Helicopter shopping involves a first responder or healthcare facility making calls to a number of air ambulance providers in turn. When one turns down a flight, the caller tries the next on the list, without informing them of who has already turned down the flight or why. In the following article, we’ll examine what steps providers can take to ensure they’re making solid go/no go decisions, even in an environment where shopping may occur.

Multiple calls

Perhaps the first thing to acknowledge is that calling more than one provider isn’t in itself bad practice. In a joint position paper issued in March 2019, the Air & Surface Transport Nurses Association (ASTNA), the Emergency Nurses Association (ENA), and the International Association of Flight and Critical Care Paramedics (IAFCCP) noted that it can be reasonable to call more than one provider, as it may be that a storm is affecting a service in one location, but not another elsewhere.

Similarly, Krista Haugen, Co-Founder of the Survivors Network for the Air Medical Community and Director of Patient Safety and Medical Risk Management at Med-Trans Corp, says

it’s important not to oversimplify the issue

it’s important not to oversimplify the issue: “In many circumstances, it is reasonable for referring facilities and agencies to explore their transport options if an aircraft isn’t able to respond for reasons such as availability, duty time, out-of-service issues, local weather, and the like. There are also circumstances in which a VFR aircraft turndown may occur, but an IFR-capable aircraft and pilot may be able to safely complete a transport. So, to say that helicopter shopping needs to be stamped out is not entirely accurate – it’s not unreasonable for referring providers to explore and understand their options.” However, she adds that there are circumstances where helicopter shopping can be incredibly hazardous, particularly if crucial pieces of information are not passed on.

Proactive questioning

Where providers don’t routinely cover the same territory as others nearby, requests to fly outside of their usual patch can be a cause to make more enquiries. Jonathan Goldman is now President of the New Hampshire Emergency Dispatcher’s Association (NHEDA) and used to work for Boston MedFlight. He commented: “The Northeast Air Alliance discourages [helicopter shopping] and will work together to not fly into each other’s service areas, unless they have spoken to the other programmes prior to accepting a mission.”

If we receive a request for a flight for which we are not first due, our dispatcher will ask the requester, ‘Has anyone else turned this call down for weather?

As another example, Susan Rivers, Programme Director of Carilion Clinic LifeGuard, said: “If we receive a request for a flight for which we are not first due, our dispatcher will ask the requester, ‘Has anyone else turned this call down for weather?’”

She added that for programmes that are CAMTS-accredited, this is a required piece of the call intake process.

In their joint paper, ASTNA, ENA and IAFCCP went further, urging that communications centres should ask if other operators have already been called as a matter of routine. They called for ‘acknowledgement that proactive communication is the shared responsibility of both sender and receiver’.

Similarly, Haugen said: “All parties – requesters, helicopter air ambulance communication specialists, and operational control centres should ensure the question of previous weather turn-downs is answered before the flight is accepted. It may be helpful to include the question of previous weather turn-downs as a checklist item for referring providers and also for the helicopter air ambulance communication centre call intake process to help facilitate this critical communication.”

Casey Ping, who recently retired as Programme Director at Travis County STAR Flight, noted that asking the caller if the flight has been turned down by other programmes has benefits for reasons other than weather, including patient condition and patient weight/size.

Industry co-operation

The ASTNA, ENA and IAFCCP joint paper called for all transport services to set aside competitive influences and work co-operatively ‘to ensure the focus remains on proactive communication and mission safety’. One such way that providers can co-operate is to share information with each other directly, so that each crew is kept up to date regardless of what a caller might tell them.

The CAMTS accreditation standards detail how information should be shared: notify other programmes within your coverage area of a turndown as soon as possible; provide the on-duty pilot with contact information from other programmes for questions about the weather; inform the on-duty pilot immediately if notified of a weather turndown by another programme; and have written evidence of tracking the requests turned down for weather and of participation in regional notification systems.

