Duty of care legislation in many countries has changed the way the operators view staff safety measures; the aeromedical sector has embraced this change accordingly. Indeed, there has been significant change in the past few years in the industry’s approach to safety, most notably at the level of procedures, paperwork and documentation requested from the operators.

Staff safety considerations

The Commission on Accreditation of Medical Transport Systems (CAMTS) has placed increased attention on its standards to ensure that safety management systems (SMS) encompass all provider and patient risk in the organisation. “Historically, the focus within the operator’s SMS may have been directed entirely on transportation and vehicle risk. CAMTS has shifted attention to a wider view of safety risk management that focuses on the risks related to all aspects of transport care, including risks outside of those inherent to the transport vehicle itself,” pointed out Tina Giangrasso, Senior Vice-President of Clinical Services at Air Methods.

“The EMS, and specifically the aeromedical sector, take a more holistic view based on an inherent safety culture which is far more proactive and responsive than in most other industries. The aeromedical industry operates in tandem with the general aviation sector,” said Doug Stevens, Medical Director at FAI rent-a-jet in Germany. “Advances are made as a continuous evolutionary process. Over the last few years, this has embraced several areas, including the extension of crew resource management (CRM) principles to flight medical crews and flight deck crews, continuous training, measuring and tracking benchmarks and data indices, reporting through propagation of a culture of ‘no fault’ incident recording and accreditation across the aeromedical industry.”

Equipment development

The use of personal protective equipment (PPE) has long been established in the aeromedical industry, and advances take place continuously in the areas of comfort, durability and effectiveness. “This is driven largely by global competition, pricing, and local regulatory compliance,” commented Stevens.

At the HeliSOS service in Guatemala, the medics wear bright blue flight suits with high visibility reflective striping. “Blue is because often they are in the jungle and it’s easier to see them. We tend to follow the UK / European model of medics being brighter than anyone else. PPE wise, aircrews wear a different colour to the medics for ease of recognition and dealing with local authorities. All wear helmets, gloves, flight suits and survival vests,” said Chris Sharpe of Black Wolf Helicopters, a consultancy that helped set up the HeliSOS service.

At Air Methods, ensuring the team is protected against infection is key. “The PPE we provide includes N95 respirators, gloves, gowns, goggles, etc. and is the standard set by the Centers for Disease Control and Prevention (CDC). We evaluate its guidance regularly to ensure we are maintaining the highest level of protection for our teams,” Giangrasso told AirMed&Rescue. “One consistent improvement is the use of night vision goggles (NVG), which better support the entire crew and enables safer operations at night.

Many regions also now ensure that each crewmember carries a personal survival kit in their pocket

"Many regions also now ensure that each crewmember carries a personal survival kit in their pocket.”

“All of our flight medics are provided with full PPE appropriate to their operating environment, including approved dual visor helicopter flight helmets, Nomex flight suits and gloves, approved boots, ALPS vests, [and] NVGs. We also provide ballistic protection vests and fire blankets for use in high-risk landing zones,” said Bill Probets, Sergeant and Chief Pilot at East Bay Regional Parks Police in California.

According to Stevens of FAI, the Ebola outbreak of 2013 to 2016 in Africa, during which cases spread to Europe and the US, provided a real catalyst to advances in the safe management and aeromedical transportation of highly contagious patients, who are often in critical condition and require multiple interventions. “This is especially so in the design of new-concept portable medical isolation units, with solid shell modules able to withstand depressurisation incidents, amongst other benefits,” he said. “Powered loading systems have lagged behind somewhat, limited by weight, space and cost considerations, not to mention limitations in battery capacity to power the units, especially over time, when aircraft remain out in the field over days, doing back-to-back missions.

So, the need remains especially important to close this gap, to enhance safe loading in the interests of patient safety, and prevention of occupational injury to loading teams. Often these teams consist solely of the flight medical crew and the pilots, performing manual loading under adverse conditions.”

