Monday, December 28, 2015

Hoisted On My Own Petard...

It's one thing to know what's right...

          It's another thing to say what's right...

                       But it's another thing entirely to fly right...

                                                This is the main thing...

I was flying at two thousand feet from a metropolitan-area hospital back to my base at a small hospital in the country. It was a beautiful day and all was well with the world. During a break in the conversation, and after a few seconds of silence, my paramedic asked, "hey Dan, where would we go if the motor quit right now?" 

And I put him up to it...

Here's the back story;  after a friend flew a helicopter into a storm and killed his crew, I volunteered to present AMRM training for my company. I studied crashes in all segments of rotor and fixed wing flying, looking for the "why," and how to avoid repeating the mistakes. What I found was that crashes usually happen because of mistakes that can be identified and prevented. The mistakes are right there for us to discuss; the folks who made them paid a terrible price. Read, do not repeat.

Working as a relief pilot allowed me to go around to different bases and focus on human factors during shift briefings. I look at some young man or woman and wonder - is there something I could say here today that will save their lives?

I was moved from a BK-117, to an EC -135, then to an Astar. Single engine aircraft are reliable, but engines do fail. From observing many of my peers, and myself, I realized that many of us pilots fly our helicopters as if the engine will never quit. We don't often fly "defensively." We hop into the machine, load coordinates, and push "direct-to." And we usually fly an altitude out of habit, without much thought to what we are flying over. 

An anecdote: I was filling in at Stuart, Florida. As we prepared to cross over a river in an Astar, I climbed steadily to 1500 feet, and altitude that I judged would let me reach a shoreline in the event the motor quit. One of my paramedics joked to his partner,"okay Brett, your job is to look out for airliners." I didn't get the joke. I asked, "what are you talking about?" He explained that I was flying much higher over the river than the other pilots did. I asked, "how high do they fly?" 

"Oh, about 500 feet..."

That aircraft had no floats...

Pilot's flying at 500 feet over water aren't thinking about the motor quitting. I understand that some jobs in single-engine helicopters require operating at airspeeds and altitudes such that an engine failure is going to hurt. And I know that engines are reliable.

But I wonder why we accept risk needlessly.

In truth, most of us single-engine pilots aren't given much chance to become proficient at autorotations.  Maybe we should stack the deck in our favor with...


Salient points in this video are made at 3:22 and 6:02. "Today's the day..."

The over water issue became a big thing a couple of years after that crew and I had that discussion. Nowdays, no one is flying a single without floats at low altitudes that won't allow us to reach shore should the motor quit.

This is a tour Astar. It lost power in flight with tourists on board. There was a
place to land, a narrow strip of beach, between rocky wooded terrain and water
and everything worked well. Kudos to this pilot for being ready. Not all are.

The FAA thinks that we are operating our single engine helicopters - at any time - such that an engine failure can be safely terminated with an autorotation. That's why they let us fly patients at night in a single.

Code of Federal Regulations, Part 91, explains that our altitude should allow a landing without undue hazard to persons or property on the surface. What about the persons and property on board the helicopter? Shouldn't we be concerned about them too? The fact that the weather minimums will allow you fly at very low altitudes doesn't mean you must. Your personal minimums can account for the fact that your motor might quit and you might have to land right now. If the weather won't allow you to fly at an altitude at which you are confident of a safe landing, maybe you should not go...

 We should fly defensively.

So, back to my team member and his question. I ask teams to "inquire, advocate, and assert" during my shift briefings. And one of my often-recommended questions for a team to ask a pilot is, "hey, if the motor quits right now, where are we going?

So Wes asked the question of me, at two thousand feet on a beautiful day. I looked down and saw nothing but a broad green carpet of 50 foot pine trees, with no clear spots that I could hope to reach in the event of a power-failure. See, my "direct-to" course took me over terrain which would not be kind to an autorotating pilot and crew, and I was just following the GPS.

He had me.

Maybe we should give more thought to our route (is there a place to land?) and altitude (can I reach that place?) And maybe you crew members should get more involved in discussions about this. After all, if your motor goes bang in the night and drops you into hostile terrain with no place to land - it will suck.

The question for you single-engine pilots is; after losing power from your one motor, are you going to be just another dead pilot, or are you going to be the Chester "Sully" Sullenberger of Helicopter EMS? You know what Sully had going for him when all his engines quit?


May your engine never quit - and may you be ready when it does...

Engines do fail. If  the oil-pressurre light comes on, it's best to stop flying.

                                                                                                  edited, January 29th 2017, tightening.

Tuesday, December 22, 2015

Professionalism 101...

I came across a bit recently on a helicopter forum,

"Yes I am an Air-Evac pilot so I know you hate me before I even vent about the Vanderbilts "RudeNess" but I think everyone will agree.  

Well I was at Vanderbilt a few days ago and had to orbit the heli pad for about ten mins while another helicopter off loaded their patient.    The inside was wide open and still they would not let us land there.  Our patient was post CPR and tanking on us and Vanderbilt said  "DO NOT LAND ON THE INSIDE PAD"   its private.  Ok I understand that but they were so very rude about it over the radio.  

Well when we landed one of the Vanderbilt managers came up to me and said very LOUDLY to me.....   "THE INSIDE PAD IS PRIVATE FOR THEIR OWN HELICOPTERS AND THEY DIDNT CARE WHAT CONDITION OUR PATIENT WAS IN" and "THAT IF I DIDNT LIKE IT I COULD JUST TAKE OUR PATIENTS ELSE WHERE"   That is exactly the way she said it.     And when the medical crew came up the same Vanderbilt Manager repeated her self again to them.   

All I can say is that Vanderbilt needs to police their own..

Its no wonder Vanderbilt has the reputation thay have.   

I am sure this will get deleted because Vanderbilt HATES this forum.   

The truth hurts..........

I am sure many will agree with the problems that have had with Vanderbilt..."

Friend - there are winners and losers in every company. If you have a problem with a person, it probably has more to do them than the company. Your best defense and offense is nothing short of absolute courtesy and professionalism. Smile. Offer assistance. Be cheerful.
Be an ambassador for your company, and the person your parents would be proud of.

Vanderbilt  flight nurse Kevin High wrote in an industry publication years ago. He anticipated some of the issues that would arise as the HEMS market became over-saturated and competitive pressures heated things up. Kevin wisely counselled that we should all take a deep breath and remember that we are now - and should ever strive to be - professionals. We fly sick people for a living. It's an honorable profession. 

Don't let someone strip you of your professionalism or the dignity of caring for other human beings.

At the worker-bee level, those of us who occupy the aluminum office may not understand all the hidden agendas at play in HEMS and the hospitals. Unfortunately, HEMS attracts it's fair share of scoundrels and miscreants.

There's a ton of money washing around in the healthcare tub; and money makes people behave badly. Contracts come and go, new competitors pop-up, influence is bought and sold, people and companies strive for dominance...

