Pushing Back...

I witnessed a special moment in the evolution of the helicopter emergency medical services (HEMS) industry recently. This occurred during a safety stand down and group meeting/training session involving several aircraft and crews affiliated with a major HEMS provider. The stand down was precipitated by three HEMS mishaps in a recent period, two of which were experienced by the company in question. In two of the three crashes, people were killed, in the third the aircraft suffered significant damage after suffering engine failure and landing hard – there were injuries.

This meeting offered a rare chance to have so many people involved in HEMS in one room, from the newest clinicians and pilots to the guys calling the shots from the head shed. HEMS has changed much in the 13 years I have been around it. When I started flying sick people to hospitals in 1999, most EMS helicopters were operated by a few vendor companies, who employed pilots and mechanics working at a hospital. The clinical staff; nurses, paramedics, respiratory specialists, and on some aircraft – physicians, were affiliated with or employed by the hospital.

Then a couple of events happened that changed the industry into what it looks like today. First, Health Care Finance Administration (HCFA) reforms went into effect increasing the government payment for HEMS patient transports. Private insurance company payments are influenced by what the government reimburses along the lines of a rising tide lifting all boats. Second, and with inexplicable timing, hospitals began to opt out of paying for a helicopter to bring people in.

This may be related to the drying up of funds for trauma care. Perhaps hospitals wanted to reduce the size of their catchment area for indigent, uninsured, or underinsured patients. When the vendors were faced with the prospect of losing contracts, they created a new operating model, the community-based HEMS operation. The vendors hired the clinical staff away from the hospitals, and set up shop out in the areas surrounding the big cities. Where-as the checks previously came from the hospitals, and to a large extent were guaranteed regardless of whether or not any patients were transported, under the new operating model, the vendors turned into health-care companies and billed for services rendered themselves.

This turned out to be extremely lucrative, and all this easy money drew participants into the marketplace. There are still hospital-based and funded flight programs, but the numbers are dwindling as more health care executives grasp the reality of the situation – they control the hospital, and patients have to go there. In practice, the receiving facility determines how the patient will arrive notwithstanding the EMTALA stipulation that the referring or “sending” physician makes this determination. Within the limits of the law, a hospital might even receive a subsidy for facilities. This funnels the money for inter-facility (hospital to hospital) transports to whatever helicopter operator the hospital has a relationship with – as many wise people have stated, it really is all about the relationship.

The goal for helicopter companies today is to be “that” helicopter. With a hospital relationship established, a HEMS company is in a stronger position to market the other types of service provided; accident-scene response flights and specialty care services such as Intra-Aortic Balloon Pump transports and Pediatric or NeoNate team trips. While the two models described, hospital based and community based HEMS are not the only models in existence -hybrid and consortium are two other examples - they constitute the lion’s share of HEMS services today. In the new paradigm, helicopter companies seek first to fly as many patients as possible. The number of uninsured and non-paying patients does affect profitability, and some areas of the country are less lucrative than others, but rarely does payer-mix come into the discussion.

Under the old way of doing business, with a check coming from a hospital every month, the imperative was to minimize risk. The best way to minimize the risks of flight are to remain on the ground. Interaction between HEMS and the marketplace used to consist of utilization reviews (did this patient actually need to be flown?) and safety-related training on helicopter operations; often conducted by the flight crews themselves. Times have changed. In the effort to increase demand for service, fly more people, and generate more revenue; a new category of HEMS professional has been created. The Business Development Manager (BDM) is now the point of contact between the company and the customers. He or she typically has a medical or business background, and is for all purposes a salesman.

Whereas the objective was previously to fly patients who actually needed the level of care and speed of transport afforded by HEMS, today the BDM will ask the customer to fly anyone and everyone.  HEMS and the healthcare industry have their dirty little secrets just like any other endeavor. The BDMs are very aggressive in their efforts to increase the demand for HEMS flights, and to improve the service whenever and wherever possible. They are out there hearing the comments from the hospitals and EMS first responders in the field.

One common complaint is that “it takes too long for the helicopter to arrive.” So we try to reduce this time by asking everyone to be ready to go on a moment’s notice, and to move as quickly as possible once alerted. This is fine, to a point. One bone of contention is the lift-off time limit. Most operators expect the crew to move to the aircraft and depart within ten minutes. In some cases the goal is eight, or even five minutes. Often this is implied rather than written, because past experience has taught that hurrying and helicopters don’t go well together. We have a rational business objective hard-up against a bit of conventional wisdom.