In the experience of Ornge, which provides air medical transfer services in Canada, the most significant equipment enhancement from a crew and patient safety perspective in recent years has been the introduction of the HeliMods Powered Aero Loader Stretcher System (PAL) into its fleet of AW139 helicopters. “The PAL is a zero-lift, push-button operated powered stretcher loader system for rapid loading and unloading of land ambulance stretchers into air ambulance helicopters. The PAL significantly reduces the need for paramedics to manually lift or transfer patients between stretchers and vehicles, improving safety and efficiency while reducing the risk of patient and paramedic injury. The cot also features an equipment bridge to carry all the necessary equipment to treat our patients,” said Joshua McNamara of Ornge. “The system enhances our capability for bariatric transports without requiring aircraft reconfiguration. The stretcher design enhances patient safety by cradling patients to ensure stability throughout transport.”

Mitigating high-risk missions

Staff safety is given particular consideration in the definition and implementation of risk mitigation measures in high-risk zones, whether they be conflict areas, bushfires, or areas in which guns are an active concern. “All the operations of East Bay Regional Parks Police are subject to a comprehensive safety risk management process, including completion of an online flight risk assessment tool (FRAT) that includes mitigation and review processes. This would include risk assessments into active shooter environments or in the vicinity of wildland fires etc. Information for on-scene conditions is obtained directly from on scene police and fire personnel via direct radio, text, sat and cell communications,” said Probets.

Missions in El Salvador, Peru and Guatemala may often be conducted in high-risk zones due to either the zones being narco-controlled territories, or by the nature of the rescue operation itself. “Risk mitigations include a 12-hour minimum planning phase for high-risk extractions with information either gained through civilian security advisors, or former military networks. Where this information is not possible, then a normal mission is planned using military flight profiles.

The use of an armed quick reaction force in a second helicopter – if the client is willing to pay obviously – is an option we have used in the past

"The use of an armed quick reaction force in a second helicopter – if the client is willing to pay obviously – is an option we have used in the past,” said Sharpe. “Normally, it is just extensive mission planning focusing on separate flight navigation tracks in and out, minimising ground time, or in some cases just delivering the medics onto the ground with prolonged field care bags and the helicopter departing immediately. The medics do not wear blue on this occasion, and all the crew has to be ex-military and strict tactical combat casualty care protocols are followed to minimise the time on the ground.”

Stevens of FAI observed that in general, not many aeromedical services are equipped or prepared to offer high-risk missions. “In most cases, they are operated under the auspices of a government or inter-governmental agency, which will incorporate its own intelligence and risk management capabilities, often in conjunction with the military. The caveat here is that communications can break down when [teams are] operating under multiple layers of authorisation, which may counteract any risk mitigation measure,” he said. “Where private operators perform such missions, it is absolutely critical to have a 24/7 risk management approach managed by a specialist aviation security partner.”

Training

Training is an important risk mitigation measure when it comes to dealing with staff safety, in particular with regards to high-risk cases such as handling a combative patient or collecting a patient from a risky site. According to Stevens, the key success factor is to engage in simulation training with real-time scenarios, which force the participant to focus on a rational decision despite multiple environmental stressors and distractions such as noise, vibration and low-light conditions. “The main emphasis should be on primary exclusion or correction of reversible factors related to altitude and flight, followed by a systemic search for causes based on the underlying patient condition or health risk factors. The last approach is the employment of chemical or physical restraint, where all else fails. The overall goal lies in teaching the participants to remain calm and objective under duress,” he told AirMed&Rescue.