Let someone else worry about that stuff. If you focus on being the best pilot, nurse, paramedic, comspec or technician, everything else will take care of itself. Do not fear what the future might bring. If you are excellent, your future is secure. HEMS is a very small world. Reputation is everything.

Think forward a few years. The way you are now will matter to you then. A hospice nurse told me once that not one of her patients ever said "I wish I had made more money." The thirty or forty odd years of service you provide will end much more quickly than you might believe, and the way you have conducted yourself across that span will be very important to you. Think of being decent now as an investment in your future self-satisfaction.

Managers get wrapped up in turf wars, struggles for market share, and quests for power. They get paid for this, that is their job and they no longer have to get into a helicopter at 3:00 am.

Let them worry about their worries, you mind the wonderful human resource that is you.  Remember that we crews are much more alike than we are different, no matter who we work for. We rarely get to pick the helicopter we crew, the equipment we carry, or the market we serve. "We are just glad to have a job." (Dutch Martin, retired HEMS pilot).

It is foolish to take an adversarial position with teams from another company, and trust me when I tell you that the senior leadership of your company are cordial when dealing with competitors. After all, mergers and acquisitions can make your competitor today your coworker tomorrow.

From personal experience, twice... When there is blood on the ground and we gather to show respect, all those "differences" become trivial. Believe it or not, competing crews refusing to talk to each other contributed to a fatal mid-air between two EMS helicopters.

If you want to land at a hospital, and they say no, don't get upset. If there is a delay, ask how long. If it is too long, divert. Go to another available hospital pad or airport. Call for an ambulance. That's what you would do if there was bad weather on top of the initial destination. Just roll with it and record everything. As long as you are behaving according to what's best for safety, patient, and company - in that order - you can face anything or anybody.

That's all we as crews can do. We can't force the owner of a  private helipad to let us land. And if we can't and the patient dies, it will be for someone else to sort out.

At the end of the day, all we can do is seek to maintain our perspective and our status as a...



Sunday, December 13, 2015

Three Will Say Go...

I find out on facebook - usually.

A helicopter crashes. A crew member or two or three whom I have worked with announces that they are departing HEMS to return to the hospital, or to return to school, or perhaps to leave heath-care altogether.  Cited reasons are schedule, or time with family, or a better job beckons... I miss them when they leave, but I understand the forces at play.

These departures occur in the aftermath of a fatal crash. Crashes get people thinking, considering risks and options. And some folks decide that the risks of flying sick people outweigh the benefits. The companies aren't much help with this - not in my experience. The mindset of management seems to be, "hey, if you don't want this job, don't let the door hit you on the way out. There is a line of people waiting for your job." Perhaps there is a half-day "safety stand-down" in which management and speakers discuss events, and then we are expected to saddle-up and get back on the horse.

Some of us don't climb back up.

That's too bad. We lose capable, compassionate caregivers every time someone flies a helicopter into the earth. They don't come right out and say why. They just go away quietly. They represent the "other" cost of a crash. Consider the costs to recruit and train a flight nurse. And then orient her or him to health-care during flight-operations. Six weeks as a third crew member? Not uncommon. The most precious assets in HEMS are wearing flight suits, and some of them will leave after this last crash in California.

I attended Krista Haugen's presentation on what survivor's go through during the recent AMTC.  She also discussed how programs should prepare for and respond to crashes. It was the last class, the last hour of the last day of the conference, and the room was full. Krista was the co-founder of the Survivor's Network for the Air Medical Community. She lived through a crash and it affected her. Sometimes we need to talk things out, with someone who has been there. That's what the network does, they offer someone to talk to.

Click there to visit their facebook page...

Long ago, a friend took my helicopter and crew in Honduras and crashed. The guy sitting in my seat died along with everyone else on board. I experienced emotional aftershocks, and physiological effects. Two months later, after the Army un-grounded the Chinook fleet, I climbed into a pilot's seat and my legs began to jump and hop on the pedals. My voice was okay, and I knew what I had to do, but for the life of me I could not stop my legs from jumping. The instructor in the other seat said, "don't worry, it will pass."

I tell you this too friend. If you are upset about this last crash - or any of the others we have suffered, that is okay and normal. Different people will respond in different ways. Some may cry, some may laugh, some may scoff, Many will say it's because of this or that factor. And some fools will look you in the eye and tell you that crashing is part of flying and if you can't deal with it too bad.

Crashing helicopters is not part of flying. We CAN stop crashing helicopters. And you are part of the answer. I won't tell you not to go if you feel you must, but consider that your replacement will be some young person with stars in her eyes, someone who won't have your depth of experience, someone who won't understand - as you do - how important it is for a crew member to know when to say...


Pilots, please consider easing up a bit for the next few weeks. Consider what is going through your crew's minds. If one of them asks about the weather, that is a sign. An extra dose of conservatism may let them work through some things that are bothering them. This is especially true if you are working with people you don't know well. You may have "flown in much worse weather than this" and you may be sure of your skills and a good outcome. But please remember, the crew is your first concern - not the patient. You may not like them, you may not like this, but it's true. Your job is to protect the crew. And this includes being mindful of their feelings.



Saturday, December 12, 2015

Bullets in the Gun

Our friend Josh Henke wrote this when he was a flight nurse with CALSTAR. He switched programs and coasts, but he is still as passionate about patients and safety as ever. We hope he is well.

“Nobody would ever go out if they thought they weren't going to come home.”

That seems like an easy sentiment, right? Just as easy as “nobody would point a gun to their
head if they thought it was going to go off.”
This seems like simple logic to a lot of us. Something that complacency and confidence has
fostered in our minds. The “it would never be me” mentality. Or the, “just 5 minutes farther and
well see what the weather looks like then.”

We all do it, have done it and unfortunately will do it in the future. (despite the warnings from
other more experienced, “luckier” crews from the past.) We have all at one time or another put
the gun to our head, without checking it, hoping it doesn't go off. And in that I mean, we’ve all
climbed into an aircraft feeling a bit unsure. Maybe feeling a bit “exploratory” IE: “lets just go up,
fly around and see if we can get in there.

The simple logic in this is, how often are we not checking the gun. How often are we NOT
making sure the gun isn't loaded. What are the little things we can do to make sure that gun is
empty before we leave the safety of the ground?

I'll use a recent example of mine in which i feel like a “checked the chamber” before we left.
“Medic engine 21, medic engine 22, battalion 514, medic 36, medic 39, medic 41 Medevac 10:
respond for a vehicle over the curb at JFK elementary. Multiple victims with reports of victims
still under the vehicle.”

“Shoot……..this is going to be interesting”

And so we checked the weather, even though the school was only 2.5 miles away from our
base. We tuned our radios to the county frequency so we could keep tabs on the tenor of the
call and be in touch with the battalion chief and have a heads up on the LZ plan, etc. While we
listen to the county frequency, we get bits and pieces of patient information too, such as “victim
appears to be a young male, trapped under the vehicle with agonal respirations”
As the pilot walks out, i ask my partner in the aircraft to turn his radio off as the piloting getting
in. He gives me a quizzical look, but complies. “thank god” i think.

