Accepting the Challenge to Get Involved

        Having returned home from our most recent Air Medical Transport Conference (AMTC), I have had some time to reflect on a variety of my experiences and interactions. With this reflection I find myself consistently returning to a few key topics—reinvigoration, camaraderie, and involvement.
        I have been fortunate in the past to have had the opportunity to attend many of these conferences. In attending many of the great educational sessions offered, or by simply networking with all the other participants from our industry, I always have found some new idea to take back and apply to my practice. However big or small these new ideas may be, I find myself reinvigorated by the prospect.
        During our conference in San Jose, I had the opportunity to share the AMTC experience with a number of staff from my program. Included in our group were nurse, paramedics, EMTs, communicators, and managers, some of whom had been to a number of previous conferences, while others were attending their first AMTC. I always find it interesting to watch first-time attendees as they are exposed to new ideas, develop friendships from across the country, and experience the camaraderie of the air medical industry.
        I reflect back to the AMTC held in Reno, Nevada, in 2003. At that conference I was having a conversation with David Kearns, a past president of ASTNA, and was telling him that I wanted to get involved in ASTNA and thought that joining a committee would be a good place to start. I will never forget his response to me that evening when he said, “Why not just run for the board of directors?” What he did that night was plant a seed in a transport nurse who wanted to get involved at some level. I took his advice, and now after 2 terms on the board of directors, I have assumed the role of president of this great association.
        I shared this story with those at our annual membership meeting and challenged them to become involved at some level. A few short days after I arrived home, I received an email from one of our members who informed that she was taking my advice and was looking to increase her involvement.
        In closing, I look forward to a great year and encourage and challenge each and every one of you to reflect on what being a part of the air medical industry means to you and how you can become involved in making it better.
        Kyle Madigan, President


        No Pressure Initiative

        The entire NEMSPA board were both pleased and honored to receive the prestigious Vision Zero award at this year's AMTC in San Jose, in recognition of safety-related achievements. The $10,000 given by American Eurocopter as part of this award will be used to further the combined efforts of IAFP, AMPA, ASTNA, NEMSPA, and AAMS in moving forward the recently introduced No Pressure Initiative. NEMSPA wishes to thank all of those who generously supported this initiative, both financially and through encouragement and assistance in various associated activities.
        Earlier this year NEMSPA, conducted an informal survey of more than 250 pilots to determine, in part, the extent to which internal and external pressures may be an influence on aeronautical decision making. The survey revealed the need for further study and for the reinforcement and further development of safety practices. To enhance current practices, NEMSPA has proposed an additional procedure that can contribute to the pilot's in-flight risk assessment processes and decision making. We believe that this procedure, along with other elements of the initiative, can add significant layers of protection against real or perceived pressures on the pilot and medical crews to initiate or continue what may be a higher risk medical mission. The No Pressure Initiative specifies three major defensive layers: organizational culture, pre-flight risk assessment, and an en route decision point protocol.

        Layer One: Culture

        Programs should adopt policies and establish practices that integrate the following “do's and don'ts” into their active culture:
        Flight Team (includes communication specialists and controllers):
        • DO practice good AMRM (air medical resource management) protocols when discussing flight requests.
        • DO understand and use good ADM techniques to form flight acceptance and flight continuance decisions.
        • DO support and provide positive recognition when fellow team members make appropriate decisions.
        • DON'T allow patient type or condition to influence flight-related decisions.
        • DON'T allow pressure from management and other work-related associates to influence flight-related decisions.
        • DO support and provide positive recognition when associate flight team members make appropriate decisions.
        • DON'T apply pressure to any flight team member.
        • DO support and reward good decision making.
        • DON'T allow or tolerate an environment where there is pressure to accept flights.
        • DON'T emphasize flight volumes or post tracking numbers in flight team areas or quarters.
        All Participants:
        • DO ask questions during the team or organizational meetings that offer solutions or answers to questions that may arise during the en route portion of the flight.
        • DON'T apply pressure either to yourself or any member of a flight team.

        Layer Two: Risk Assessment

        It is recommended that all EMS flight programs incorporate a RAST (Risk Assessment Scoring Tool) as part of the flight team's preflight decision-making process. The RAST should consider the basic risks associated with EMS flight operations and should be tailored to the specific needs and environment of individual programs or bases. By helping the flight team identify and realize the inherent risks to individual flights, a well-designed RAST will significantly reduce pressure on the flight team.
        A well-designed RAST should account for the following variables:
        • 1.
        • 2.
          Pilot experience
          • a.
            EMS operations
          • b.
            Flight area
          • c.
            Specific aircraft model
        • 3.
          Fatigue (preferably Fatigue Risk Assessment Tool)
          • a.
            Circadian rhythms (ie, Circadian low: 0200-0500, schedules, etc.)
        • 4.
          Night vs. day
        • 5.
          Other factors specific to your area of operation
        There are numerous methods for accomplishing a RAST. Sample protocols are available in FAA Notice 8000.301.
        Outside Consultation:
        Reduced pressure on the flight team is significantly enhanced through the requirement to involve aviation personnel (where available) outside of the flight team when risks exceed a predetermined level and the flight team is inclined to accept the flight. This consultation should not occur when the flight team is not comfortable with accepting the flight; the flight should just be declined.

