Air Ambulance Operations
Air medical transport, particularly using helicopter ambulances (HEMS), remains potentially dangerous despite years of attempted safety improvements. There are approximately 1.18 fatal crashes per 100 000 HEMS flight hours, and this crash rate has remained relatively stable over time.
The most important causes of fatal crashes are: (1) inadvertent flight into terrain, (2) pilot disorientation and lack of spatial awareness during night operations, and (3) adverse weather conditions. Many potential crashes can be avoided by ensuring that aircraft involved in patient transports are equipped with terrain-avoidance devices, that the pilots have appropriate night vision equipment, and that the operator has strict and inflexible rules regarding operating in inclement weather. Additionally, all pilots should be qualified in instrument flight rules (IFRs) in case the aircraft is forced to operate in IFR conditions. The managers responsible for the team should ensure that these provisions are met before allowing the team to fly. Additionally, a hallmark of truly excellent air-medical programs is continual training of pilots. In choosing a provider of air-medical services, teams would be wise to consider the amount of continued training afforded to the pilots.Additionally, all team members must undergo thorough training to function safely and effectively in the air-medical environment and to comply with Federal Aviation Administration (FAA) and Commission on Accreditation of Medical Transport Systems (CAMTS) regulations. This training is, by necessity, divided into 2 types; nonmedical and medical. All crew members, regardless of role, must understand the specific dangers associated with working around aircraft, especially helicopters (see section on vehicle orientation). Team members have to know how and when to approach the aircraft, the hazards associated with certain kinds of clothing and equipment, the impact of environmental factors like noise and altitude, and especially, the dangers of rotor-wash.
They need to understand how to safely move around the aircraft when the terrain is uneven or when movement is difficult because of ice, mud, water, or other obstacles. They must also understand how to safely load and unload the helicopter. A thorough orientation to each specific aircraft is also necessary. Transport team members need to be able to assist the regular crew in the event of an onboard emergency and should be well schooled in the emergency procedures necessary to manage problems like on-board fires and emergency landings. Teams that fly over remote areas should have wilderness survival training (see section on training for survival and emergency conditions). Finally, all teams should participate in Crew Resource Management and Air Medical Resource Management, which emphasizes a team culture of shared decision making and mutual assurance of safety and quality.Medical providers must also learn how to manage medical emergencies in flight and must understand the physiologic effects of flight on patients. Procedures that might be considered straightforward in the controlled setting of a well-lighted critical care unit can become difficult or impossible in a dark, noisy, moving helicopter. Alternative means of dealing with such emergencies as inadvertent extubation and acute pneumothorax while in the aircraft must be learned and practiced. CAMTS standards thoroughly delineate the training requirements and capabilities needed.