TAKING THE SKIES
January 23, 2015
By Audrey Fraizer
A call comes in from a remote stretch of road favored by bicyclists. The EMD gathers information. The situation is critical. A vehicle hit a guardrail, spun, and in the process, collided with the local elite racing team. There is at least one fatality. Multiple people are injured, and some injuries are considered to be life threatening. Arrival by ground ambulance would take valuable time.
Based on patient conditions, and the remote location, the decision is made. An air ambulance equipped to provide Advanced Life Support will be dispatched, along with the appropriate medical team to treat the acute respiratory or specialty trauma issues.
Critical care by air
Critical care aircraft—fixed and rotary wing—are specially equipped as flying intensive care units. They provide a Federal Aviation Administration (FAA) approved flight stretcher, specialized medical equipment, and a full assortment of patient-specific drugs and medications. The aircraft is staffed with a medical team and flight crew. There are currently 75 air ambulance companies in the U.S. that operate about 1,515 helicopters.1
North Memorial Health Care in Minneapolis-St. Paul, Minn., owns and operates Air Care and its fleet of eight air ambulances dispatched from five bases (soon to be six) covering the entire state of Minnesota and portions of Wisconsin, Iowa, and the Dakotas. Founded in 1985, Air Care responds to an estimated 4,500 requests for services each year.
A majority of calls involve intra-facility transport.
The twin-engine Agusta “S” helicopter can reach cruising speeds of 190 mph and is the fastest civilian helicopter on the market. It is a passenger aircraft reconfigured for medical care and includes instrumentation for flying at night and in adverse weather conditions. The crew consists of a pilot, a flight nurse, and a flight paramedic.
Helicopters take off from the hangar within six to eight minutes after a request for response. The EMD provides the pilot with a radio frequency to connect to a first responder ground unit at the scene. Both a high and low reconnaissance is flown prior to landing. The pilot manages the landing zone, while the nurse and paramedic provide patient care.
Since ground crews generally arrive prior to the helicopter, the patient involved in a traumatic accident is generally ready for flight—airway secured and IVs in. The patient is strapped onto the gurney and slid feet first into the helicopter.
Patient transfer requests involve orders from the sending facility as well as the receiving facility’s documented acceptance, and fulfilling checklists Air Care requires for activation and arrival. The list includes facility name, pickup location and destination, the medical problem, special circumstances (e.g., intubation), and patient age and weight.
Patient weight can determine whether helicopter travel is manageable, said Jan Althoff, EMD and Quality Assurance (QA) Coordinator, North Memorial Health Care.
“It’s a matter of ensuring the patient can fit within the safety straps and be safely secured onto the stretcher,” she said. “At 400 pounds, we coordinate fixed wing or ground services. At over 300 pounds, we ask for more details.”
Maximum girth is 63 inches, and it’s a tight fit for even an average-sized patient.
Crewmembers cannot weigh more than 200 pounds, fully dressed.
The Air Care Patient Transfer checklist nearly mirrors recommendations from a 2006 report by the American College of Emergency Physicians and the National Association of EMS Physicians2, and they apply to response (not necessarily transport) with the understanding that air transport requires a certain level of over-triage.
The similarity is no accident, Althoff said.
“We’re super focused on safety,” she said.
Althoff has spent 15 years at North Memorial’s centralized secondary Public Safety Answering Point (PSAP) handling all types of emergency calls for the multifacility health care organization. Her schedule dedicates eight hours per week to QA duties and the remaining 32 to calltaking and dispatching medical calls requiring ground and, at times, air ambulance response. The communication center employs 30 EMDs.
The communication job takes multitasking to a whole new level.
As a secondary PSAP, the calls they receive for response are transferred from 9-1-1 centers not equipped to provide EMS or from facilities requiring air ambulance for intra-facility transport. In an emergency, they “always, always” send ground ambulance, Althoff said, supplemented by air ambulance, depending on the situation.
Air Care is deployed primarily for three reasons:
• Intra-facility transport: patient transport to a facility better equipped for optimal care, such as to a level-one trauma center from a local hospital for an individual critically injured, for example, during deer hunting season (11 percent of land in Minnesota is publicly owned, giving a lot of access for deer hunters).
• Request for air ambulance: Ground ambulance, first responders, or law enforcement arriving at the scene calls for air ambulance due to the severity of the incident and time factor
° Within six to eight minutes of a 9-1-1 call to any of the five bases, an aircraft is in the air and, depending on the location of the call, can deliver a patient to the hospital more than two times faster than a ground ambulance can. For example, air ambulance response to a deer hunter wounded in Ely, Minn., takes 60 minutes or less for pickup and delivery from the Air Care base in Bemidji to the closest trauma center. The same distance could take several hours for a ground crew.
• Emergency Medical Dispatch Dual Response: From the 9-1-1 call, the North Memorial Health Care dispatcher uses criteria to determine whether the patient requires air ambulance, in addition to ground ambulance. The request to deploy, however, doesn’t mean an automatic “go.”
“There are several variables the pilot must consider to complete the flight safely,” Althoff said. “Weather is just one of them.”
The EMD answering the call stays on the line, gathering information and providing Pre-Arrival Instructions (PAIs), when necessary, particularly if the call comes in from a non-EMS responder. The decision to send ground and air response depends on travel exceeding a specified radius and the urgency of medical care or procedures, including burn care, traumatic injury (e.g., head and spinal cord injury), heart problems, and strokes.