So at this safety stand down, we get to the point in the proceedings where awards for performance are being handed out. The well-spoken, well-intentioned, and personable BDM announces an award for the base (there are several in the area) with the shortest average liftoff times for the past reporting period. At this point a voice from the back of the room booms “THAT IS A BAD IDEA!” Many of us present, mostly the pilots, understand his concern. Asking people to hurry – indeed incentivizing it – amounts to a moral hazard. Haste, coupled with lack of experience or too little attention to detail, has led to dozens of mishaps. Cowlings not latched, fuel caps not closed, shore-power cords not unplugged, baggage doors not closed, checklist items skipped; the list is long and the outcome is bad or fatal. Understanding the BDM’s objective, I proposed tracking the time it takes for the pilot and crew to arrive at the aircraft, noting the elapsed time between the acceptance of the flight and a “mission-ready” radio call. The decision was made to table that award and give it more thought, a smart move. Ironically, the same pilot who so assertively voiced his concern was subsequently recognized for having flown the most patients of any pilot in the room.

It’s nice to see conventional wisdom still has a place at the table.

Environmental Flight

A couple of decades ago, I was a B/3/160 pilot who got sent to Desert Storm. At the time I went over, I had a couple of thousand hours, and had a wide range of flight experience. I was also an NVG IP. I was pretty comfortable flying in any environment. Then I had my first flight across the desert at night with NVGs on. It was so dark that seeing the ground was barely possible at 100 feet, and impossible at 300 feet - the bottom of our normal profile (300 to 500 AGL). The guy I was flying with said - "welcome to the sandbox, we do it a little different here; 100 feet and 100 knots." Each time I let altitude increase, I would lose the ground, and then it was very very had to push the thrust control down to find it again. It was a new environment, and I needed training in it to be comfortable and more importantly, proficient. Recently I flew some HEMS shifts near the toe of the Appalachian's in Alabama. A guy at another base was turning flights down with good ceiling and visibility, so as the new guy in the area I called him to see what was up. He told me that the flights he was refusing were to his northeast, in the mountains, and the wind that day would make the turbulence worse than what he was comfortable with. Fair enough. I have been mountain trained (years ago), and have ferried aircraft across the mounains frequently, but this was a new environment, with new hazards and new things to think about. I mentioned environmental flight training, specific to mountains, to a company instructor. He replied that as experienced pilots, we "at this stage of our careers" are assumed to be experienced enough to get by in any environment. This begs the question of why I am forced to demonstrate proficiency at flying a traffic pattern once a year, but am assumed to have enough experience to prepare me for whatever else nature throws my way. Now we have had two mishaps in a short time span, in which cold temps and visible moisture were likely a factor. I can't help wondering if the parties involved were up to speed on flight in the cold weather environment. I myself was finishing up a ferry flight from PA to SC recently, and as I neared my destination, I noticed the OAT at 2 degrees and had a rain shower on top of the destination. I have flown SPIFR into ice, and it only takes once to have the short hairs on the back of the neck standing up when conditions are ripe. The regulatory distinction that allows VFR helicopters to fly to the point of "known" icing versus the IFR pilot's duty to avoid "forecast" icing is of little help, and may even hurt. Temps less than 4.4 C and visible moisture can result in icing in the windscreen, in the inlets, and on the main and tail rotor blades. This is an environmental flight issue, and a person who hasn't had training in that environment recently may not correlate the weather at hand to the hazards involved. The aforementioned instructor posited that local "tribal' knowlege would be sufficient and indeed desirable to a company-wide policy on environmental flight, and to wit, training on same. So now we are going to have a safety stand down. Perhaps we will talk about environmental flight. Sidebar: What is the turbulence penetration airspeed for the aircraft you fly? For the Astar, googling around will yield that the Brits publish 80 knots in their books. The RFM is no help, but does advise "slowing down". For some reason, it doesn't advise to what speed. Googling will also reveal that jack stall will not occur at collective travel less than 50%,. What is the maximum level of turbulence you should fly in? When was the last time you encountered severe turbulence? For that matter, do you remember the descriptions of turbulence levels, and do you know what aircraft these descriptions are based on? Is this company policy, personal policy, or medcrew policy. If you don't know, it might be time to discontinue beverage service and do some research. safe (environmental) flights rf

Beyond money....Why this job matters.

