARE should do...

They should stand up for the safety of the current and former service members and family members they cover who might be transported by HEMS, and tie reimbursement to the capabilities and redundancies of the equipment used, and the skills of the persons employed.

I don't agree with everything the NTSB puts out, but in this case they are spot-on...

safe flights.

Friday, March 21, 2014

Our Cup of Goodwill...

I sipped my Jameson, put down the glass, and said "I take sick people to the hospital in helicopters." 

Helicopter Air Ambulance image courtesy David Lear

A while back Jeanne and I went on a Smooth Jazz Cruise. We had a great time going to the shows each night, hanging with cool people, and soaking up the tropical vibe. The best part of the trip took place the night before we stopped in Key West. We went to the early evening show in which Marcus Miller did things with a bass guitar that were mind and eardrum blowing, and were then walking back toward our stateroom. We passed by a small, almost empty piano bar and I suggested we stop in for a drink. The room was dark, and the ships piano player was "tickling the ivories," I stood there for a minute and as my eyes adjusted I noticed Jonathan Butler - one of the featured musicians on board - sitting at a table with his family. "Hey Jeanne, that's Jonathan Butler. Let's sit at the piano for minute..."

I sat down and exchanged hellos with the piano player, an older fellow with a tired grin and a vast talent. We ordered drinks. After a few minutes, in this dark little space, J.B. got up from his table and walked over to the piano.

"Oh snap, he's gonna play!"

The house-player gave up his seat at the piano and then Rick Braun walked in with his horn in his hand. He and J.B. started talking and smiling. Then the fellow who had chartered the boat, the entire boat with 2000 passengers, came in and sat down. Then a couple more performers bellied up to the piano, and the cruise host... Someone said, "close the doors."

I don't know what your favorite music is, but imagine if you had the chance to sit in a dark bar with the people who make it, and listen to them talk and play for each other. We sat there and took it in, loving every minute of it.

Then it happened. Someone from across the piano didn't recognize us and asked "who are you, and what do you do?"

I sipped my Jameson, put down the glass, and said "I take sick people to the hospital in helicopters." 

"Wow." "Cool man." "That must be really something..."  We were made to feel welcome, and J.B. played Jeanne a love song for her birthday. J.B. and Rick Braun played a couple of songs together, and then the others took turns performing.

It was a really good time. A once in a lifetime kind of thing.

Jeanne and I were welcomed because of what we do. She takes care of sick people and I fly them.

Society - today - looks up to us, literally and figuratively. We enjoy significant good will and support from the communities we serve, and will continue to do so unless we lose our way and get out of touch with the "service" aspect of our business

I know that operating a HEMS business is challenging. The risks are significant. The amount of capital required is staggering. There is no guarantee of success. The old joke about making a small fortune (by starting with a big one and buying a helicopter) has played itself out time and again. It is understandable, and rational, that as business people in the business of transporting ill and injured persons for profit, we  attempt to maximize our profits, and perform as many transports as possible.

We don't check for insurance before flying someone, and some people don't pay a single dollar. We also don't get paid for airborne standby flights that get cancelled. Or other community-services we provide. But obviously there is money to be made because the number of EMS helicopters has exploded in just over a decade.

Occasionally, profit-motive can run over caring and compassion like a squirrel in the road and leave the caring aspect a little flat.

An anecdote:  A rural hospital employee suffered a stroke and was transported by helicopter to definitive care at a stroke-center. She recovered, and got a bill approaching $20,000 for a 15 minute flight. She was contacted by the transport service's billing department and the discussion went something like this:

"Well ma'am, your insurance has authorized payment of $5000.00 for this transport which leaves you with a balance of $15,000.00. How do you intend to pay this?"

"Sir, I don't have $15,000.00 to pay this bill. I work in a country hospital and don't make much. I can come up with another $5,000 and hope that can be acceptable to settle my bill."

"No ma'am that will not settle your account. Do you thing you might get your church to have a fund-raiser? Or perhaps you could have your husband come out of retirement and get another job..."

Now consider that if this patient had been a Medicare beneficiary - thanks to "assignment," whatever Medicare had paid would have amounted to 80% of the total allowable charge. This woman's obligation would been only 20% of that allowable amount. And the company would have been satisfied. But she wasn't under Medicare and was stuck.

This is the kind of story that goes viral. It smacks of greedy helicopter companies sticking it to people at their worst and weakest point of life, and if the word gets out that this is the way our industry is, that good will I was mentioning earlier will be...

Courtesy AP
In the state of Georgia, rural hospitals are closing their doors one-after-the-other. The state is considering changing the rules to allow for alternative facilities, a sort of "hospital-lite" to allow for stabilization prior to transfer (flight). Mentioned in the same article about this was the statement that Georgia has allocated $12 million dollars for EMS helicopter trips in southwest Georgia. Everyone knows that helicopters save lives and shore up an underfunded, overburdened healthcare system. well, almost everyone.