My rationale? I know that my pilot has school age children and lives in the area. I'm not sure
what school they go to, but I know he lives in the area. He’s also a newer pilot to our base. But
my rational is this: i don’t want my pilot thinking that this might be his kid. Or any kid for that
matter. I don’t want him to rush his startup and miss something because he’s trying to go faster
for the sake of a child. (we all do it. when we hear its a kid, the hackles go up, concentration
gets focused, and we try to do things just a bit faster because, its a kid. An innocent.)
I wanted to take the bullet out of the gun so to speak. I wanted my pilot to startup and fly like he
was going to pick up his dry cleaning. Just like he does every time we fly. And i wanted him
thinking about nothing else.

We all go out and fly. And we all like to think that we are doing our job as safely as possible. But
are we really checking the gun? or are we just thinking about the standard list of safety items
that we always do? (weather, wind, duty time, etc.). Are we thinking outside the box when it
comes to leaving the ground?

We should because you know what, complacency and excitement are little bitches and they'll
sneak a bullet in that gun when you're not looking. so before you put the gun to your head, take
the 5 seconds, slow down, think and make sure that thing isn't loaded.
Please keep our neighbor flight program Sky Life and their families in your minds and prayers.
This is going to be a crappy Christmas for some of our family.

Fly safe, slow down, think.

Learning from our past... Life Flight Down...

Thursday, December 10, 2015

At Last, Real Cat "A" Performance From A Twin Engine Helicopter at Gross Weight...

Jeff and I are riding over to his house near Penn State University for a visit. The years apart have vanished and we have taken up right where we left off, both eager to talk helicopters and HEMS. He tells me about his trip to AMTC in St. Louis  a few years back, paid for by Eurocopter (now AIRBUS Helicopters) so that he could stand next to Geisinger's new ship on display. He assures me he sold several aircraft on that trip, and was offered a sales job. That boy can talk - when the two of us both get going at once, cabin O2 levels drop.

Our conversation moves onto the newest variant of the BK, the AIRBUS H145T2. We discuss how it got certified. As you may know, the type certificate claims that an EC145 is really a BK-117C2. The company saved themselves a ton of money by saying that the 145 was simply a modified BK. Yes, sure, if you consider different engines, different fuselages, different engine monitoring systems, and different cockpit layouts simply "modifications" to an original. Now, with the addition of a fenestron the only thing about a H145 that resembles a BK is the rigid "blades bolted to the mast" rotor system. The French half of the marriage that made Eurocopter/AIRBUS got their way and added a fenestron, too bad they didn't add a starflex rotor system as well. The BK rotor system sucks, when in the clouds in turbulence.

Jeff says, "it's the first one with true Cat A capability." I hadn't thought much about Cat A lately, because here in America operators aren't required to comply with Category A takeoff requirements. We could, but we don't. It would reduce our payload and fuel range too much.

What is CAT "A"? Basically, it's a set of standards and procedures that result in a twin engine helicopter never being in a position from which a single engine failure will result in a crash. Most twin engine aircraft will not hover at maximum gross weight with one motor off-line, but Jeff assures me that the new 145 will. That is going to change how departures are made in this machine, I suspect.

Dare County Med Flight is the US launch customer for the H145T2
The addition of a fenestron makes the ship easy to identify.
If you want to read more about Category A standards, click here...

A category A takeoff looks different than a "normal" takeoff. As the pilot brings the aircraft up to a high hover, she backs up slightly, keeping the pad just departed from in view down below and slightly in front. Once at a "takeoff decision point" the ship is rotated and flown away. If a motor quits prior to rotation, we are going back to the pad. If a motor quits after rotation (pitching the nose down to accelerate) we will fly away on one motor. Likewise, on approaches the aircraft has enough power to land on one motor, without bending metal. When I got checked out in an EC-135, we practiced engine failures (using the FADEC's training mode) on approaches, and the 135 has near flyaway capability, but I am not sure it would meet true CAT A capability at max gross weight. The Bell 222s and 230s I flew years ago would have laughed at me if I mentioned CAT A. In those ships, the second engine would do no more than fly us to the scene of the crash. As happened here..

Luckily, motors don't quit very often. And we fly singles here every day. This is perhaps why, here in America,  Cat A capability isn't required. The airlines have a different deal. A twin engine airplane must have enough runway to accelerate to flying speed at which point the pilot makes a decision to abort or continue. There must be enough runway to stop safely from that decision point. They call this number of feet of runway required the "accelerate-stop distance." The aircraft must have enough power to fly away on one engine from that decision point. These requirements guarantee  the safety benefit of having two motors.

Here's hoping no one ever has to use the Cat A capabilities of the new H145T2. But it will be comforting to know that the capability is there, just in case.

Tuesday, November 24, 2015

Case Study... Winter weather crash...

It is a good thing to learn caution from the misfortunes of others.
— Publilius Syrus

"It was a cold night in the dead of winter when Billy Wynne lifted off the helipad responding to a cardiac arrest call in the neighboring city of Watonga. Billy called his wife and told her he loved her. She was pregnant with their second child. It was February 22nd, 2013. Sitting next to Billy was 41 year-old nurse Chris Denning. In front of Chris was veteran pilot Mark Montgomery. In 60 seconds, both of these men would be dead.

The EagleMed had just reached its cruising altitude of 500 feet when the helicopter began to shake violently. It became instantly apparent this was not turbulence when the pilot began muttering, “don’t do this…don’t do this to me now.”

Preliminary reports on the crash would indicate that the helicopter hadn’t flown in three days. At the top of the helicopter, where the engine is mounted, ice had accumulated at the base of the air intake which feeds air into the engine. Once the helicopter leveled out, the air intake began receiving air at full capacity. The speed of the aircraft created so much wind velocity it jarred the ice obstruction loose and sent it hurtling directly into the engine.

The engine died immediately. The helicopter began to fall.
It would take 10 seconds for the helicopter to impact the ground. In those precious seconds, the pilot searched for a place to land the helicopter. They spotted a tiny street below, only a quarter mile long, but it was lit on both sides.

Billy remembers the nurse, Chris, patting the pilot on the back saying, “You got this, Mark, you got this.” Billy recalled the look on Mark’s face: “Mark knew he was about to die.”

Billy remembered something Mark had told him about helicopters. No airborne machines are really made to crash, but helicopters definitely aren’t. The engine mount sits on top of the helicopter. The (fuel tank), full of jet fuel, rests below the helicopter in the belly."

Text copied from the Chive. Discuss this event with your flight team. What factors played into this crash - make a list.  What could have been done differently? Could this happen to your flight team at your base?

Thursday, November 19, 2015

Training Quality Concerns...

We found this on a forum that pilots use to vent their dissatisfaction. There is a lot of chaff on the forum. And a fair amount of wheat. Read on and share...

What do you think about this? 

How would you rate your training?