I don't fly the line much anymore, but I did in Charleston this past weekend. After not seeing the familiar faces for a while, it was nice to catch up. On Saturday evening, I got toned out for a 2yo near-drowning in Myrtle Beach right after arriving at work. The good news about that trip was that the kid was moving and fighting and puking during the before-takeoff-check for the flight to MUSC. A kid crying in a helicopter is a very good thing...

No sooner did I land and begin fueling after dropping off the kid, then my nurse for the night walks up with a phone in her ear and says, "balloon pump".

We don't do many of these.

The Intra-Aortic Balloon Pump is a fascinating device that helps the damaged heart move blood through the body, most importantly to the heart muscle, and of course the brain. A damaged heart leads to a downward spiral, in which the heart isn't moving enough oxygenated blood to itself, and so becomes progressively weaker and more damaged. Then the good blood doesn't go to the brain and other parts, and pretty soon it's all over but the crying. The neat thing about the balloon pump is that it helps a weak heart by inflating a small balloon that has been inserted up through the leg-pipe into the big pipe near the heart at just exactly the right time with each heartbeat. A pressure of 40 over not much is then increased to perhaps 70 over alive. While the pump is working, doctors and nurses can strategize and a patient can rest and recover. That's the good news about the pump. The bad news is that it is top-heavy and 148 pounds, awkward, on wheels, and connected to the patient by a relatively short set of lines and leads. Moving a sick guy from a hospital bed to a stretcher, and then wheeling him out of a hospital to a helicopter can be a real goat-rope. At best it's time consuming and labor-intensive. At worst you can lose control of the pump-patient connection and start pulling things you ought not to.

Any of these patients is going to have a whole crowd of drugs flowing, and when you walk into the room and see all the stuff hanging and running in and around a balloon pump guy, it's breathtaking. As machines get unhooked and switched, and alarms begin to go off, it sounds like a four year old kid playing with a keyboard. Beep, Boop, Bomp Bomp...Beep, Boop, Bomp Bomp. If you want to gain some extra respect for a nurse and paramedic, go watch them prepare a balloon pump patient for a ride.

Sidebar: If you are wondering why we are talking about balloon pumps on a helicopter blog, you should understand that helicopter aviation is by it's very nature a support business. Offshore pilots learn the oil and gas production business, and tour pilots become great public speakers; we exist to make other businesses better. As a flight-lead in the 160th, I took shooters to the objective so that they could accomplish the mission.

So there we were at the Georgetown hospital ICU, and I met - again - a really cool doctor. Young Dr. "Scott" stood with us the entire hour-plus that we unhooked and rehooked lines, wires, pipes, and tubes, and entertained me with stories from his past. As a youngster Scott was an enlisted man in the Air Force, and worked crash-rescue. And now he is a Doctor of Osteopathy. That's an American success story if ever there was one. He was going from trading war stories with me to commenting on patient care and condition and what we might do to improve both, without missing a beat. Some people just exude competence, confidence, and cool, and it is a real pleasure to be in their presence. Scott is like that.

When we finally got ready to roll, Scott said, "I'll drive the pump". I walked along right behind him and to his right, with my left hand on the leading edge of the stretcher. He walked backwards, keeping a nice smooth pace; my job was to prevent the stretcher from getting out of formation; first tugging then braking. It was a real road-show, and you will rarely if ever see a ER doctor pulling his load (sorry, I had to say that)in the way that Scott did last Saturday night around 1:00 AM. Kishma watched the drugs run and the monitor report, Brian pushed from the back end, and kept track of the ventilation pump doing the breathing, and we moved down through the hospital, through doors, elevator, and parking lots.

When we got to N909 LickinChicken(LC), so named because that month and year are sad and special to us, we discussed how to get patient and pump into the back of the volkswagon bus all at once without dropping or pulling something. A little prior planning goes a long way at this juncture, and Scott and Brian each lifted about 75 pounds of pump from ground level while a helpful hospital nurse and I and Kishma loaded the stretcher.

