Wednesday, December 31, 2014

Signs Of Icing - from the JH forum

Bigger, rounded items of the aircraft create a flow field that slows down the rate of ice accretion, compared to smaller, thinner items. 

So look for ice to begin accreting first on things like windshield wipers, OAT probes, and wire strike protection blades.

Those kinds of things on the aircraft are what you pick out to look at. 

You will see ice accreting on these sorts of shapes and projections first. 

You should be aware of likely icing conditions during preflight planning, so as to stay out of them.

But there is an old saying, "Ice is where you find it," it's hard to predict, many variables.

So no matter what the forecasts or rather lack of icing forecasts, I always tell people, when you punch into cloud, take a look right away at your OAT gauge and scan it regularly. 

If the temps are right in cloud for icing, basically +2C to -15C or thereabouts, take some action to get out of that environment. 

Know the temperatures aloft from preflight planning, climbing won't always get you into the colder air and descending won't always get you into the warmer.

On that note, a temperature inversion mixed with cloud is a likely recipe for freezing rain type conditions, DON'T GO THERE.

Air Ambulances Lack Oversight on Medical Care... The Bend Bulletin

Courtesy Marklan Hawryluk/The Bend Bulletin...

Want to know how we got to where we are in HEMS?

Click here for the full and informative story...

Tuesday, December 30, 2014

Rapid Growth in Air Ambulance Industry Raises Safety Concerns

Fueled by high reimbursement rates and scant regulation, the rapid growth of the helicopter EMS industry over the past 15 years has transformed what many consider a life-saving service into an industry fraught with safety concerns but little oversight.

Saturday, December 27, 2014

Feedback on Sleeping on Duty...from our friend Josh

Dan, i couldn't agree with this post more. I say this having worked in both arenas. 7 years in a busy level I trauma center ED and in the flight arena. And I can say this, working a long 3+ hour flight at night with a sick pt. is just as tiring as a 12 ED shift. However, there are a few things to consider when comparing the two. First, i 
think that the "powers that be" fail to recognize what i call "insensible flight stressors." These include low humidity, low O2 environment, high stress, high noise and relatively high pt. acuity. these things combined create an increased metabolic state in the flight crew. (pilot included). Stated plainly, we chew up all our natural glucose and we're damn tired with our bodies having been in overdrive to maintain homeostasis for the duration of the flight. Now, in the hospital, the effects of being tired can range from fairly simple, like walking into the wrong pt. room to moderately bad, such as a med error. In the flight arena, the consequences can be much more dire. Walking into a tail rotor, in my opinion is a FAR greater consequence. (i know we've all been habitualized to maintaining our situational awareness, but people still get punchy, or they're new, or they're just plain tired and not paying attention) The tired flight nurse/medic is also prone to making pt. care mistakes. Often the pt's we fly are of the higher acuity and thus, much more medically fragile. Medical mistakes in this pt. population have far greater consequences that giving 60 Keterolac IV instead of IM in the hospital. Furthermore, when and IF a pt. goes south in the hospital, multitudes of people rush in and the medical menagerie begins. In the aircraft, its just you and your equally tired partner. No help. No pulling over. No flying faster. Just you and your partner.
I guess what I'm saying is this; Nurses get tired on duty, but comparatively, flight nurses face greater fatigue factors than hospital based RN's. The consequences however are far greater for the flight team. Not only for the safety of the crew, but for the quality of care provided, the utilization of limited care providers and the reputation and quality of the flight program.
12 hr shift or 24 hr shift? it doesn't matter. I've also worked both types of schedules flying, and there is little difference given the topic of fatigue. (I much prefer 24 hr shifts however.)
Flight crews should be required to rest while on duty. Their duties, responsibilities and the sheer gravity of the job they volunteer for demands their full attention, not standardization of flight RN vs. Hospital RN rest requirements.

Tuesday, December 23, 2014

To Sleep on Duty, or Not to Sleep on Duty...That is the Question...

Flying at 3 am  is different than working in a hospital at 3 am.

Long ago, I showed up at a HEMS base in the early morning to teach an AMRM class. I went around back, found an open door, and walked in quietly finding on-duty clinicians napping in recliners. There were no beds for them at that base. It brought back memories of "the rule" for many hospital-based programs with clinicians working 12 hour shifts.

No Sleeping On Duty...

One can imagine how this rule got started. When helicopters were all hospital-based, the medical staff worked for the hospital, and were peers of the clinicians working in-house. As no ED, ICU or floor nurses are permitted to sleep on duty, why would a flight-crew be permitted to sleep? Even the appearance of being treated preferentially could cause problems for the flight program. If word got out that leadership was letting aircrew members sleep, other staff on night shift might demand the same treatment.