"About 6 years ago my program decided to stop supporting an IFR program.  We kept the airframe, lost the training.  The training was just meeting the minimums anyway, and barely kept anyone competent enough to fly SPIFR.   I was sad to see it go, but we didn't make any money off of it.  It was supposed to be for safety, but I was still in an IFR twin, so, hard to complain.  I get it, business is business.  
Then about 4 years ago, we lost the twin and went into an ASTAR.  Flying around at night over hazardous terrain, houses, mountains, etc...  IIMC without an autopilot and no instrument training.   I have plenty of time in singles, so I was convinced I could maintain safety by lowering my weather minimums, and flying higher at night, choosing my flight path over more favorable terrain etc..  It made my job a little more difficult, but I still considered it safe.  I feel I was able to mitigate the risk.
Then about 3 years ago my employer decided it was "too dangerous" to train me to do autorotations.   I haven't doen an auto in 3 years, I go back to training to practice my power recoveries and my first auto is litterally the worst of my entire career.  I overshoot my spot by 100 feet, and I flair way too high.  The instructor is tickled with my performance and deems it "a really good auto".  This guy must see some crap if my worst auto ever is considered good. 
Training is supposed to last 5 days.  2 travel days and 3 training days.  I show up and get my "ground" done in about an hour.  The trainer puts on as much gas as he can fit and we do the entire training and checkride in one flight.  That is it for the year.  
Every year I am worse than the year before.  Every year they take away more redundancy, and skimp on the training.  
I'm done.  I can no longer justifiy the risk.  Being sent out there with no hope if anything goes wrong.  No training, and no redundancy.  Sad state of affairs.  
I took a job over seas.  I will miss being home, but I would rather be alive and I am not ready to stop flying yet.
Stay safe guys and don't accept the risk they expect you to so they can make money.  
I just got back from training"

Tuesday, November 17, 2015

Insufficient space available for the patient and equipment? Think twice about stuffing that bag...

I got a call from a friend at a program in the northwest... He wanted to talk about cabin size and storage/securing of equipment.  He flies a twin, and thinks twins are better not because of twin-engine reliability and redundancy, but because they have a bigger cabin with more storage compartments.

Then today I read this,..

         While loading a patient into the aircraft, a D oxygen cylinder was
        left between (the patient's) legs and secured with a seatbelt. In flight, the
        patient became agitated, causing the oxygen tank to dislodge and break
        through the nose cone of the aircraft.
        All crews have been educated to properly secure oxygen tanks in the
        aircraft and to not leave them between patient’s legs.

Any one of us who has flown patients in single-engine aircraft knows that finding a place for all the equipment can be a challenge. A BH-206 or AS-350 cabin simply does not have enough cabinets or drawers to accommodate the "stuff" that we have to take with us on flights. The EC-130 cabin is cavernous, but even here there is a dearth of cabinets and drawers.

Some cabins are bigger than others, with lots of cabinets and drawers. Even in this large cabin, items are clipped to a wall ring or seat strap - and depending on strength of restraint - could fly loose in a violent acceleration or deceleration.  

Like Gunny Highway, we end up improvising, adapting, and overcoming the limitations imposed on us by the folks who select the aircraft we work in. This equates to stuffing functionally-grouped items into a bag or soft-sided case and "securing" these with a D-ring through a strap or handle. While some aircraft have a baggage compartment, this cannot be accessed in flight, so the things that might be required must be kept at hand in the cabin.

Like I said, it's a challenge. And there is a certainty about the items that are tucked, stuffed, or clipped - when things get "real" in flight, they are going to go everywhere - including outside the aircraft. In the picture on top, a bird coming through the windshield caused an over-pressurization of the cabin and the doors popped open slightly. Pieces of medical equipment were strewn across the countryside.

An inconvenient truth... "Those items that you think are secure in your cabin? They aren't." ( from the paramedic who was on that flight)

In retrospect I am fairly certain that an FAA inspector would determine that this medical cargo was not adequately secured. Consider the requirements when you fly on a commercial jet, like Delta.  You must put all items in the overhead bins or underneath the seat in front of you. If you look under the seat you will see a metal restraining bar placed there to keep the bag from becoming a missile-hazard in the event of a sudden-deceleration in either the vertical or longitudinal axis (a crash). No items can be allowed to block emergency egress - and the definition of what constitutes blockage is pretty exacting. You cannot hold a laptop in your hands for take-off and landing, and any item bigger than a tablet or phone must be stowed as described above. You are not allowed to put your laptop in the seat pocket in front of you. You are not allowed to secure items in an empty seat with a seat-belt either - but we do that in our single-engine HEMS aircraft regularly.

Now compare our operations to the part-121 carriers (the airlines). When a critical patient is on board and multiple interventions are occurring in flight, the aircraft looks like a combat-zone after landing. Perhaps it's the nature of the job. One thing is for certain, the appearance of the aircraft cabin on the way to the patient should meet the requirements for stowage and security. The best resource for determining this is going to be your maintenance personnel. They should be consulted as you make decisions about what will go where. Pictures of cabin layouts eliminate doubt and the chance for any questions, or fines, after the fact. In fairness to his license and your company's operating certificate, your Director of Maintenance should probably be the determining authority as to whether what you want to do complies with the rules or not. Take some pictures of your cabin when it's configured for a patient flight, email them to your base mechanic asking for verification that everything is okay, and print and save the email.

An anecdote...

Years ago I operated a BH-206 with a spiffy new medical interior. The stretcher system included a restraint-bag that was intended to go on the patient's feet and be secured with seat-belt straps and buckles. My medical crew took one look at this foot-bag and determined that it was going to be too much trouble - and would become blood-soaked and dirty. They removed it from the aircraft. After a few months my director of maintenance got wind of this and blew a gasket. He explained to me in very clear terms that every bit of the medical interior was required by supplemental-type-certificate and every flight we performed with a piece of equipment removed constituted a separate violation of the Federal Aviation Regulations... He then proceeded to self-disclose our screw up to our FAA principal operations inspector, and we learned from this. Your aircraft has medical equipment installed and medical cargo carried on board. There are strict rules for both categories.

Pilots - The fact that you could put stuff wherever you wanted in the military has no bearing on what happens in the civilian world. Civilians are expected to be treated with a higher degree of regard than soldiers. The medical crew are - in the eyes of the FAA - passengers. You are the responsible party for whatever happens on your aircraft. You are held to the highest standard against negligent behavior by the law. The fact that your base is a long way from HQ and the FSDO will not protect you should things go south, or you get a friendly visit from the men in ties. As a matter of fact, in their efforts to protect the certificate, your company's leadership will first say that they had no idea what your were doing. The fact that "we have been doing it forever" will not help when the FAA begins digging in the dirt,

Remember over-water flights in single engine aircraft? It was no big deal - right up until the minute it was...

In another incident, a pilot decided that the balloon pump could be fastened into the rear facing seat of a BK cabin, instead of using the "approved" straps and floor mounting location. Another upset director of maintenance... Although rare, there are certain instances where people have to get out of an aircraft cabin right-this-second - and anything in the way is a no-go.