Ping told AirMed&Rescue that, in his experience, many aeromedical companies share weather information either by direct call to the dispatch centre/crew quarters or through web-based systems like weatherturndown.com. However, he noted that these processes still have some limitations. For one thing, someone will still be the first helicopter called: “That programme will either accept the flight or turn the flight down either before or after lift-off. Only then will another programme have information that may help them make a flight decision.” Also, he added, there is the time delay factor: “It could be 20-30 minutes depending on who is entering the data. Assume programme A launches on a flight request. They encounter non-forecasted weather and abort. They return to base, refuel the aircraft and then start their post-flight procedures, which may include entering weather turndown data. Even if this information is entered by the dispatch centre, there could be a time delay. In the meantime, the customer immediately started calling other resources to get the patient moved.”

In Virginia, providers can access an electronic system called Medevac WeatherSAFE through the Virginia Hospital Alerting and Status System to submit a weather turndown each time a pilot declines a flight due to weather, as Rivers explained: “All medevacs that serve Virginia have an opportunity to register (at no cost), which allows them to both submit their weather turndowns as well as to receive the weather turndowns from neighbouring medevac programmes. Most Virginia HEMS programmes have a dedicated screen in their communications centre which alerts [them] whenever a weather turndown within their region has occurred.” The information shared usually includes helpful details such as ‘low ceilings at departure base’, ‘thunderstorms at sending facility’ or ‘IFR conditions – pilot (or aircraft) is VFR only’, she added, which helps other pilots when making their own decisions based on their location and capabilities. According to Rivers, if done in a timely manner, the system may alert neighbouring medevac programmes even before the requesting hospital or EMS agency has a chance to call the next medevac provider. She continued: “Of course, the timing of the electronic submission is not always that immediate, so we still confirm at the time of the request as well.”

Competition and culture

But what of those competitive influences? If you know that the caller will move on to your competitor if you don’t take the flight, how do you stop that from affecting your decision making? One answer is to establish a robust safety culture.

Speaking of the dangers of perceived competition leading to poor judgement in the accepting of a flight when weather is marginal, Rivers said: “I believe this falls mostly on the shoulders of the leadership team to develop a culture otherwise, to include speaking up in an ‘all to go, one to say no’ stance.” She added that management should also ensure that flight volumes are not shared with the ‘boots on the ground’ in a way that can be perceived as threatening to the viability of the programme.

messages about being able to accept flights that others can’t may put pressure on crewmembers to live by those words

Ensuring that crewmembers are comfortable turning down a flight is essential. The ASTNA, ENA and IAFCCP joint paper says that providers should have a policy that encourages clinical team members and communications specialists to raise issues regarding a safety concern ‘without fear of punitive action’. It continues: “The policy also must include language regarding zero tolerance for punitive action against members of the transport team for declining of a mission or voicing concerns. Just Culture and CRM principles support the ability of flight teams to communicate freely about issues, including assessments of safety compared to the value of a specific transport, without fear of punishment or retribution.”

Randy Mains, Chief CRM/AMRM Instructor for Oregon Aero, said that education of staff within the air ambulance provider is vital: “The answer has to be education. The folks from top and middle management down to the communication specialists where the ultimate decision is made must understand the danger in helicopter shopping.” In particular, Mains warned that the way a provider promotes itself should be carefully considered – for example, messages about being able to accept flights that others can’t may put pressure on crewmembers to live by those words.

One phrase that makes industry veteran Rex Alexander cringe is the mantra, ‘We save lives’. He said: “In my opinion, this phrase is often used to justify and perpetuate unsafe behaviour and goes to the very heart of a bad safety culture. Sometimes, the right answer is saying ‘no’, which is oftentimes very hard to do, especially if you have brainwashed yourself and those around you that you are expected to save every life. What I tell flight teams is, the life that I expect them to save is your own so that they go home to their family in something other than a body bag at the end of the day.” If you save you and your team’s life first through good decision making, then the patient will be taken care of as well, it just may not be by you, he added. “The sooner that the first responders can be told ‘no’, that an air ambulance cannot come, the sooner they can then begin the process of getting that patient moving by ground.”