This is a case of safety taking a back-seat to politics, perceptions, and appearances. The nature of flight duty on night shift is completely different than that of working in-house. Sitting around and waiting is different than walking around and talking to people in a busy health-care environment.

Some leaders will read this and consider forcing flight crews to work in-house while not on a flight, but the truth is - that option degrades the quality of the program and the morale of the staff. Flight crew members are special; they volunteer for hazardous duty, they take on much more responsibility than a typical in-house clinician. They are expected to be "better." They should be treated that way or they will end up leaving.

When your experienced staff leaves, it costs money for training, orientation, and mistakes. How much better and simpler things will be if we look at every policy and rule from an operational standpoint - and remember that often, what's best for your staff is what's best for your company. You don't want just any clown taking care of sick people in your helicopter.

Morale and training costs are not the main reason that flight crews working a night shift should be permitted to take naps. The real reason is that you - Mr. or Ms. Manager - don't want to be the person explaining to the media why you are hosting a memorial service.

In 2009 I was the pilot of the last aircraft in this memorial-flight line-up. My second. We can go a day, We can go a month. Can we go a full year without a HEMS helicopter crash? It's not up to me... It's up to you!

The NTSB and the FAA have done research on aircrews and fatigue. So has Dr. Mark Rosekind, currently leading the NHTSA and an expert on fatigue. Fatigue is a hidden factor in many of our mishaps. Fatigue affects mood, performance and judgement.

The nature of flight operations at night are completely different than taking care of patients in a hospital setting. Especially the empty-leg back to base after dropping a patient at a distant facility - the leg in which bad things happen most often. Crews get "up" for the patient-care portion of the flight, then they struggle to stay alert on the way home. If this return trip occurs at the nightly physiologic low-point - typically between 2:00 am and 4:00 am - then your crew will be as sharp as a bowling ball.

Fatigued crews lose the mental-edge that prevents loose latches, cowl-strikes, tail-rotor strikes, open fuel-caps, objects dropped from aircraft in flight, still-connected cords and cables, and -  God-forbid - mid-air collisions. Surely you remember a time when you were wide awake at work, and almost fell asleep on the drive home. Well now imagine that it's your pilot falling asleep, and the crew is sleeping with him.

Flying at 3 am  is different than working in a hospital at 3 am.

As Dr. Mark noted in his research, when you are tired, "any sleep is better than no sleep." Maybe you don't want to provide beds in bedrooms, comfortable recliners in a quiet dark room will suffice...

In the interest of safety, it should be the policy of your flight program that crews are permitted to nap on night shift. Even crews working 12 hour shifts. They are probably doing it anyway, and forcing them to break a rule to do what comes so naturally creates cognitive dissonance and emotional discord.

safe flights...

Monday, December 22, 2014

Is Mechanism of Injury a Valid Reason to Fly a Patient?

“It’s sort of the perfect storm,” said Dr. Michael Abernethy, chief flight surgeon for University of Wisconsin Health’s Med Flight. “It’s great money, it’s unregulated and there’s really no utilization criteria.” (quoted in The Bulletin, Bend Oregon)

If your system does not support viewing this video clip, access it by clicking here...

When we fly a patient who walks out of the hospital hours after arrival, some question the appropriateness of the flight. Then again, there are injuries which cannot be detected in the field, which might prove serious or fatal after some time has elapsed.

In some cases, staff at receiving facilities give helicopter crews a hard time.  "Why did you fly this patient?" asks the overworked and fatigued resident. Few if any cases allow a crew to decide that a patient does not need to be flown after arriving on scene. If first responders call, the patient will fly...

What do you think? Do you have any stories about flights that ended up being appropriate after all?

Here is one anecdote...

Some years ago I flew a mechanism of injury patient who was alert, oriented, and telling us not to make such a fuss over her, she was "fine".

We were only minutes into the flight when she decompensated, she became unresponsive and her belly began to show evidence of internal bleeding.

We were on our way to the "closest trauma center" in Camden, NJ, and upon arrival were unable to land as the pad was occupied by the State Police helicopter, shut down and unmanned delivering a patient the facility.

My crew made the decision to "cross state lines" (if you operate in the Philly area, you will understand that statement) to take her to our trauma center in West Philly (all of a 2-3 minute furthther flight).

We landed at our facility before the helicopter at the original destination had cleared the pad, in fact as I recall, the patient was in the OR, exanguination protocols in effect, by the time the other pad was clear.

