Physician Staffed HEMS for Trauma...

Dr. Bill Hinckley (Retrievalist, Flight Doctor, Medical Director at UC Health Air Care and Mobile Care - past president AMPA) notes on LinkedIn that the results of a study on the benefits of having a physician aboard a medical helicopter are being published in the journal "Injury."

The study indicates that having a physician on board resulted in an additional 5.33 lives saved per 100 flights to pick up severely injured patients. This is a significant number.

While flying with Geisinger Life Flight in 1999 and 2000, I routinely carried a resident in addition to the normal crew of flight nurse and flight paramedic. I thought then and think now that this practice was good for the resident, good for the patient, and good for HEMS/HAAO - as these doctors got to see first-hand how helicopters influence healthcare.

What are your thoughts?

Leave us a comment...

Dr. Bill writes,

Thanks for posting this, Dan. 

First, we need to clarify slightly exactly what this particular study was comparing. The control group was ground ambulance transport with paramedics. The experimental group was bringing a physician-paramedic HEMS team to the scene, by helicopter when possible but sometimes by ground in unflyable weather, and then transporting the patient accompanied by the HEMS team to the trauma center, usually by ground. This is a common model in Europe, but definitely quite different than the "typical" US model of nurse-paramedic HEMS teams that essentially never transport patients by ground. (Obviously, many exceptions to this "typical" model exist in the US, including here in Cincinnati.) So we can't necessarily extrapolate too much from this Dutch study to our situation in the US. It is convincing, however, that the concept of bringing critical care to the patient as opposed to just bringing the patient to critical care is a concept that can save lives.

However, looking more broadly at all of the HEMS outcomes literature in trauma that's been published since 1980, in my opinion the question of whether or not HEMS saves lives in trauma has been repeatedly asked and answered to the point that we know it to be true with as much certainty as we know anything in the realm of EMS (both here in the US and abroad). How much of the mortality benefit comes from time savings vs bringing additional clinical capability to the patient prehospitally remains up for discussion, though I certainly believe the latter to be the more important of the two. We also know that of the 12 studies that have specifically compared HEMS-without-a-doctor to HEMS-with-a-doctor in trauma pts, 10 of the 12 studies showed mortality improvement with the doctor on board. I suspect these benefits extend far outside the realm of trauma to other time-dependent critical illnesses, though very little outcomes research has examined that question to date. 

With that said, HEMS overutilization and HEMS safety remain as very significant issues here in the US, on which our community must continue to work diligently to improve to the level of our European and Australian colleagues. We have a long way to go.

Dan, thanks for doing what you do!

Connecting the Dots of Situational Awareness... Or Not.

Leading up to most aviation mishaps, some person has a clue, an inkling, a "sense" that something is wrong.

When I spend time with teams discussing AMRM and accidents, I always point out that in a helicopter any new noise, or sound, or vibration is not good and must be investigated.  

Now.

The cause of the change must be determined. We have to think through what the change might mean in the future.

Now if I could just listen to myself.

Here is a story with a happy ending, told in reverse...

The crew lived and went home safely.

The helicopter's pilot landed in a pasture. He did a great job.,,,

In flight, there was an obvious failure of a mechanical component. With vibration, fumes, and sounds. The pilot was unsure of what was wrong, and an emergency situation developed and was declared.

End of story? Not quite. Let's go back further.

I flew this helicopter several times in the days and weeks before this incident. During the first flight,  weeks prior, I noticed that the air conditioner blower seemed to run a bit rough on high speed. It just didn't feel right.

This was a level-1 situational awareness event. That is as far as my SA went though, no level 2 or 3.

Level 1: Simple sensory perception.

Level 2: Realization that the sensory input is relevant to what is happening now.

Level 3: MOST IMPORTANTLY... projecting forward... predicting what will happen in the future based upon the events unfolding now. This takes conscious thought and effort.

When I sensed the roughness in the AC fan, I wasn't even aware of the sensation. I was in the middle of starting a helicopter with a critical patient on board. We needed to go. I placed the blower switch on low speed, it ran smooth and blew cool. I placed the switch on medium speed, smooth and cooler. I placed the switch on high speed and felt the roughness and heard a change in the sound - a low rumbling or roaring sound. It didn't feel right.

Without conscious thought  I switched back to medium speed and it smoothed out. Solved...(?)

I continued on with my patient transport, indeed with several of them. With no conscious thought of why, I operated the AC at medium, or low. This is almost the same as discovering a rough ride at high speed due to a rotor system out of track or balance - slowing until the ride smooths out, and leaving it at that.

As it turns out, I am not the only pilot who operated this aircraft and sensed this roughness - and avoided the high speed setting. In my mind, that makes this a human-factors issue.