This is serious business folks. The O2 bottle coming loose in the event described in the report above could equate to a hefty fine against the certificate holder levied by the FAA, and the pilot could lose his license. Just imagine that D-cylinder falling down through someone's roof while they were eating breakfast or writing a blog-post.

It's better to ensure that your method for storing and securing equipment meets the requirements of the regulations before a problem is noted, not after. A picture is worth a thousand words, and an email is forever...

Friday, November 13, 2015

Meeting Ira...

Dr. Ira Blumen with the University of Chicago Aeromedical Network Dauphin.

I attended two educational sessions presented by Dr. Ira Blumen while attending the recent Air Medical Transport Conference in Long Beach, California. I have heard Dr. Blumen's name mentioned over the years as an authority why HEMS helicopters crash. I confess to wondering why there aren't more helicopter pilots answering these questions - why are we asking doctors how to fix HEMS, why aren't we asking pilots?

After meeting him and gaining some insight into his work on our behalf, I realize that my thoughts were wrong-headed. Dr. Blumen, joined by a team of HEMS professionals from all over the country and representing multiple disciplines, set about the most comprehensive project yet to determine why we crash HEMS helos, and what we should do to stop crashing them.

Dr. Blumen's recommendations are evidence-based, and go beyond the National Transportation Safety Board's work. Indeed, the completed NTSB reports served as a point of departure for the team's investigations into every crash between 1998 and 2009, 140 separate investigations...

But the team didn't just read the NTSB final reports, they read the entire "docket" (the entire file of every bit of information relative to a crash). This represented a tremendous amount of work, performed by volunteers. NEMSPA was represented by Bill Winn - thanks Bill for this service.

What did they find? Sometimes the NTSB gets it wrong. The NTSB doesn't fully understand what we do in HEMS and how we do it.. They do good work with what they have - but Dr. Blumen's team dug deeper and gained further insights.

I located a pdf of an earlier powerpoint on Dr. Blumen's work. Click here to view.

The first of Ira's presentations recapped the team's research work, "The Opportunity for Safety Improvement in Helicopter EMS." The next was titled "The Wizard of Odds."  His second presentation was coincidentally scheduled to follow mine in the same room.

As I was spending time with my group, Ira was sitting on the floor behind the rows of chairs, laptop open, reviewing or tweaking his presentation I think. It reminded me of nights in the 160th, prepping and briefing missions - with work going on until the time-hack. I was struck by the fact that a mere-pilot was in the same room with an acknowledged industry expert. Ira and I both want the same thing - to prevent the next crash. The experience was collegial.

Are you a pilot? There should be more pilot's speaking at AMTC. Why not you? You can increase your knowledge - for the surest way to learn more about anything is to teach a class on it - and you can elevate all of us pilots in the eyes of our partners in HEMS. Presenters get a free pass to the conference and a free room-night in the show hotels. AMTC is in Charlotte next year and you can submit a presentation idea through early December...

So, about those odds...

Ira dispelled some myths. Do you think that flying on the backside of the clock - at night - is significantly more dangerous? I did. It's not. I have been putting out the information gleaned from various sources, and it turns out those sources are frequently wrong. We all know the joke about things on the internet, but it turns out things being published in the media are wrong too.

Even the FAA get's things wrong. In their fact sheet to accompany the new HAA rules, they note that there are approximately 1515 (ems) helicopters being operated in the United States. This isn't what Dr. Blumen found, his number was closer to 900.

Flying HEMS is not 6,000 per cent more dangerous than other types of flying as was published in the media. For the patient, the HEMS flight is the least risky part of the health-care experience. When they go into the hospital, that's when things get "real." In 2008 flying HEMS may have been the second most dangerous occupation behind commercial fishing. Not so anymore. We have made real safety improvements in HEMS - the numbers don't lie. The 40% probability of being killed in HEMS over a 20 year career as was noted in a medical publication is simply wrong.

We still have a way to go and both Ira and I think that AMRM is the answer. It's number one on his list of "fixes."

Dr. Ira Blumen is very gracious, and funny, and wickedly smart. He has been in movies and TV shows. His program, UCAN, uses flying doctors. So he has been there and done what we do. He is our friend, and we are lucky to have him in HEMS. I look forward to sitting in more of his presentations, and hopefully you will be there with me.

Wednesday, November 11, 2015

The Fifth Law of Trauma : Pediatric... From Dr. McGonigal's Trauma Professional's Blog

Dr. McGonigal writes...

I knew there was a fifth law! Any time I give a pediatric talk, I mention it. This one applies to anyone who takes care of children, and is particularly important to EMS / prehospital providers and emergency physicians.

On occasion, medics are called to a home to treat a child in extremis, or occasionally in arrest. Similarly, extremely sick children are often brought to the ED by parents or other caregivers.

Here’s the fifth law:

A previously healthy child who is in arrest, or nearly so, is a victim of child abuse until proven otherwise.

Bottom line: It’s so easy to go down the sepsis path with sick kids, especially those who can’t talk yet. But healthy children tend to stay healthy, and don’t easily get sick to the point of physiologic collapse. If you encounter one as a prehospital provider, glance around at the environment, and evaluate the caregivers. In the ED, ask pointed questions about the circumstances and do a full body examination. What you hear and what you see may drastically alter how you evaluate the patient and may save their life.

To read more from Dr. McGonigal, click here... (used with permission)

Thursday, November 5, 2015

A video produced by the FAA Safety Team in Orlando, Florida. A good primer for anyone interested in learning more about CRM and it's offshoot, Air Medical Resource Management...

Monday, November 2, 2015

Congratulations Randy, your 45 year career is an inspiration. Best wishes for a long and happy retirement...


Saturday, October 31, 2015

What is a life worth?

Money hates risk, and demands a premium for being exposed to it. Operating a helicopter air ambulance involves high levels of risk.

Do we really prevent death? Do we help avoid pain and suffering? Would we be better off grounding the fleet and sending everyone in a ground-ambulance?

Many in healthcare speak of patients being flown unnecessarily. We who perform the transports have our own opinions; we know that some patients get flown because a rural county simply has no other option. Patients get flown because the paramedic at the scene isn't really sure about injuries, and would rather be safe than sorry. Patients get flown due to distance, or traffic, or road conditions. Doctors at rural hospitals with limited services know that a metro facility has more specialty care capability, and they use a helicopter for both speed of transport and quality of care. Helicopters reduce out-of-hospital time.

The American Health-Care system is broken... Helicopters are band-aids that staunch the flow of blood.

We don't have enough trauma centers, or burn centers, or pediatric specialty hospitals. These are located in areas with dense populations. America is mostly rural, with small hospitals and limited resources. Because the majority of trauma patients come from a lower-income demographic - and are often either uninsured or under-insured - trauma hospitals struggle to make ends meet. The federal government could remedy this, as could society (the citizens of Georgia rejected a $10.00 car-tag tax that would have expanded the number of trauma centers in the state) Patients who become victims of trauma a hundred or more miles from definitive care need a helicopter.