Every operator has its own procedures to follow, and these will be determined by mission parameters. “We have a written protocol for the medics in order for them to plan ahead and sedate early if necessary. There is also a written authority to use the minimum force necessary should a crewmember deem it essential; they are carried as ‘crew’ as opposed to ‘medical passengers’ though,” said Sharpe. “As part of annual aircrew requirements, training for combative patients focuses on the legal aspects behind assault or battery together with legislative references that give a basis for defence in any subsequent legal action. This is then covered practically during annual aircrew training, which includes the use of force, conflict resolution and personal weapons refreshers. We do not teach ‘hand to hand’ combat skills per se, as we utilise similar techniques taught to SWAT officers that use body weight, takedowns etc without the risk of injuring one’s hands.”

The East Bay Regional Parks Police trains its medical personnel and carries restraining equipment onboard. “If a patient cannot be reasonably restrained mechanically or sedated, we will not transport. In addition to one flight paramedic, the other two crewmembers are armed police officer pilots and tactical flight officers to provide scene security if needed. Rifles are also carried on board. A full risk assessment would be completed prior to accepting or declining the flight,” said Probets.

Crew resource management

CRM training is a long-established form of aviation training. In the aeromedical industry, a particular form of CRM is implemented called Air Medical Resource Management (AMRM). At Air Methods, the initial AMRM training provided to all flight crews takes around five hours on all facets of CRM, including building and maintaining team relationships, identifying and applying psychological principles in order to enhance safety, decision making using communication and risk assessment processes and techniques and the recognition of behaviors and actions that are required to address a changing operational environment. “We also utilise online refresher training for pilots and medical personnel to review the concepts, principles and techniques detailed in the initial face-to-face course,” commented Giangrasso.

According to Alex Pollitt, a maritime SAR helicopter pilot and CRM trainer, CRM training creates a forum to raise safety concerns and propose changes, raise awareness of specific safety issues that are relevant to the type of operation and its activities, and dovetail with the operator’s SMS. “A good CRM set up will be an important part of the feedback loop from crews that feeds into, and provokes, safety changes and updates to the SMS. For example, if crews had concerns over the quality of their kit, or certain risks that were involved in a hoisting operation because of the equipment being used, then it would be expected that this topic would be discussed in depth during CRM training on risk, and fed back into the operator afterwards as a risk raised or a red flag to risk in the SMS,” he said. “One of the most important tools in allowing individuals to contribute to making changes in safety equipment or procedures is the occurrence reporting system.”

Indeed, a fundamental aspect of good CRM practices is open and interactive communication. “Effective communication between our various frontline roles encompasses a large portion of our AMRM," McNamara told AirMed&Rescue.

Effective communication between our various frontline roles encompasses a large portion of our AMRM

“Coupled with increasing situational awareness, AMRM emphasises that team members should proactively speak up any time they have information that could potentially affect the safety of transport operations. They are also encouraged to do so in our ‘just culture’ environment, without fear of retribution or other negative consequence. Ornge trains all staff, including corporate staff, annually in CRM principles. This is a yearly course presented to all frontline staff and brings together all aspects of Ornge operation including pilots, paramedics, aircraft maintenance engineers and staff who work in our Operations Control Centre.”

According to Stevens, there can never be too much training. “It is the number-one area that can be neglected in a busy service. Good CRM training offers an integrated approach for medical and flight crews as one unit. It cannot be conducted in isolation. It should always fall under the oversight of the service safety officer, in conjunction with medical and aviation departments,” he said. “The curriculum traditionally focuses on leadership, communication and decision making under stress. However, what is often overlooked with flight medical crew CRM training are specific modules covering aircraft safety, emergency and evacuation procedures, and essential survival training relevant to specific local geographic requirements. This cannot be stressed enough.”

The vast array of measures taken by air medical and SAR operators to keep their staff safe is undoubtedly impressive, but as ever, more is yet to come. As new and emerging risks develop, so too must mitigation strategies and coping mechanisms. Mental wellbeing is one area in which keeping staff safe has recently seen renewed focus, while the need for high-quality PPE in the midst of a global pandemic has shone a spotlight on where this is sadly lacking in some countries. Keeping the front-line crews safe is everyone’s priority.