In one of the opening moments of his series "Cosmos," Dr. Neil Degrasse Tyson mentions how humankind has risen to prominence on earth because of pattern-recognition. So here is a chance to learn from a pattern: It's all too easy to sense something wrong, make the problem go away (for now) and forget about it. But mechanical problems seldom correct themselves. A subtle hint may be our only warning of a pending failure - and we might not like circumstances when the failure happens.

I  failed to deduce what might happen in the future based upon what I "knew" to be true now. My fan didn't feel right on the highest speed. 

 In most aviation mishaps, some person has a clue, an inkling, a "sense" that something is wrong. But they don't think it through. Perhaps they are too focused on starting the aircraft or talking on the radio or to the crew. Or maybe they are trying to get home before running out of crew-day.

And as happened at the Mayo Clinic's flight program years ago, a "slight ticking sound" turns into something like this...

I am very glad that my failure get to the third level of situational awareness didn't end in tragedy. When operating an aircraft, we must use all senses to detect any change, or problem. And then we have to do something about it...

What Happens When A New Trauma Center Opens In Your Back Yard

For trauma centers, it’s a zero sum game. The number of trauma patients in a given geographic location is fixed. (Actually, it goes up slowly over time as the population increases). So if a new center opens, those patients are redistributed. The new center gets more patients because they are now “designated.” And the existing centers get fewer because there are not as many patients left.

Click here to read more at Dr. McGonigal's blog. (linked with permission)

For helicopter air ambulances, the effect can be dramatic. A local hospital achieving level-two status means many of the patients that would have previously been flown are now driven into town. Flight volumes can be cut in half. A close working relationship with a hospital has always been key to success for any HAA program - in this case it is even more so. The facility that used to refer patients out can now receive many of them. But the referral areas shift and new relationships (or better ones) with EMS agencies must be developed. 

Sidebar: Some thoughts on gaming the system...

More so than ever before, flight teams must seek to be an integral component of every agency they serve. The temptation to cross over the line of what is ethical, legal, and moral must be resisted however. Paying a fee for calls which circumvents the practice of using the closest appropriate aircraft is a dirty secret which cannot be concealed forever - and the anti-fraud arms of the government are long and strong. People talk.

What the Heck...Pop Quiz Final Answer...

Were you thinking needle decompression? This layman was...wrong.

Click here to read Dr. McGonigal's post on The Trauma Professional's Blog

The link to the original post and quiz is here...

With permission from Dr. McGonigal.

Turning to avoid or exit weather...

From an accident report.

After a short discussion the pilot then stated he was going to divert, and he began a left turn to return to Tulsa, Oklahoma. Soon after beginning the left turn the helicopter impacted trees and terrain at a surface elevation of about 850 feet msl...

From a fictional story about crashing after entering the clouds and turning...

He put  the aircraft into a standard-rate turn to the right, still climbing, and as things settled down he leaned over to change the frequency on the radio. This required him to put his head down for a few seconds. It took him two tries to roll in the frequency - why was everything so hard to do? He pressed the flip-button to move the frequency into the active-field and looked up to the instruments.

"HOLY SHI...!" As his head came up in the turn, he accelerated the fluid in the three semi-circular canals in his inner ear in different directions. He had an overpowering sense that the aircraft was rolling, pitching, and yawing - all at once. He tried to look at his instruments but his eyeballs were jerking laterally in his head. He had a sudden urge to throw up....

A thought for your consideration...

We should be extremely careful during a turn to avoid weather (clouds, heavy rain) or to exit it. Especially at night. Most IIMC procedures call for a turn only to avoid known obstacles, for good reason. Transitioning to instrument flight is harder than we remember if it has been a while. Climbing or flying straight ahead lets us get our cross-check going and lets things (and us) settle down. 

What we absolutely DO NOT want to do during a turn is let our attention be divided or distracted, and under no circumstances should we put our head down to change a radio frequency or change GPS settings or destination (as in direct-to back to base). Doing this - putting our head down in a turn - causes trouble when we rotate it back up to the head-up position.

 We accelerate the fluid in our 3 semi-circular canals in different directions and this causes disorientation (the coriolis illusion) and - in severe instances - nystagmus.  When we hear of pilots losing control of aircraft after entering clouds or other weather, or flying them into the earth, this is what we think of. He or she was trying to do too many things too quickly when all that is required is to fly the aircraft...

This is what happens when we neglect to fly the aircraft.

If your aircraft has an autopilot, and it has a go-around button (perhaps on the collective) that rolls you wings level and puts you into a climb-speed  attitude after it is pressed, and all you have to do is pull collective for climb...