I overheard a remark made by physician in a trauma bay while delivering a motorcycle-crash victim from an outlying rural area : "I HATE HELICOPTERS." Was he joking? I don't think so. The helicopter expanded his catchment area. Trauma services and trauma helicopters are under-supported by the same federal government that makes it mandatory to take care of every sick person that shows up on the doorstep thanks to the Emergency Medical Treatment and Labor Act (EMTALA). A physician in Columbia SC announced that EMTALA is the largest unfunded mandate in our nation's history.

EMTALA killed the rural hospital. - and led to hub-and-spoke healthcare.

Depending on your location and perspective,  you may see over-utilization of HEMS - or you may see it as a last-chance lifeline.   For your anecdote about a patient walking out of the ED within hours of being flown, I have one about a young man shot-in-the-head who had his life saved by doctors who were minutes away by air and hours away by ground. When blood is leaking into a closed space (your skull) it has to be stopped or brains will get pushed out of the way by herniation.

 SideBar: I flew that kid. His fraternity brother shot him by accident out in the woods of Georgia. Alison Herrington and Jeff Clifton - nurse and medic - (and I) are praised in a book his mother wrote about Kip's journey to recovery. Jeff Foxworthy held a benefit show in Atlanta for him.

The plural of anecdote is not data. But data can be skewed to further one's agenda. Many of the folks we fly are really sick. Would they be just as well served by a ground transport? Perhaps the only way to tell would be to conduct a human-trial in a representative area of the country. No helicopters - period - for x number of days or months. So what region wants to be first in line for such an experiment? Not mine...

The media is eager to headline stories about HEMS companies' "sky-high" bills. A story about the little guy getting a $53,000 bill for a 10-minute flight is dramatic, and drama sells advertising. It's too bad they don't tell both sides of the story, or even consider what goes into that helicopter arriving at your hospital or accident scene to provide your flight for life.

The patient, who is now healed and out of danger, admits that the transport saved her life and in the next sentence states that there is "no way it costs that much for the helicopter company to provide that ten-minute flight."

Imagine you want to start a helicopter ambulance company. You arrange to lease a helicopter, a three or four or ten million dollar asset that burns buckets of money even when sitting still. When you fly the aircraft and add in the direct-operating-costs, the numbers get much bigger. People who know nothing about aviation have no idea that everything involved is much more costly than "what it should be." Incredibly expensive components like engines and transmissions and rotor blades have a finite service life - every hour of  flying  may cost $400 to $1200 dollars beyond the daily lease rate. Now insure the hull.  Insure against an accident, insure against a mistake. The bill to operate your air ambulance grows. Now hire 14 professionals - each of whom has spent years acquiring the requisite education and experience to perform the job. Four pilots, four nurses, four medics, one mechanic and a program manager to keep everything running... Let's swag the bill for staff at $100,000 per person (training, checking, salary, benefits etc.) Then you need a base of operations and must also help pay for a communications center and, if this is your tenth aircraft, an operational control center. Now consider equipment that you have to buy and maintain.  And utilities. And supplies. It's a 24/7 proposition and the meter is running continuously. Those salaries and the aircraft lease and the rent for the quarters and the equipment maintenance etc. etc.- those bills come due every month, whether we do 1 flight or 100.

Before we have performed our first flight we have spent a couple of million dollars.
There is a huge investment required. And a real risk of losing it. Some patients balk at the costs involved - perhaps they are lulled into a false sense of what healthcare really costs by EMTALA and assignment and constantly being told that healthcare is a "right". Some people think that insurance is a blank-check. Or they assume that whatever their insurance pays is all they are responsible for. Too bad more folks don't actually read their policy.

A happy ending...

I met Debbi at a Mexican restaurant near where I live. She is on the smart side of fifty and has a lovely smile and bright personality. After we spoke for a few minutes she told me about her experience with HEMS. I asked her if we could meet again, as I wanted to interview her for this post. She agreed. She showed up with her CPA daughter, I brought my in-residence clinical expert (the flight nurse I am married to).

Here is Debbi's story.

She was working at a self-storage facility one day, speaking to a customer at the office counter. She felt something "different" in her head and knew immediately that it was a serious problem. She maintained eye-contact with the customer, but with her hand lifted the phone handset off its cradle. That's where her memory stops for a time. Her next recollection is waking up while laying on the floor, looking up at a police officer who was staring at her intently. She wanted to talk to him but her mouth didn't work. She heard him say, "we had a 911 call..."

As he turned and walked away she felt an overwhelming sadness. She thought, "please, please don't leave me." He wasn't leaving, he was going to get the ambulance crew.  She remembers nothing else about her event. The crew took her to the burn center in Augusta, Georgia. They have an ER there and it was the closest hospital. The ER doctor was pulling a shift for some extra money and wasn't the kind of doctor she needed. As luck would have it, he had only recently read a fact-sheet about a new treatment for head-bleeds being offered at Emory hospital in Atlanta. The doctors at Emory had devised a method to stop head-bleeds by using a coil inserted through a blood vessel to the point of rupture. This treatment was what Debbi needed, and she wasn't going to survive a ground trip.

Cue the Copter Crew.

Debbi did survive her trip and her bleed. Then she had two more head-bleeds and had two more coils put in. She is a very lucky lady. When she finally came to, her daughter told what the doctors had said. Most people in her shoes are dead-right-there. If not DRT, they suffer severe impairment, and are never the same. Almost no one with her type of bleeds gets away unscathed.

Debbi is 100%. Her bill for her flight was $27,000.00 Her insurance didn't pay one penny of it. In fairness, her total bill for treatment of about one and a quarter million dollars ate up her coverage. She has no regrets. She worked and paid off her HEMS bill. She considers it a blessing that she is here to pay bills. She told me that the bill for her morphine was also $27,000.

You won't be reading any stories in the newspaper about sky-high hospital bills. And the stories about the helicopter bills won't tell you the full story. They won't take the time to investigate the success stories, because good news doesn't sell paper or advertising. Here's our bit of good news, HEMS saves lives.

Tuesday, October 27, 2015

The Role of an Air Medical Team Member in Aviation Accident Prevention...

 If there is only going to be one grownup on board, let it be you.

This post is adapted from the author's presentation at the 2015 Air Medical Transport Conference in Long Beach, California. 

Flying HEMS is a Team Effort

On December 29, 2010, at 0223 eastern standard time, a Eurocopter BK117-C2, N854EC, ... was landed hard during an emergency landing at Cherry Point Marine Corps Air Station (Cunningham Field) (NKT), Cherry Point, North Carolina, after the pilot became partially incapacitated. 

