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Helicopter emergency medical services (HEMS) provide life-saving transports for the critically ill or injured. However, the rising number of U.S. HEMS accidents over the past decade is cause for serious questions as to their operational safety. For this reason a national effort is underway to reduce HEMS accidents.
 
In the classic tale of the Seven Blind Men and the Elephant, each man formed a different impression of what an elephant was, based on which part of the animal’s body he experienced directly through his sense of touch. The final result of this non-collaborative approach to system description was that none of the men was altogether wrong, and none was altogether right.
 
In the ongoing efforts to identify and resolve the problems in the air medical transport industry, it will be important to avoid a similar fragmented approach. The various players in the nationwide air medical transport industry are partially constrained by their roles to view the challenges confronting the industry, as well as the potential solutions, through the filtered lenses of their personal microscopes. This is not a bad thing of itself, if the interested parties subsequently merge their perspectives regarding what needs to be fixed, and then pool their expertise to create effective solutions.
 
Obtaining the macroscopic perspective needed to ensure effective improvement requires that we zoom out to a perspective that can view all of the domain-specific concerns, so that the entire landscape of pertinent issues becomes visible, along with any conflicts and inconsistencies that may need to be resolved. How easy or difficult this process will be depends largely on how divergent these individual views may be. So, the first step is to consider who the likely players should be in this process.
 
Many readers may disagree with my assessment of which groups or agencies are best positioned and most able to impact improvements in the effectiveness and safety of air medical transport operations. I admit that the following list is my personal opinion. Together, one or two representatives from each group could form a Working Group to address the changes needed within the industry. The groups are presented in alphabetical order, with no intent to suggest their relative importance to the process. (I look forward to any mail that I might receive from groups who will be offended by their absence from this list).
 
·       Association of Air Medical Services (AAMS)
·       Association of Critical Care Transport (ACCT)
·       Air Medical Operators Association (AMOA)
·       Commission on Accreditation of Medical Transport Services (CAMTS)
·       Federal Aviation Administration (FAA)
·       Helicopter Association International (HAI)
·       National EMS Pilots Association (NEMSPA)
·       National Transportation Safety Board (NTSB)
 
With that list in view, I have to confess that the title of this article is presumptuous. As a member of NEMSPA and an air medical transport safety professional, I am not qualified to represent all of the perspectives pertinent to the task of fixing everything that may be broken in the air medical transport industry. But neither is anyone else (even though some may feel that they are). What I am suggesting here is an overview of the process to follow in order to successfully create and implement effective and holistic solutions to deficiencies within this industry.
 
You will notice that there is no representation for federal or state legislators on the preceding list. The intent of the Working Group should be to focus on improvements and interventions that can be implemented without a need for amending existing laws, or for drafting new ones. If that goal should prove to be naïve, then the group can draft recommendations to be presented to the appropriate government entities.

 
The Process
 
The first step in a campaign to fine-tune the national air medical transport industry is for each organization that will participate in the Working Group to designate one or two representatives who are willing to commit to participation in the project.
 
The next step will be to draft a broad, very high-level statement of the intent and the goals of the project. As the effort progresses, the group will more carefully determine what the final specific objectives need to be. Those objectives should fall onto the table naturally as the result of detailed discussions of what the problems and challenges are within the industry.
 
After reading the preceding paragraph, some readers from the organizations listed above may be thinking that they have already done this within their own group. They probably have, and in some cases there may also have been some cross-talk between organizations. But, they have most likely only addressed the repairs to a tusk or a trunk; other parts of the elephant are still ailing.

Rules of engagement
 
It is critical that the Working Group begins by unanimously adopting the optimum process to utilize in order to move toward the final set of recommendations that they will eventually present to all stakeholders involved in the air medical transport industry. The structure of that process must be such that it fully taps into the potential for synergy that is latent in the combination of individuals who comprise the Working Group. Synergy has become such an overused buzzword in some organizations that many readers may have experienced an involuntary rolling of the eyes when you read it just now. But true synergy is still the most powerful means to real solutions, when the right processes are used to achieve it.
 
In his most recent book The 3rd Alternative, venerable author Stephen R. Covey has zeroed in on what is perhaps the most important of the 7 strategies he presented in his landmark book The 7 Habits of Highly Effective People, published in 1989. His 7 Habits book has sold more than 15,000,000 copies in 38 different languages. The 3rd Alternative was published in 2011. A discussion of the contents of that book is beyond the scope of this article. So, I will mention just two of the concepts that facilitate the creation of true synergy.

Talking Stick protocol
 
In a diverse group of individuals with distinctive perspectives on any issue, it is often a challenge to get people to listen to whoever is speaking without conducting a simultaneous mental critique of what they are hearing and preparing a detailed rebuttal to be launched as soon as the speaker pauses for breath, if not sooner. This phenomenon typically accounts for a lot of noise and inflated emotions, with too little real communication actually occurring. Covey soundly endorses and teaches a Native American custom of passing the Talking Stick to each person who is to speak. The essence of this concept is that no one may interrupt the person holding the Talking Stick except to ask questions that may be needed to ensure complete understanding. While the speaker holds the stick, the responsibility of every other member of the group is to concentrate on understanding what the speaker is striving to communicate. There are some interesting Native American symbols attached to the design of the Talking Stick. It would be interesting to see what kind of design a group of air medical professionals would come up with for their version of the Talking Stick.

The Magic Theater
 
Think of the Magic Theater as an environment for brainstorming, on steroids. Like brainstorming, the Magic Theater entails a rigorous suspension of any form of filtering or evaluation while all members of the group offer up an unrestricted palate of ideas, suggestions, and opinions on a designated topic. There are no rules and there is complete respect between all members during this all-out free-for-all. As Covey puts it, "People lose their egotism and pride of authorship of their ideas because all ideas in this room are tentative. They can propose a solution one minute and turn around and propose exactly the opposite solution the next; nobody cares about being consistent."  Covey then goes on to present detailed guidance on how to structure the environment needed to facilitate this fertile exchange of strategies and solutions.
 