Moral of this true story, unless you have a CT scanner available in your A/C or ground unit, perhaps mechanism of injury is not such a bad thing.

For all the naysayers, if this one life was saved for certain by that criteria, how many others have been as well?

Thursday, December 18, 2014

What Will Cheap Oil Mean For Us In HEMS?

Image courtesy BBC News

The effects of America's flood of oil are rippling out across the world. OPEC decided to continue production at current levels, effectively assuring a collapse of prices. We probably won't again see oil selling for less than $12 a barrel - as it did in 1999 when my entire new-hire class of  Gulf of Mexico pilots got laid off from Air Logistics. But the drop in prices is going to be big.

Click here for a story about trouble in the oil and gas industry...

Every change to the status quo brings winners and losers - and fear of belonging to the latter group is why so many fear change.

So, should we in HEMS be afraid?

That depends on what you do here. If you are an operator, your fuel costs have gone down and are going to go down further. The airlines are in the news because they are enjoying reduced fuel costs, and "keeping the money." We are airlines too. HEMS stands to benefit from cheap oil. History however is full of unexpected adverse outcomes. Every silver lining has a cloud.

If you are a HEMS pilot, cheap oil - resulting in less offshore oil and gas production - will mean more competition for a finite number of  HEMS pilot seats. When the wells are idle, there is no need for a helicopter to move workers to and from platforms. Offshore pilots are going to be looking for work, and filling open HEMS positions at entry-level wages. This will decrease pressure on HEMS operators to raise pay, so we can expect stagnation in wage-growth in the immediate future.

Overtime - or "workover"  opportunities will diminish, and relief pilots (like me) will be less important  (oh well, it was fun while it lasted!) Companies will be in a position to pick and choose from the available-pilot pool, and experience-minimums will increase. On the downside, there will be more people with no HEMS experience making the same mistakes new HEMS pilots have always made, and we will suffer more crashes due to stupidity. On the plus side,  people with questionable histories will be passed over in favor of spotless candidates.

And yes, operators do compare notes about pilots...PRIA notwithstanding. There are few secrets in HEMS.

There will likewise be an increase in the size of the available mechanic pool, and the same downward pressure on wages. Companies might even be able to properly staff bases with two mechanics working week-on week-off which would improve the mechanic's lot in life. So - perhaps for you "wrenches," less pay and a better quality of life.

Cheap oil will mean more people traveling and crashing cars, More spendable cash will mean more risky behaviors - smoking, drinking, speeding, falling off golf carts and 4-wheelers. Flight volume should increase. This will keep more bases in operation, and should be good for clinicians who aren't facing a mass-reduction in other health-care production. When I started flying HEMS there were about 300 helicopters in HEMS service, now there are about 1500. So lots of nurses, medics, and RTs get to scratch the flying itch.

So, is cheap oil good or bad for HEMS?

I guess it depends on your position and perspective...

Tell us what YOU think...

safe flights.

Sunday, December 14, 2014

The Details Matter...Even When We Are Tired

I had the pleasure of speaking with the Director of Flight Operation of a very large EMS helicopter company. We were discussing crashes. I mentioned that I had read a pilot's report to the NTSB stating that he had felt like his approach was fast and steep, as might occur if one was landing with the wind or "downwind" prior to initiating a go-around. As the pilot applied power to climb and accelerate, the aircraft began an uncommanded yaw that turned into several rotations in the yaw axis, loss of control, and a crash. People were killed.

The D.O. stated that this has happened more than once.  Pilot's preparing to land at 2:00 am don't perform as well as they might at 10:00 am, and this is made apparent by studying HEMS crashes and hospital security-camera feeds.

All pilots know that they should go through a deliberate set of steps prior to landing. A before-landing-check should be verbalized, a statement of the planned path in (and out) should be made with an announcement of any hazards observed. If you only have one motor, the forced landing location(s) should be announced so that you and all others on board know where you are going when the engine quits.

Sidebar: If your pilot has not announced a visible hazard, like a tower or wires or a vehicle - she might not see it. You must announce it.

And - very importantly - the pilot should announce his or her opinion of where the wind is coming from and how it might affect the helicopter. Often when we land there is no wind sock on scene. So we must determine the wind direction and velocity through other means. If I state where I think the wind is coming from, and you disagree, now is the time to speak up.

Unfortunately for us, when we are out in the wee hours, we don't perform as well as we do during the day when fresh and rested. It's a proven fact. Read the NTSB reports.  Our mood, performance, and judgement are degraded.

And that's why we tend to crash more in the middle of the night. When tired we just do the minimum to get by; to get the aircraft, crew and patient to the destination.

We can miss the details.