        Layer Three: En-route Decision Point

        The EDP (Enroute Decision Point) protocol has been field proven to be a simple yet very effective tool to minimize the possibility of helicopter CFIT (Controlled Flight Into Terrain) accidents caused by continuing flight into adverse or deteriorating weather conditions. NEMSPA believes, and pilots have confirmed, that this protocol can be an effective countermeasure to both internal and external pressures placed on pilots to complete flights in marginal weather conditions.
        Basic Concept:
        An EDP is analogous to the decision height on an ILS approach. When a predetermined limitation is reached, the pilot must exercise one of the required decision options. Continuing on the present course is not an option.
        Sample Limitations:
        Tabled 1
        Airspeed(Cruise – 30 KIAS)
        eg, for 120 KIAS cruise, use 90 KIAS
        (Cruise – 30 KIAS)
        eg, for 120 KIAS cruise, use 90 KIAS
        Altitude300′ AGL500′ AGL
        Minimum Enroute Cruise Altitude – See A021
        Minimum Enroute Cruise Altitude – See A021
        * eg, for 120 KIAS cruise, use 90 KIAS
        ** Minimum Enroute Cruise Altitude – See A021
        Note: Aircraft type, terrain, use of NVGs, etc., may influence limitations, which should be tailored to individual program requirements.
        Decision Options:
        When a pilot experiences any of these limitations, he or she must
        • 1.
          Alter course (or turn around)
        • 2.
          Transition to IFR (instrument flight rules)
        • 3.
          Land as soon as practical
        Flight Team Interaction:
        It is a basic assumption that the elements of the No Pressure Initiative will be implemented as part of an established safety management system that includes a fully functional system of operational control. The medical team, communication specialists, and operational controllers provide an integral part of the flight team, especially in marginal conditions. Individual program AMRM practices should dictate the exact role of these team members under various scenarios. While all team members must support the EDP protocol, their active participation in its implementation should generally be limited to assisting the pilot in making the decision regarding the optimal option to pursue if the EDP limits are reached.
        For further information, please go to
        Kent Johnson, President


        Lessons from the 2009 AMTC

        As I write this piece, the AMTC has just finished in San Jose—my own personal 24th conference. Reflecting on the long and convoluted road since my first conference, I have seen many conflicts and controversies confront our industry. Some problems remain the same or have periodically reoccurred, and some new ones have been thrust upon us. It is clear to me that all of us, regardless of discipline or training, must work to solve our common difficulties together. Some of you have heard me quote Ben Franklin, when he said to the Continental Congress, “We must hang together or, most assuredly, we will all hang separately.”
        Our problems are not insurmountable. We work in an industry where triage has been honed to a fine art. The act of triage is to divide an unmanageable task into manageable parts. We can use our triage skills to divide our seemingly unmanageable problems into manageable pieces that can be solved. We have more in common than we have differences. Rhetoric does not solve problems: dialog does.
        This year's AMTC had much in common with those of the past. The keynote speakers, Ms. Lee Woodruff and Dr. Mark Rosekind, were outstanding, possibly the best speakers that we've ever had. There was extensive interdisciplinary and international interaction and networking. International dialog is important for our industry because we can learn from each other how to improve transport quality and safety in a system-wide or countrywide fashion. Every person involved in our transport community, no matter what country they come from, wants two things most: a safe transportation environment and quality patient care.
        One poignant event at this year's opening session was the presentation of the MedEvac Foundation International Children's Scholarship Award to Joshua Codding, a pre-med student at University of California-Santa Barbara. This scholarship is to honor children who have lost a parent in an air medical accident. His mother, flight nurse Diane Codding, was killed in an air medical accident in 2003.
        A sad part of the AMTC was someone who wasn't there: Mr. Gerhard Kugler, who died soon after the end of this year's conference. Mr. Kugler was known to many of you, as he was at many AMTCs. He also was instrumental in coordinating the International AirMed Conferences over the past 25 years or so. Mr. Kugler basically established the German HEMS system as he led ADAC, the German Automobile Association. He was a major force in our worldwide community. Shortly before this year's AMTC, he was presented with an honorary membership in AAMS and a plaque by Past President Sandra Kinkade. One important lesson is the way that Germany finances an integrated EMS system for air and ground by financing the infrastructure and paying after patient transport. It is a model that deserves scrutiny as being potentially useful here. Gerhard Kugler will be sorely missed by all.
        The biggest single challenge facing our entire industry is healthcare reform. Within the past 24 hours of writing this article, the U.S. House of Representatives passed a bill. The next step will be passage of a Senate version, and then these versions must be reconciled. All of us need to keep the perspective that emergency services in general (emergency medical care in hospital and out) is a very small part of the healthcare pie, ground EMS (emergent and interfacility) is smaller still, and HEMS is smaller yet. AAMS has an active Health Care Reform Task Force, chaired by Dudley Smith, that has been monitoring the maneuverings in Washington around this process, as well as discussing the situation with representatives and senators when appropriate. Once a bill is passed and the fallout of what is going to happen becomes clearer, AAMS will work to keep the critical care ground and air components of transport viable. We will also keep the membership informed about developments and the need to institute a grassroots approach to molding the rule making process and the implementation of the healthcare reform legislation.
        When it comes to finding out what is going on in Washington that will affect us all, keep the AAMS Spring Conference in mind. The conference is March 17–19, 2010, in Washington, DC. Information was in the AMTC attendee kits or can be obtained from the AAMS office.
        Other pending conferences to be aware of include:
        • The Medical Transport Leadership Institute (MTLI) April 25–30, 2010, Oglebay Resort, Wheeling, WV
        • The Critical Care Transport Medicine Conference April 12–14, 2010, Sheraton Gunter Hotel, San Antonio, TX
        • Safety Management Training Academy June 13–17, Oglebay Resort, Wheeling, WV
        Lastly, I would like to personally thank Jonathon Godfrey for his tireless and innovative promotion of Vision Zero. The new Vision Zero website and Vision Zero toolbox will be available shortly. Remember: zero IS an achievable number.
        Dan Hankins, President