The patient on this flight was a guy we really wanted to help. He is a firefighter who collapsed in front of his buds while fighting a fire near Myrtle Beach. He died right there and got resuscitated twice. His heart was tired and quitting. The rescuer needed to be rescued. It was a pleasure and honor to serve a man who has been serving his entire working life. He couldn't talk to us, but we talked to him. We had his back.

So we took him to the big house. The Ashley River Tower is where hearts go to heal. I hope the best for our guy. So do the dozen or so uniformed firefighters from Charleston FD who met us on arrival. They all wore a look of concern and compassion and Kishma gave it to them straight. God Willing...

So it was a long night. There was another kid to go get around 4:30, but the weather got in the way and I had to go back and a ground trip ensued. I drove home to Savannah with the sun, tired but happy with my nights work.

safe flights...

Returning the Favor and Keeping the Faith...

A few years back Les and I took the BK to Beaufort to the airshow, and watched a young Blue Angel pilot burn it in. We went looking for him, and landed and walked the ground where he died. It was a significant emotional event for me, and for Les too I suspect. After that happened I kept thinking about his parents - what was going through his mom's head. They were at the show and watched their son die. I thought about something Les said to me as we flew over the path his jet cleared on the way in. Les opined that Kevin rode the aircraft in to avoid letting it kill people on the ground. You may remember some time after that a Navy guy punched out of a jet out West that killed a man's family on the ground. It was ugly. It's what happens when you eject out of several ton's of metal moving at several hundred miles an hour over a populated area. So anyway, I am thinking that this mother is absolutely crushed, and has nothing to comfort her. So I wrote her a letter.

I told her, amongst other things, that Les and I decided that Kevin deliberately stayed with that jet to avoid hurting anyone.

Was it a kind sentiment or the truth?

God only knows.

We - the Meducare family - also bought Kevin's parents flowers on the first anniversary of his death. She did write me back and tell me what that letter meant to her.

Why am I telling you this? Because Jeanne just told me that during her visit to the Beaufort airshow yesterday, a Blue Angel on a golf-cart rode up to her and asked if they were Omniflight. She said yes. He went away and came back with a signed picture of the team/aircraft. It said thanks for what we do.

The favor has been returned and the faith has been kept.

Concerning a Crash

The only thing I can add about Patrick, Claxton, and Diana's crash in Georgetown is that I knew two of them, and liked them. Patrick was a retired marine, had moved to the Myrtle Beach area and bought a home, had recently had a baby, and was a "motivated troop" when it came to aggressively pursuing flight opportunities. On independant bases, all involved know that flight volume equals job security, and the conventional wisdom is that it takes 30 flights a month to stay in business. Patrick set about ensuring that Conway performed enough transports to keep the base open. He was a capable pilot, had a great sense of humor, and was very popular.

I briefed him on base manager duties when he assumed that position. As we in Charleston shared radio nets with the Conway team, we knew what they were doing, when, where, and in what weather conditions. Some of the flights they pursued caused us to "raise our eybrows" at each other in Charleston, and on one occasion one of our pilots even tried to raise a "safety" flag. But at the end of the day we tended to our business and Conway tended to theirs. I regret this now. As a guy with 10 years of experience in this business, I should have seen where things were headed and raised my voice to bring attention to the situation. The night that Patrick and his crew crashed, Charleston pilot Tim Lilley was in Greenville, stuck for weather, and monitored them leaving Charleston toward Conway. Tim called Pat on the 800 radio, advised him that he had just checked weather and seen a storm moving into their path. Tim suggested they stay at the Charleston crew quarters, since they were going to be empty all night. Pat refused and advised that they were heading home. They never made it.

The investigation on that crash is not yet complete, so no definitive answers can be given, but the initial report does state that the aircraft flew toward an area of convective activity (or words to that effect). Witnesses on the ground saw the aircraft fly overhead at low altitude just prior to the crash. The training point to emphasize here is that we never have to press on. If someone on the ground could see the aircraft, persons on the aircraft could be assumed to be able to see the ground. An off airport landing is better than pressing on into a bad situation. We as AMRM instructors want to drive this home, and we want to drive this point into medical crews as well as pilots. While the pilot should be the first to realize that a bad situation is developing, sometimes we get tunnel vision, or fixation, or suffer some other lapse. Perhaps we succumb to perceived pressure from "above" to "get er done". Regardless, someone on that aircraft needs to speak up and call a halt...