A medical crewmember seated in the left front seat manipulated the collective control with the pilot's instructions and the pilot manipulated the cyclic control with his left hand. The pilot elected to make a run on landing and upon contact with the runway, the helicopter became airborne again, and then touched down again.  (NTSB)

Here is what happened

The crew was in flight when the pilot's right arm dropped off the cyclic to his side. He explained to the nurse, sitting beside him, that he could not move it. He moved his left hand from the collective to the cyclic and manipulated the cyclic with his "wrong" hand. The nurse, who was experienced and accustomed to working under pressure - and who had never in her life touched a helicopter control - assured the pilot that they were going to work through this problem and live to fly another day. She agreed to move the collective control as they declared an emergency and asked Cherry Point tower for assistance. They were given directions to the airport, and emergency vehicles positioned themselves alongside the runway for the crash sure to follow.

The nurse realized the pilot was having a stroke, as evidenced by his loss of use of one arm, and his slurred speech. Only after the first attempt at landing, when the pilot was unable to see the runway and the several emergency vehicles lined up to assist, did she realize that the pilot's vision was also affected by his acute condition. A lesser person might have given up, or lost composure, but not this crew member. As the situation deteriorated, her resolve to work things out was strengthened. 

Her measure was being taken and she was measuring up.

As they flew down the runway on their second attempt at landing, she pushed down the collective, without the benefit of muscle memory or practice. The aircraft bounced and became airborne. At this point the woman - who enjoyed flying on most days but on this day had had her fill - again pushed the collective down - like she meant it...

The aircraft landed hard and slid to a stop. The tail boom drooped from the impact forces. No one was injured in the landing. The medical crew got out and began to administer care to the pilot...


We all hope that when our time comes, we will perform like this crew.

In truth, the likelihood of your pilot becoming incapacitated on any given HEMS flight is very small. Pilots don't often slump over at the controls. What is much more likely to happen to your pilot is a human-factors related event and you - the medical team - can positively influence the situation. You must determine how to be a benefit without being a distraction. Calm statements of what you are seeing, feeling and thinking can help.

Here's an example. Imagine you are flying into an obstructed hospital helipad with a pilot new to you and your area. You have seen other pilots struggle to control the aircraft while landing here - you know more about this place than this pilot does. He cannot let himself appear weak, uncertain, or incapable in your eyes. Your pilot does not have another pilot to query about the situation, and if you say nothing he may think that you expect him to land regardless of the difficulty. Now, if you say, "hey other pilots have had a hard time getting in here, and if you feel like this is too much, we can go to (insert an alternate safe landing location -like an airport). You saying this takes a load off of your pilot's shoulders. He can now decide to attempt to land - or not - without worrying about what you are thinking. If at any time during the approach, YOU GET SCARED, tell him or her and direct a different course of action. Don't sit there worried to death.

But before we get ahead of ourselves, let's consider your role on-board the helicopter. There are at least three parties to this argument, all with different ideas about the role of the medical personnel who climb in, strap in, and hopefully do not shut up. 

First there is what the government (FAA, NTSB) thinks. Then there is what the company leadership thinks. Finally, and most importantly, there is what YOU think. How you view your role will drive your attitude and actions. It is important that you understand what you should and should not do. Only with the help of pilots with the "right stuff" will your potential to increase safety be realized. 

Not all HEMS pilots have the right stuff. 

In the same way that your value as a resource can be developed by a pilot, the pilot's value to you can also be developed. It's all about how you manage the relationship. The manner in which you inquire, advocate, and assert determines how well you will work together as a team. How you say something is almost as important as what you say.

Not too long ago, the NTSB began to advocate that all legs of a HEMS patient transport be conducted under the rules pertaining to "the transport of persons or property for hire," Known as "part 135" of the federal aviation regulations (FARs) or "code of federal regulations" (CFRs), these rules contain limits on the number of hours that a pilot can be on duty. Certain operators wanted to be allowed to exceed 14 hours of duty (the limit per part 135 for single-pilot crews), and posited that the medical personnel on board were in fact, "crew members." The NTSB pushed back...

"Further, the Safety Board (NTSB) is aware that some certificate holders may train medical personnel to perform duties that loosely relate to the operation of the aircraft, such as looking outside the aircraft for possible obstructions or evaluating a landing site, so that these personnel are classified as flight crewmembers, which permits positioning flights to be operated under Part 91.15 
The Board does not consider the assignment of limited operational duties to medical personnel to provide a sufficient basis for operating under the less rigorous requirements of Part 91, which provides inadequate safety controls for the transport of these medical personnel passengers."

Without specific flight training (which medical personnel generally do not receive), medical personnel cannot be expected to meaningfully participate in the decision-making process to enhance flight safety or to significantly contribute to operational control of the flight. 

Therefore, regardless of any operational duties medical personnel may be assigned, they should be considered passengers on all EMS flights. 
The Safety Board concludes that the minimal contribution of medical personnel to the safe operation of EMS flights is not sufficient to justify operating EMS positioning flights under the less stringent Part 91 requirements.

(to our knowledge, not one NTSB board member has ever served on an EMS helicopter - in any capacity)

As the FAA, responding to pressure from Congress to "do something" about HEMS crashes, prepared to issue the "new HEMS rules," they referred to these NTSB remarks. In an FAA information-brief the FAA reiterated these comments. So the FAA considers you are a passenger too. 

It's funny how things can get taken out of context, how meaning and intention can be twisted, and how agendas can get hijacked. Remember that the NTSB's goal in all this was to protect medical personnel from over-zealous operators seeking to avoid time-duty limits.

The HEMS operators are of two minds about medical personnel status. The way they refer to you depends on if it will cost them money or make more of it.  Even you yourselves aren't sure about how you want to be considered. You aren't drug-tested or duty-limited; if you were crew in the FAA's eyes your days of 24-hour shifts would be over. 

Note: Dr. Ira Blumen, in his seminal research on EMS aircraft crashes, lists the medical crew as a contributing factor in a significant portion of mishaps : Either for knowing something was wrong and saying nothing, or not knowing something was wrong when they should have.

While the larger hospital-based programs tend to schedule medical staff for 12 hours, the community-based folks are overwhelmingly working 24-hour shifts. This reduces the required number of full-time-employees and cuts costs for the operators. So in this regard, the operators want you to NOT be flight crew. 

It's different when we talk about flying with night-vision-goggles. As the rotorcraft flight-manual supplement pertaining to NVG flight includes a requirement for a "second crew member wearing goggles," the same manager who calls you a passenger in one context calls you a crewmember in the other.

All of this is nothing but a rhetorical exercise except for one problem. And this problem affects you personally.

The drongo pilots flying HEMS have jumped on these NTSB and FAA statements as confirmation of their malformed attitudes about "medical passengers." The belief that we should "get the medical crew out of the cockpit" was given bona fides. 

AMRM Training Solutions. Live, in person, and meaningful.
Schedule your training today. Visit AMRMTrainingSolutions.com

Let's consider the way "crewmembers" are regarded in another segment of the helicopter industry. "Utility" involves using helicopters to build, patrol and repair powerlines, to move timber, etc.