There is no doubt, at least in my mind. I transported sick people for 17 years. In my case, the plural of anecdote is data. The vast majority of primary and secondary care facilities are not staffed or equipped to treat the sickest and most injured victims of trauma. These patients must be moved to tertiary care - quickly. Helicopters reduce "out-of-hospital" time, and foster good outcomes. 

But if the people running the companies don't cotton to the fact that law-makers respond to stories like this, and use some common sense regarding business development, billing, and utilization-review, the rules we operate under will get changed.

Thus far, the primary defense against any state or local government interference in how HEMS conducts business has been the stipulations in the Civil Aeronautics act of 1938. This act was created to foster the growth of commercial aviation nationally, and to prevent state and local rules and regulations from the stifling such growth.

On April 14, 1938, McCarran introduced S. 3845, a bill to establish an independent civil aeronautics authority to regulate aviation-related commerce and safety. In floor debate, McCarran emphasized the likely increases in air traffic, the growing segment of the economy represented by aviation, and the reality that aviation would soon be a major source of inter-state transportation in the United States. On this last point, McCarran observed, "If we are ever to have safe, regular, and economically sound air transport, it must be administered by a strictly nonpolitical body. Safety regulations are largely nullified by political influences, and, in my opinion, the time is not far distant when the air-traveling public will rise up and demand reasonably safe air transportation."  (courtesy Encyclopedia.com. Click here to read full article...)

But HEMS operators would be foolish to think that the force of public opinion and government-action can forever be held back by an act of Congress dating back to a time before ambulances - much less helicopter-air-ambulances - were even imagined. The original stated-purpose of air transport was to move mail. Then people - people who were awake, alert, and oriented - and knew up front what a trip was going to cost. There was no element of duress. There was no maze of insurance rules to decipher. There was no price-discrimination. The same logic that tells us that torture is not a source of valid intelligence regarding enemy activity also tells us that people under duress will opt for any lifeline tossed their way. They are not in a position to make rational decisions about accepting or refusing such offers of assistance.

The surest way for a politician to win over our hearts and minds will be for her to "protect" Americans against unscrupulous, greedy "body-snatchers."  If the media trend continues, this is coming. (Do you remember a certain New York attorney-general who, before hiring a hooker, made a name for himself by "protecting" New Yorkers?)

Here's another threat to consider. An ambitious young attorney contacts a group of recently-transported patients; all of whom were balance-billed amounts far exceeding what companies accept from Medicare (or Medicaid). These "victims" form a class-action lawsuit demanding that the maximum allowable amount for any patient not fortunate enough to be 65 years old or older (and thus entitled to Medicare's price-controls) be limited to the amount they would pay. And the lawsuit demands reimbursement of the difference in dollars paid. I am not a very smart guy - if I can think of this, so will someone else.

There are some universal truths regarding the treatment of the sick, the weak, the very old and the very young. Everyone - everyone - understands that these souls should be, to a certain extent, protected by public policy. This understanding is what created Medicare and Medicaid in the first place. When the idea that HEMS companies are preying on people at a time when they cannot protect themselves, and are taking advantage of peoples fear, an upheaval will occur.

There will be a backlash. And AMOA won't stop it.

So, for now what are some things that HEMS can do? For starters, it's time for damage control. The first complaint from "victims" of unfair billing practices is that "there is no way it cost (insert amount here) to transport my daughter." And the people hearing these stories think, "yeah, no way!"

But wait! What does it cost to buy or lease a helicopter, hire, train, and compensate twelve to twenty professionals, rent or buy a base of operations, and cover the myriad associated expenses. Then pay for all of this 24 hours a day, 365 days a year, not just for the hour or so that one person needs the service. Then add that we still must make enough profit to present an attraction to investors who must pony-up the millions in advance? When investors put their money at work and at risk, they expect a reward. No one is explaining the back story of that helicopter landing on I-95. Why not?

The patient is not simply paying for a transport. The patient is paying for the transports capability to be exist.

Finally, here is another idea. Most HEMS companies offer a "subscription" for less than a hundred dollars a year. This "membership" provides that whatever insurance a patient has will be good enough to satisfy the financial obligation of being transported. But there are many HEMS companies, and many subscription programs. A sure-fire way to mute public backlash is for the biggest players in the market to get together and agree to honor each other's subscriptions. If we can say to a person, "buy this and your worries about a helicopter transport bill are over," we take the wind out of the sails of discontent. Such a mutual agreement has been in existence in the northwest U.S. for twenty years. Between multiple providers. First, agree to honor. Then sell like hell.

And hopefully, our cup of goodwill will never run empty...

edited 3/25/16

Monday, March 3, 2014

FAA Publishes New Rules for Helicopter Operations...

                                                               image courtesy of the FAA

There are new rules.

Taken in total, it appears to be a lot of light but not much heat...

The FAA can be seen to be "doing something" without really doing anything meaningful.