Putting a Chinook in the water, or not...

After getting signed off to instruct Amphib Two, which is what the video is showing, I had a couple of guys with me out in a river near Fort Smith/Fort Chaffee. I was having each guy do three evolutions of landing to the water with the ramp open (which is actually quite a bit different than landing on the water with the ramp up), onloading a combat rubber raiding craft or CRRC, flying a pattern, and putting the boat back in water for another go. So I had, if memory serves, Marie's husband up front and we are getting it done. As it was night, I noticed clearly the port position light was occasionally disappearing under the water, but I didn't consider the ramifications. This was a level one SA failure. As it happened we were also training crew chiefs to perform the ramp duties. Oh, and the guys in the boat were training too. (Bad call, never have more than one piece of a complex operation in training). As we were at JRTC, which was in Chaffee then, we had a generic miles gear kit installed, with a wire running up the right sponson, and into the forward compartment where, as luck would have it, an engine control box lived. The wire broke the seal on the compartment door, and allowed air to escape, which allowed water to flow in thru the open drain ports at the floor of the compartment. This was getting ready to be a problem. The first problem though was that we were too deep, and the ramp opening was too close to the water. The boat made a run for the chemlights taped to the ramp opening, and ran a soldiers head right into the ass end of the aircraft. He went swimming. The boat made a go around, and the FEI made it about half way thru explaining this when we lost comms with the back. Water got into the ICS box near the ramp. I took the controls, lifted the aircraft (now pretty heavy with a belly full of water pouring out of a hundred and something drain holes) to a 30 foot hover, and tried to get control of the situation. Then the number two engine began to decelerate with a torque split and a drop in rotor. That was the water getting into the N2 control box in the compartment on the front of the sponson. We were in a trick.

It was at that moment that a piece of training that I got in the IP course saved the day. As a younger pilot, I had been conditioned to pull the cyclic rearward after losing an engine, as this is what you do when you "get one" in the traffic pattern. My instructor in the IP course took to giving me engine failures at a OGE hover, and I got the habit of accelerating in my muscle memory. So that night, at Fort Smith, as that motor drifted downward I just stood on the beep with my thumb and moved forward thru ETL. We got pretty close to the water. I declared an emergency with the Fort Smith tower, and freaked him out when I did a run on landing with "fuel" pouring out of the aircraft all over the runway. We were done for that night.

Safe flights boys!

rf

Lunch Date

It is easy to forget what is going on "over there" as we all grind through these "tough economic times" and worry about the future of health care or our job or whatever.

A couple of weeks ago, I had lunch 3 other 160th Flight Leads. One currently serving, three retired. I work for EMS brand Y (as in Why did they do That?). Another fellow just took a job with Hermann in Houston. Yet another fellow is going to be a missionary in a foreign land. The active duty guy wants to work in our area when he retires, and hence keeps the communication open. So we have lunch when he is stateside.

So we are sitting there at the Macaroni Grill on a regular day when I ask him about a recent mission in which his chalk two aircraft crashed on departure from a "warm" landing zone. The gist - people were shooting and they were leaving and there was no support anywhere nearby. The zone was typically dusty as all get out, and a 47 really pumps it up. On departure chalk two crashed. Americans died. My buddy in the lead aircraft had to make a decision.

Leave or land.

He says at the lunch table, "I had to go back and look for survivors, any man here would have done the same."
I appreciate his faith but can't help wondering how I would have acted. In my nine years in the seat, I did trash one perfectly good MH-47 under fire, but never had to make a decision like that. After 12 years flying in the "real world" I am also more cynical, more jaded, more aware that it's really all about money here in the U S of A.

He flew back into that dark hell of dust and dirt and blood. They trust the the velocity vector and the acceleration cursor more now-days than we did when I did it. He landed on his system, and did the right thing. And found out the bad news.

Apparently the military isn't quite so generous with awards these days. For what he and his crew did, I would recommend the Medal. He didn't die. We'll see.

So I am sitting there and I can feel the karma flowing out across the table. I am not a big karma guy, but I don't know how else to describe it. Honor? Integrity? Do those words still matter in our country? I sit up a little straighter. I hold my head a little higher. I feel somehow - for just a few moments - elevated. I tell him that. It's the only award I have to offer.

The waitress asks, "will this be together or separate?"