If it’s a DELTA- or ECHO-level, the radio dispatcher generally sends both, Althoff said.
“The calltaker uses the ProQA tool to clearly establish the patient’s condition,” she said. “The decision to send air [in addition to ground] takes solid judgment based on the information provided.”
The dispatcher coordinates ground and air response. The pilot works with the dispatcher and a designated ground crew contact on-scene regarding the description of the landing zone (LZ), obstacles, wind direction, and other variables. If the pilot determines conditions are unsafe for landing, the helicopter changes course to an alternate LZ, such as the nearest hospital, airport, or other designated safe landing spot where ground resources may intercept.
The ground crew treats the patient and transfers care to the air ambulance crew for flight to the designated care center.
North Memorial Air Care also works with other air ambulance services like the Mayo Clinic’s Mayo One, Life Link III, Sanford AirMed, and Avera McKennan Care Flight to coordinate flights closer to the patient.
“People make one call, and we coordinate everything else,” Althoff said.
Air ambulance is ranked as one of the most dangerous jobs in EMS for a number of reasons. Alone or in combination, there are several factors adding some degree of risk every time an air ambulance is dispatched for patient transport.
According to FAA statistics3:
• From 2011 through 2013, seven air ambulance accidents resulted in 19 fatalities and seven commercial helicopter accidents claimed 20 lives.
• 2008 proved to be the deadliest year on record with five accidents that claimed 21 lives.
The Air Medical Physician Association (AMPA) reported that even though only 38 percent of all helicopter EMS flights occur at night, 49 percent of accidents during a 20-year period occurred during nighttime hours.4
The report also cited controlled flight into terrain (CFIT), in particular during the takeoff or landing sequence, as a common problem, as well as collision with objects (wires were the most common obstacles for EMS helicopters); inaccurate weather forecasts (26 percent of helicopter EMS accidents were weather-related, with most occurring due to reduced visibility); and communications problems with air traffic control (ATC) or a lack of communications due to remote locations and high terrain.5
According to a query of the National Aeronautics and Space Administration’s (NASA) Aviation Safety Reporting System, patient condition was cited in 44 percent of the EMS accidents or incident reports as contributing to time frame pressure leading to inaccurate or hurried preflight planning.6
The North Memorial Air Ambulance program is committed to safety. This is why they operate twin-engine aircraft and HTAWS (Helicopter Terrain Avoidance Warning System), with pilots and helicopters certified for IFR (Instrument Flight Rules).
Since August 2004, the FAA has promoted initiatives to reduce risk for helicopter air ambulance operations. While accidents declined in the years following that effort, 2008 proved to be the deadliest year on record with five accidents that claimed 21 lives. The FAA oversees air ambulance operators and its oversight goes beyond inspection and surveillance. It issued a final rule on Feb. 20, 2014, requiring stricter flight rules and procedures, improved communications and training, and additional on-board safety equipment.
Communication staff does not work directly with FAA regulations, although they are regularly briefed on government mandates, especially as they pertain to training.
Communication between North Memorial Health Care dispatchers and Air Care crew is ongoing.
Twice daily—at 7 a.m. and again at 7 p.m.—communications staff conferences with Air Care crew to discuss transport issues such as weather, obstacles that might interfere with flight and landing, and requests for intra-facility transfer (although many of these trips are scheduled in advance).
New communication hires spend a shift on a helicopter as part of their eight weeks of training and orientation. An every other month in-house dispatch education course devotes two of the session’s four hours to aviation dispatch safety.
Other FAA requirements
Also specific to air ambulance operators are requirements to7:
• Equip with Helicopter Terrain Avoidance Warning System
• Equip with a flight data monitoring system within four years
• Establish operations control centers if they are certificate holders with 10 or more helicopter air ambulances
• Institute pre-flight risk-analysis programs
• Ensure pilots in command hold an instrument rating
• Ensure pilots identify and document the tallest obstacle, such as a skyscraper, along the planned route before departure
• Comply with Visual Flight Rules (VFR) weather minimums, Instrument Flight Rules operations at airports/heliports without weather reporting, procedures for VFR approaches, and VFR flight planning
• Conduct the flight using Part 135 weather requirements and flight crew time limitation and rest requirements when medical personnel are onboard
• Conduct safety briefings or training for medical personnel
The FAA examined helicopter air ambulance accidents from 1991 through 2010 and determined 62 accidents that claimed 125 lives could have, perhaps, been mitigated by the sweeping final FAA ruling issued in February 2014. The estimated cost to the air ambulance industry is $224 million to implement improved communications and training procedures and additional on-board safety equipment.
1FAA Initiatives to Improve Helicopter Air Ambulance Safety, FAA. 2014. http://www.faa.gov/news/fact_sheets/news_story.cfm?newsId=15794 (accessed Sept. 17, 2014).
2Policy Resource and Education Paper: Guidelines for Air Medical Dispatch, American College of Emergency Physicians and National Association of EMS Physicians. 2006. http://www.acep.org/uploadedFiles/ACEP/Practice_Resources/issues_by_cate... (accessed Sept. 18, 2014).
3See note 1.
4Special Investigation Report on Emergency Medical Services Operations, National Transportation Safety Board (NTSB Number SIR-06/01) 2006. http://www.ntsb.gov/safety/safetystudies/sir0601.html (accessed Sept. 19, 2014).
5See note 3.
6See note 4.
7See note 1.