If we are landing, and you see smoke from a stack flowing in the
same direction we are flying, call a go-around. Landing downwind
leads to vortex-ring-state and loss of tail-rotor effectiveness

For this reason, at night is when established procedures, protocols, checklists and company best-practices must be adhered to. Like performing a high recon, like knowing where the wind is from, Like getting the aircraft slowed down per company policy. Like flying the correct angle.

Note that if I am falling short on any of these items, the only persons who can point this out to me are you two or three crew members flying with me. There is no second pilot to catch my mistake.This means you have to know how things are supposed to look and feel, and speak up if something is off. I am a damned good pilot. And I haven't crashed.


This makes me just like your pilot.

As a human being, I am subject to make a mistake, like a guy in Texas did. He initiated a go-around, aborting his approach because it didn't feel right. And it led to a crash.  In another event - on video - another guy did the same exact thing and got into the yawing spin. That helicopter went around about 45 times, yes forty-five times, before the pilot initiated a climb in desperation. He got some altitude , reduced power, and let the helicopter fall off to one side. The aircraft weather-vaned, stopped spinning, and he was able to fly out of it.

"Well pardon the crap in my pants..."

So, perhaps we should focus on getting it right the first time in - especially at night. Some aircraft are more susceptible to loss of tail-rotor effectiveness than others, but they are all subject to vortex-ring state, and hitting things. In any helicopter, a small decrease in rotor RPM - such as might occur during a massive power increase when aborting an approach and starting a climb - will equate to a much greater loss of tail-rotor/fan RPM and authority. In a BK the ratio is 8 to 1 TR to MR.  And when that tail rotor stops being effective we will push more pedal until it either is effective or it stalls.

Note: In the first event referred to here, the pilot reported that he did NOT apply FULL pedal against the yawing spin. We should be ready to apply full pedal to control the aircraft. This has never happened to me, but experts say full pedal will arrest the yawing motion. Both pilots reported that "the cyclic stopped working." This led the DO to surmise that the aircraft, when spinning rapidly - on the order of 360 degrees per second - can get out of sync/phase with cyclic inputs. If the nose is down, and the pilot inputs aft cyclic, the delay in cyclic effect means that the aircraft has spun to the point that the input is reversed. This is something to consider, and more reason to avoid letting the yaw get away from us. Apply full pedal against yaw as required...

Crews can assist with determining wind direction. Look fo flags in the wind, smoke from stacks, groundspeed versus airspeed comparisons, and wind correction headings inbound to the destination. All these serve to tell us the wind direction and speed. Wind can change near the ground, and we have to be ready for this, and ready to call a go-around.

Wednesday, December 10, 2014

Newest Cool Device : X-Stat Dressing (from the Trauma Professional's Blog)

You land at a scene for a shooting victim. You load him into your aircraft and a stream of blood sprays up and over the patient/pilot barrier and lands in a spotted pattern on the pilot's knee-board. He exclaims.

Gauze and pressure aren't stemming the flow, and you have a long flight back to a trauma center.

Perhaps this product would help...

We were pointed to this by Dr. McGonigal on his blog. Click here.

Read more at a PopSci article here...

Thursday, December 4, 2014

Some Thoughts for Today. What is The Role of Culture?

Air Medical Resource Management Operates at the Intersection of Psychology (what's going on between my ears) and Culture (what's going on in my organization) ... William T. Winn

By Dan Foulds

I am going through my AMRM presentation slides today, making some changes and preparing for classes next Monday and Tuesday. I decided this was worth sharing and hope you agree. If you have any thoughts let's hear 'em. And "war stories?" We love stories.

As a medical crewmember, communications specialist, mechanic, or member of hospital security, at times we hesitate to speak up, to ask a question. We don't want to appear dumb, we worry about appearing to lack trust. We worry about being perceived as a trouble-maker and perhaps losing our job.
As pilot, we may hesitate to speak up for fear of showing weakness.

This hesitation is especially prevalent in new crew-members. The nurse who died in a crash in Newberry SC was new. The nurse who died in Georgetown SC was new. 

You don't get to be new here. You must ask and learn NOW.

Ridicule, intimidation, and sarcasm have no business in this business. Culture begins with senior leadership and ends with you.

The National EMS Pilot's Association has prepared a great cultural health assessment tool, CHAMPS. It only costs $500 to find out what your cultural "pulse and pressure" are, and you can compare your organization to others ( no identifying information is shared). You can also compare one part of your program to another part. Visit NEMSPA to learn more.

Corporate Culture: A Case of Monkey See, Monkey Do?