It is not uncommon during the Magic Theater sessions for the group to feed off of each other's energy and creativity in a manner that causes them to create and then converge upon a solution that is better and more than anything offered by any one of the individuals present. That is the definition of synergy.

Don’t reinvent the wheel
 
Concerns for safety in air medical transport operations have been growing in recent years and various groups have been expending time and effort in addressing the problems. Those efforts should be examined by the Working Group so that useful data can be integrated into the process of formulating effective solutions to industry challenges.
 
National EMS Culture of Safety
 
The National EMS Culture of Safety Strategy project intends to create a very broad and general structure for promoting safety throughout all types of EMS services in the U.S. It intends to create an agency, tentatively labeled with the placeholder name National Council on Safety in Emergency Medical Services (NCSEMS).
 
The following statements taken from the second of what will ultimately be four drafts of the strategy document indicates the nature and scope of the project.

The Strategy is positioned as a high-level, vision-oriented effort on a national scale. It does not attempt to serve as a substitute for the work of qualified researchers, scientists and technical experts. Rather, it is an effort to support that work by creating channels for its advancement, standardization, practical application and widespread adoption.

 

The Strategy is intended to be well-connected to science, best practices and trends both within and outside EMS, across the healthcare and business continuum. However, the Strategy acknowledges that scientific support and/or sufficient data are not always available, and waiting until these elements are available may take many years. Indeed, a significant benefit to the Strategy itself is the potential to spur research, data systems and reporting that are currently lacking. Accordingly, the Strategy relies on a combination of proven concepts and ideas that are reasonably believed to hold promise.

The Strategy’s scope is visionary rather than prescriptive; it is not intended as a safety manual, nor is it designed for practical use by individual EMS organizations. As such, it does not address highly detailed factors or make technical recommendations about vehicles, equipment, procedures, etc., nor does it include such detailed activities as evaluating products or technologies or setting protocols.  

The mission and scope of NCSEMS is envisioned to comprise four key elements for advancing a culture of safety in EMS: 

·       A national data system for operational and patient safety in EMS;

·       Evolution of the EMS education system;  

·       Promulgation of safety standards and related information; and

·       Reporting/investigation of applicable incidents.

 

OSI-HEMS
 
Opportunities for Safety Improvement in Helicopter EMS Services is a research project initiated in January 2008 under the direction of Dr. Ira Blumen of the University of Chicago Air Medical Network. Unlike the National EMS Culture of Safety Strategy, which comprehends all types of EMS services, this collection of approximately 40 air medical professionals has worked to review and identify the root causes of over 140 medical helicopter accidents occurring from 1998 through 2010. The group has conducted a meticulous review of the NTSB accident investigation dockets of the accidents to extract the apparent causes. After identifying the causes for each accident, the group pooled their various perspectives to determine an index of the degree of causality for each cause. The team then discussed possible mitigation strategies to prevent similar accidents in the future and documented the mitigations that they felt would prove most effective. The final report of this 5-year project is expected in 2013.

NEMSPA CHAMPS
 
As described above, the National EMS Culture of Safety Strategy is a very broad and high-level approach to system safety for all providers of emergency medical services. The OSI-HEMS project is a more targeted effort to address the challenges specific to air medical transport operations.
At the sharp end of this continuum, the Cultural Health Assessment and Mitigation Program for Safety (CHAMPS) is a survey-based project of the National EMS Pilots Association (NEMSPA) that is designed to identify specific attitudes and practices in the organizational cultures of air medical providers that could influence aircrew members to push the limits of safety in order to complete a patient transport flight. At this time, NEMSPA is performing final review and validation of the survey in anticipation of offering it to air medical provider programs later this year.
 
NEMSPA has been especially active in recent years in escalating its campaign to enhance the safety of air medical operations across the U.S. Their activities have been, and continue to be an influence as industry stake-holders and federal regulators consider issues such as new regulations for the air ambulance industry, the use of night vision goggles and traffic and terrain avoidance and warning systems, and the design and safety of the nationwide system of hospital heliports. NEMSPA also provides a representative to both the National EMS Culture of Safety Strategy and the OSI-HEMS projects.
 
Whereas the other projects mentioned above are supported by grants and donations, NEMSPA’s efforts are supported by the Association’s memberships and sponsors. Active Pilot Membership is open to any EMS pilot. Affiliate Membership is open to anyone associated with or with an interest in the air medical transport industry. Information about NEMSPA and an online membership application are accessible on the Association’s website at www.nemspa.com.
 
Conclusion
 
Like many of the national-level challenges confronting the United States today, fine tuning the effectiveness, efficiency, and safety of the air medical transport industry is a complex undertaking due to the diversity of the roles and perspectives of the key stakeholders involved. But this same diversity is also the key to success if representatives from the groups above, and perhaps others, can gather in a spirit of creative cooperation to learn from each other and to create the kind of solutions that can result from genuine synergy.
 
I know that there are capable people in each of the organizations listed above who are personally motivated to work for improvements in air medical transport. It will be interesting to see who will lead out in a timely manner in organizing the working group I have suggested here.
 
About the author
Bill Winn is the Safety Officer for Intermountain Life Flight in Salt Lake City, Utah and the General Manager of the National EMS Pilots Association. He flew as a helicopter pilot and instructor pilot in the US Army for 27 years and as an air medical pilot for 9 years before becoming a desk-bound safety officer. He can be contacted at William.Winn@imail.org.

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