Life is good.

Eaglemed Prelim...

NTSB Identification: CEN15FA171

Use this for your next shift briefing. Ask your team mates what each of them could have or would have done as these events unfolded to prevent this from happening...

Nonscheduled 14 CFR Part 135: Air Taxi & Commuter

Accident occurred Thursday, March 12, 2015 in Eufaula, OK

Aircraft: EUROCOPTER AS 350 B2, registration: N919EM

Injuries: 1 Fatal, 2 Serious.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On March 12, 2015, about 2315 central daylight time, a Eurocopter AS 350 B2 helicopter, N919EM, operating as "Eagle Med 35", was destroyed after impacting trees and terrain during maneuvering flight near Eufaula, Oklahoma. The pilot was fatally injured and the two medical crewmembers sustained serious injuries. The helicopter was registered to and operated by Eagle Med, LLC; Wichita, Kansas. Dark night visual meteorological conditions (VMC) prevailed at the time of the accident and a company visual flight rules flight plan had been filed for the 14 Code of Federal Regulations Part 135 helicopter emergency medical service positioning flight. The helicopter departed from St. Francis Hospital Heliport (4OK3); Tulsa, Oklahoma, about 2248, and was destined for McAlester Regional Airport (MLC), McAlester, Oklahoma.

During the previous northbound flight to transport a patient to the 4OK3 heliport, the pilot mentioned to the medical crew that he noticed that the clouds above their cruise altitude were lower than he expected. The pilot descended slightly and the helicopter landed at 4OK3 without incident. While on the ground the pilot checked weather again and after conferring with the medical crew they decided to begin the planned return flight from 4OK3 to MLC. The helicopter was southbound at a cruise altitude of about 1,500 feet msl when the medical crew reported the helicopter had twice briefly entered and exited instrument meteorological conditions. After a short discussion the pilot then stated he was going to divert, and he began a left turn to return to Tulsa, Oklahoma. Soon after beginning the left turn the helicopter impacted trees and terrain at a surface elevation of about 850 feet msl. The impact resulted in the separation of the tail boom and portions of the fuselage and the main wreckage came to rest on its right side. The helicopter's fuel tank remained intact, there was no fuel leak, and there was no postimpact fire.

After impact the surviving medical crewmembers extracted themselves from the wreckage and immediately made a cell phone call to report their situation and location. Several agencies then used the position report from the crew, data from the on-board GPS position reporting system, and signals from the 406 MHz emergency locator transmitter to locate the wreckage. Emergency responders hiked in the dark night conditions through the remote rugged terrain and arrived several hours later.

A meteorological reporting station was located at Okmulgee Regional Airport (OKM) in Okmulgee, Oklahoma, about 20 miles north-northwest of the accident location at an elevation of approximately 720 feet. An automated weather report from OKM at 2315 indicated wind from 020 degrees at 3 knots, visibility of 10 statute miles or greater, ceiling broken at 2,400 feet above ground level (agl), broken cloud layer base at 3,000 feet agl, temperature of 12 degrees C and a dew point temperature of 11 degrees C, and an altimeter setting of 30.13 inches of Mercury. Prior to this report, the lowest cloud layer had been reported as being at or above 5,000 feet agl since 2015, except for 2255, when the lowest cloud layer was reported as being scattered at 1,100 feet agl.

A meteorological reporting station was located at McAlester Regional Airport (MLC) in McAlester, Oklahoma,about 28 miles south of the accident location at an elevation of 770 feet. Beginning at 2153 and continuing through the accident time, MLC automated reporting indicated the lowest cloud bases were between 900 and 2,100 feet agl. A previous report at MLC at 2053 showed overcast clouds with bases at 9,000 feet agl.

GodSpeed Abe Bronn...

Haverfield Aircraft 

I met Abe Bronn when he showed up to fly the air medical helicopter my company operates near Charleston, South Carolina. As I was the duty pilot that day, I conducted his local area orientation and we got to know each other.

He was a veteran, a Night Stalker (Little bird guy), a golf-lover, and an all-around good guy. He got along well with his crews and flew very well. We were lucky to have him with us.

Later, when I worked another base and it came time for the  daily radio checks with aircraft all over the state, Abe would check-in with a hearty "GOOD MORNING AIR-COM! LifeNet 7 has you LOUD and CLEAR.... This always made me smile. The last time I saw Abe, he and his wife were at a party in Charleston. It was a lot of fun for my wife and I to get to know them.

Abe left us and took a job with Haverfield performing utility work. I just learned that he was killed while crashing into a river in Alabama.

Please keep Abraham Bronn's family in your thoughts and prayers.

God Speed friend...

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