Written by Fred Nickols

Did you ever wonder how your company's culture – that set of beliefs, traditions, and behavioral norms that determines "the way things work around here" – came to be? Or why, when you try to change it, it seems so resistant? Well, here's a little story about a scientific experiment that shows how culture comes into being and why it is so resistant.

The experimenters began with a cage, a set of externally enforced boundaries. Inside the cage, they hung a banana on a string and placed a set of stairs under it. They then introduced five monkeys into the cage. Before long, one of the monkeys started to climb the stairs toward the banana. As soon as it touched the stairs the experimenters sprayed all the other monkeys with really cold water. When another monkey made an attempt to get the banana they again sprayed the other monkeys with cold water. After a while the monkeys prevented any of their group from going after the banana.

After the cultural prohibition against "going for the banana" had been established the experimenters put away the cold water. They took one of the original monkeys out of the cage and introduced a new one. Upon spotting the banana the new monkey went after it. To its surprise and dismay all of the other monkeys attacked it. After another attempt and attack the new monkey learned that if it tried to climb the stairs and get the banana it would be assaulted and so it stopped going after the banana. It had been acculturated, assimilated into the cage's "don't go for the banana" culture.

Next the experimenters removed another of the original five monkeys and replaced it with another new one. The second new monkey went to the stairs and predictably it was attacked. The first new monkey took part in this punishment with enthusiasm! Similarly a third original monkey was replaced with a new one, then a fourth, then the fifth.

Every time the newest monkey took to the stairs it was attacked by the other monkeys. Most of the monkeys that were beating it had no idea why they were not permitted to climb the stairs or why they were participating in the beating of the newest monkey. After all the original monkeys were replaced none of the remaining monkeys had ever been sprayed with cold water. Nevertheless, no monkey ever approached the stairs to try for the banana. Why not? Because as far as they knew: "That's the way it's always been done around here."

Tuesday, December 2, 2014

Is The Scene Safe?

The flight nurse looked out the back windows of the aircraft in disbelief. They had landed on a two lane road at an accident scene - in front of the aircraft a horrific car crash was being sorted out - behind them, the road was open. It was chaotic, and emergency vehicles were still inbound. As she glanced behind them, she observed a large vehicle bearing down on her. Too fast, too close. She yelled.

With feet to spare, the truck veered off the road and came to a stop beside the aircraft. The truck's driver had been unable to determine distance to the obstacle to his front - a running helicopter - because of the dozens of flashing lights and apparatus surrounding the scene. He was responding to a crash with his own lights and siren going, and had some adrenaline on board. It almost ended like this... ( the action starts about 1:45 in)

If the video is not supported on your device you can access it here.

The film above makes a good case for not having trucks driving next to a running helicopter on scene. If a picture is worth a thousand words, a film should be worth a few million (dollars - what that aircraft cost) How sad and ironic is it that you can survive for years operating "a collection of parts - flying in close formation - all supplied by the lowest bidder," and get whacked by a truck on the ground.

The hazards of  landing a helicopter at an accident scene are easily overlooked, especially after landing at a few hundred of them without incident. We take it for granted that everyone involved is trained, and knows what not to do - but every once in awhile this ends up not being the case.

I landed at a scene once in South Carolina. My crew asked me to stay running. As I watched them disappear into the back of the ambulance, the man they had designated as my "tail-rotor guard," wearing blue jeans with cigarette in hand, strolled up to my left front window and casually had a look at the cockpit. When asked to move away from the running helicopter, he stated that he knew what he needed to do.

Apparently not.

The situation is made more complex by the fact that we in HEMS depend on cordial relationships with first-responders for flight requests. If we don't get calls, we stop making house payments. We face competition in our service area, and we want them to call us, not the other program - so we walk a fine line between demanding a level of performance and accepting whatever-goes on scene. One thing you don't want to do is be the guy or gal who offends the volunteer-chief of the fire service setting up your scene; but you also don't want to kill a new probie - or have her kill you.

Clearly, the answer is communication and training. Someone from your flight program needs to visit every agency in your service area at least once a year to present a class on the good, bad, and ugly of scene operations. Someone needs to call and debrief each scene operation - what the military calls "after action review." If you are relegating this task to a business-development manager you are asking for trouble - they get paid to increase flight volume, not safety. Part of your training should be a review of actual accidents and incidents. There was a time when a director of operations I worked for didn't want us to speak about crashes with customers. As a person who has taught AMRM classes for several years and seen what works and what doesn't, there is nothing like a discussion of actual events - real people, real blood - to get someone's attention and buy-in for scene safety.

Click here for a story about the type of training that should be occurring everywhere.

Fly (and land) safely...