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. 

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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.

Thursday, October 8, 2015

Good thing he had a second engine...

The odds of an engine failure are extremely rare...

But it does happen. Here is a bit from a Concern Network posting...

Part 91 ferry flight with pilot and passenger onboard. While climbing
        through 7200' MSL (1000' AGL), the pilot heard three loud pops in
        rapid succession and simultaneously a #1 engine chip light
        illuminated. The pilot immediately began a turn towards lower terrain
        and lowered the collective to an OEI profile at which time the engine
        completely failed. The pilot secured the engine in accordance with
        checklist procedures and proceeded to the closest, most suitable
        landing area wherein he made an uneventful landing.
        The company performed a full PAIP and debrief. The pilot has been
        commended for his exemplary performance in managing the emergency
        The engine was removed and sent to PWC for teardown analysis. The
        result of this analysis determined that there was a failure of the #3
        bearing. Currently there is an elective Service Bulletin (SB28340) for
        operators to replace this bearing during engine overhaul time.

UK crash report finalized...

I don’t mind telling you i’m not **** very happy about lifting out of here”. The
other replied: “it should be ok it’s... i don’t think it is because you can still see the moon”.

The planned departure time was originally 1830 hrs, but the passengers were not ready to leave until around 1920 hrs. By this time,dense fog had set in; witnesses at the departure site and in the local area described visibility of the order of tens of metres.

Click here to read full accident report from this preventable tragedy....

Tuesday, October 6, 2015

Today is the day for a new Alabama Air Ambulance Service...

Photo Courtesy Dothan Eagle

A new private HEMS service is scheduled to commence service today, October 6th, 2015. Their billing practice differs from other providers in that they appear to accept payment from a patient's insurance company as payment-in-full with no balance billing. No mention is made of subscription payments being required.

"Barrett said Haynes is the only helicopter emergency medical services provider in Alabama that accepts commercial insurance as payment in full from all commercial insurance companies, and that Haynes is also contracted with Medicare and Medicaid."

Click here to read full story at dothaneagle.com