"Noted wire strike prevention expert Robert Feerst is an adamant advocate of CRM in the wire environment. He points out that flight nurses and any other crewmember should be acting with the pilot as a team, and be thoroughly versed in procedures and inflight communications. 
Southern California Edison invests six months of training for its utility crews and pilots. The crews are integrated into the flight activity and participate in decision making and planning on weather, fuel stops, winds, lighting conditions, known hazards, how to mitigate the hazards, and how to call out clearings. Says Feerst, “Everybody has to be speaking the same language.”

Embrace or Exclude? Which will it be? It seems we are of two minds…

Don't Teach Management Bad Habits

Aviation management forms their opinions of medical personnel based upon their interactions and problems encountered. Most hospital-based programs involve a contract that has a stipulation that any pilot can be replaced at any time upon request of hospital management. Even a community-based operation's management may fire first and ask questions later when a pilot is being accused of wrong-doing by a medical team. 

What has this brought about? When a medical crewmember uses safety as a weapon to cause a pilot grief or to have a pilot removed from his or her job this causes problems and incurs unforeseen expenses for the company. It creates distrust in the minds of the aviation managers and makes them want to keep medical personnel at arms-length. This wedge, formed at the highest levels of an organization, splits deep - all the way into your cabin at 3:00 am. It reduces your teams' ability to work together and make good decisions. 

Never use safety as a weapon. If you feel one of your peers is doing this - take them aside for some quiet counsel. You may save a life. Yours.

I asked a room full of HEMS senior leaders once about loading complete crews into a simulator and subjecting them to scenario-based flight training. One company's director of  aviation operations said, "that's a good idea but we won't be doing that at my company. When we have done this in the past, and the pilot struggled through a procedure, the crew demanded his replacement."

Friends - what that crew should have demanded was for training to continue until the pilot demonstrated proficiency - the same way we would handle a crewmember struggling with intubation. We have to be reasonable.

There was once an aviation program director who did not believe in the tenets of CRM or AMRM. On the aircraft he controlled, medical personnel were passengers - period. They were not allowed to sit in the front of the aircraft. They were not allowed to assist the pilot with radio calls, GPS setup, navigation, or situational awareness. I am not sure how this gentleman came to see things the way he did, but I suspect it had to do with his prior-interactions with medical folks. His philosophy was undoubtedly part of the root cause of a sequence of events that ended up here.

The crew was okay. Not so the helicopter.

If you are a medical team member, I ask you to reach inside yourself and tap your inner excellence - it's there and it's what you brought to the game in the beginning periods. Be a team player - even if your coach sucks or your coworker isn't. If there is only going to be one grownup on board, let it be you.

Learn as much about the aircraft as possible whenever possible. Seek to understand your pilot first, then seek to be understood. Attempt to operate - always - at the third level of situational awareness; projecting what will happen in the future based upon what is happening now. This keeps you alive.

Calm statements of fact. A supportive tone of voice. A genuine desire to be helpful. This is what Air Medical Resource Management is all about.  Remember, what happens in your quarters walks with you to the aircraft. You must be decent and respectful to each other all the time - not just when flying. Do your part to foster a culture of excellence at your base - starting with your participation at each shift's crew briefing. If you think your briefings are a waste of time, say so, then suggest how to make them better. 

Set the tone. Turn off your phone.

Encourage the free flow of information between disciplines. Never forget that you may be the last line of defense on your first flight. Asking questions is OK. Learning about your aircraft and aviation is fun.

Watch out for hazardous attitudes in yourself, and also in your team. Remember :

No one is immune to human factors.
We must continuously monitor ourselves and each other.
Be willing to speak up. Even to a friend. Even to someone you have worked with forever.
Machoism, Impulsivity, Get-home-itis, Invulnerability, Anti-authority, Resignation, and Complacency complement each other and lead to bad choices and worse outcomes. 

A flight nurse wrote a comment on "Nobody Rings a Bell:" 

An issue I have experienced is that we are like family and it is very painful at times to speak up. Speaking up has to happen and personal feelings need to be put aside. I suspect what makes HEMS such a great job is also our weakness. We are a tight group and speaking up can wreak havoc among the group dynamics. It shouldn't, and big-picture; it is certainly better to feel uncomfortable than to feel nothing ever again. Be safe out there.

Remember that pilots are people too :
Pilots have a strong desire to complete a task.
Pilots derive satisfaction from getting the patient to the hospital, and the helicopter and crew back to the base.
The closer to the destination we are, the harder it is to stop. That's get-home-itis and it is a killer.

Regarding Inadvertent Instrument Meteorological Conditions (IIMC) otherwise known as flying into clouds, fog, or heavy rain. I don't think it's really "inadvertent" at all. Remember Kobe Bryant?

Most IIMC events occur as a result of pressing on into deteriorating conditions.
We do not have to fly to the absolute limit of visibility before someone on board says, “Hey, Stop!”
An IIMC event means that all team members on board failed to maintain situational awareness. 
That's my job as a pilot. But you are there with me and you will share my fate.

You can make a difference. You are not a passenger.

The FAA has changed designations for pilots.
Old: Pilot Flying (PF) versus Pilot Not Flying (PNF)
New: PF and PM, (Pilot Monitoring)
Okay, so what is being monitored? (Hint: Man, Machine, Environment)
With only one pilot, who onboard our aircraft is available to monitor my performance?

That would be you.

If you sense that I am upset or distracted, or simply doing something "different" from what is normal, speak up! Inquiry, Advocacy, and Assertion can prevent bad outcomes.

The pilot of this aircraft was upset and distracted. He thought he had forgotten to
put on his fuel cap and made a "hot" approach to check it. It was on. You can
always call for a "go-around" if you sense danger.

Consider using "challenge and response" for your pre-takeoff confirmation checklists - these are the last checks we do before pulling up on the collective. A medical crewmember calls out the checks - one by one -  that if missed will lead to disappointment or death (fuel transfer switches, hydraulic switches, engine control positions). You can add medical items like drugs or O2 - just keep it simple and short. Many single-pilot programs are doing this. All should. Challenge and response is more effective than do-verify. 

Consider having a crewmember perform "fireguard" duty outside the aircraft during engine start. This would have prevented the situation in the picture below.

This aircraft was puking oil and smoke on engine start. The crew was inside and didn't
know anything was wrong. A witness on the ground saw the smoke but did nothing.
Best Practices:

All crewmembers perform walk-around every time. A missed latch/cap/cowl equals a pizza from the pilot if he or she missed it. It's a bargain - believe me.
The last set of eyeballs to climb in checks doors, fuel cap, condition of aircraft. (Eyes in)
The last set of eyeballs checks surrounding environment for hazards, obstacles (Eyes out)
That crewmember announces state of aircraft, hazard situation, readiness for departure…

Hopefully, none of this offends you or leads you to think that I think I am smarter than you. I know about many of these things because I have made these mistakes myself. A Dauphin will hover on one motor - but not very well. In a perfect world - harm will never find you.