The only operational change I see on the horizon will be no more post-14 hour (duty day)  recoveries to our bases under the guise of "part 91" (not for hire) with medical crew members on board - no matter who they work for. The screws are getting tightened on duty days. The fractional guys tried to say they weren't on duty when they are on duty, and the Feds said that any duty related to the flying job is duty and counts towards a 14 hour maximum. How the HEMS crowd got a different interpretation than the fractional (ownership) operators puzzles me.

The Feds now require an instrument ticket for HEMS pilots and we have to demonstrate proficiency. (one unusual attitude recovery and one ILS approach a year?) but they are avoiding the elephant in the room, what the NTSB really wants after climbing through all the crash debris.

Instrument flight capable aircraft! With autopilots! For when your single pilot gets himself and his crew into the goo at 3 am and finds flying the aircraft harder than he remembered!

Oh well, one of these days...

They wanted goggles, we got goggles, but  instrument-flight-capability should have been the first priority for night ops. This means two engines, which takes care of the problem of what to do at night when your single engine quits. The Feds accepted goggles as a poor-man's answer (we will use the goggles to perform the autorotation ) but I challenge anyone to show me a picture of a single-engine aircraft that has suffered loss of that engine at night with or without goggles and performed an autorotation without tearing up the aircraft.

If the tail boom is off the helicopter - it's not a hard landing. It's a CRASH.

 It all comes down to dollars, and a fleet of twins will cost more than the occasional destroyed single, and if   we hurt a patient, well it's the cost of doing business... And in all fairness, some guys will continue to crash no matter how many engines you give them. You cannot legislate common sense.

You can read the new rule by clicking here...

Tell me what you think.

Comments welcome.

Keeping It All Together After A Mid-Air Collision With A Bird...

 "Those articles that you think are secured in your cabin? They aren't..."

I met a paramedic yesterday who experienced a mid-air collision with a vulture last October. I hesitate to use the term "bird strike" for this event because it does not convey the shock, the destructive force, or the near-death experience that this crew member and his team lived through.

There were climbing on a beautiful day, when the medic, sitting left rear,  noticed a large dark shape diving from above and in front of the aircraft. He tried to utter a warning, but it happened too quickly...


Both windscreens failed, and gaping holes appeared where the plastic blew into the cabin. The incredible over-pressurization of the cabin instantly blew the doors open. The pilot's head rolled back onto his neck, he was stunned and "unconscious" for a moment. The aircraft began to dive towards the earth.

Articles that were supposedly "secured" in the cabin began to blow out the spaces formed by the doors exploding open. The noise was unimaginable. The wind was whipping the aircraft into a frenzy of blowing debris and blood from the pilots face was in the air.

The medic, in the left rear seat, fearing that his door was going to depart the aircraft and strike the tail rotor grabbed hold and pulled until his hand bled. He was struck in the visor by a piece of the aircrafts dash, if his visor had been up it would have struck him in the eye. (Visors down in flight whenever possible!)

The pilot woke up and used his fingers to pry an eyelid open, to see through the blood and wind. He regained control and landed the aircraft...

The bird never entered the aircraft, but he almost took it down. The medic's quick thinking likely averted the door leaving the aircraft toward the tail rotor. I vote they give the pilot an award for not losing control of himself and regaining control of the aircraft. He was measured and measured up... May we all in extremis

Thank goodness the fuel flow control lever was on the floor, away from the action - otherwise it might have been knocked back to idle or off which would have made the ride much more thrilling...

I wrote another post about bird strikes recently, using research, but it is much more compelling to hear the words from the man who lived it. You can still see it in his eyes when he talks about it. He said, "those articles that you think are secured in your cabin? They aren't..." He knows from experience.

Click here to read the previous post about hitting birds...

It's migrating season again. Consider your strategies for avoiding birds. 90% of all bird strikes happen below 3000 feet. The faster we go the less time they (or we) have to react - maybe we should slow down when climbing or descending. Consider marking areas where birds congregate, like trash dumps, bodies of water, or other sources of food or habitat on your hazard maps. And talk about this at your briefings.

Take care!

And fly safe...

NTSB Identification: ERA14CA009
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Sunday, October 20, 2013 in Madison, MS
Probable Cause Approval Date: 12/19/2013
Aircraft: EUROCOPTER AS 350 B2, registration: N911ES
Injuries: 3 Minor.
NTSB investigators used data provided by various entities, including, but not limited to, the Federal Aviation Administration and/or the operator and did not travel in support of this investigation to prepare this aircraft accident report.
According to the pilot, he was climbing the helicopter through 1,300 feet when he felt an "explosion" in his face that knocked his visor up and affected both his visibility and crew communications. The pilot was eventually able to get his visor back down and land the helicopter, where it was discovered that both windshields were blown out, the center post and the cabin shell were damaged, the doors were blown open and on board medical equipment was missing. On the ground, a crew member stated that just before the event, he had seen a black bird fly toward the helicopter from above and left, but did not have enough time to call it out. Analysis of on board residual bird feathers and a photograph of the suspect bird carcass indicated that it was a black vulture, which can weigh up to 4.8 pounds.
The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The helicopter's collision with a black vulture during climb to cruise altitude.