        Physician Authority for Medical Transport

        As I write this Forum article, many of us are returning home from AMTC 2009 in San Jose. In my opinion this meeting was truly a success! Despite early concerns that the turnout might be low, the numbers of attendees were good. The conversations and meetings were great, and the educational sessions were superb. I can only say thank you to everyone who participated in making this meeting the success that it was.
        Over 70 national and international medical directors and flight physicians attended the AMPA Core Curriculum conducted by John Pakiela, DO. The AMPA Task Force attracted another 20 or so and was led by a talk from AMPA President-Elect P.S. Martin, MD. Both had very good discussions and were well enjoyed. Minutes from the Task Force will be going out to all Task Force members shortly. Doug Floccare chaired the NAEMSP/AMPA/ACEP combined meeting on Monday, with another good turnout and more good discussion.
        In all the meetings attended by air medical and EMS physicians, it was made clear that there are very strong concerns about the threats of regulations or legislation that will restrict the physician's authority to determine how and when a patient needs to be transported. Current EMTALA rules mandate that the sending physician determines how a patient is transported and is responsible for that patient until the patient arrives at the accepting facility. The transportation method and what level of care they receive during transport may play a very important role in the patient's outcome. The provider who can best determine what the patient requires is usually the sending physician, with some guidance from the receiving physician. The thought of taking this decision away from the sending physician is extremely concerning, especially to those of us who still transfer patients as part of our practice. To be held responsible for the patient's outcome but not have the ability to determine how he or she will be transported is a scary thought.
        For those of us who are active in air medicine, we know how poor reimbursement is now. Linking reimbursement to certain requirements, as suggested by the NTSB, is also worrisome. Depending on where we fly, what our mission is, and what resources are available, flight services opt to do things differently, and what is important for one service may be a hindrance to another. Having an outsider decide what a specific service should or should not have and then link reimbursement to this decision may prove to be very damaging to some services that provide safe, necessary care to some areas. I hope that this is recognized before it is too late.
        Dr. Mark Rosekind, a world-recognized expert in sleep and fatigue management, was selected to present the keynote address at AMTC. He gave an excellent talk regarding sleep debt, fatigue, and sleep inertia. Dr. Rosekind has been working with NEMSPA (National EMS Pilots Association) and the NTSB to evaluate the effects of rest/sleep in aviation. He previously worked for NASA. Keep your eyes open for more of his material, some of which can be found at the NEMSPA website,
        FARE (Foundation for Air Medical Research and Education) is now the MedEvac Foundation International. In addition to funding research that is very important for the air medical industry, they support families of crewmembers who have died in the line of duty and offer an educational scholarship for family members. If you have not donated to this cause, I urge you to consider doing so. A link to the foundation is available at the AAMS website,
        Congratulations to Dan Hankins, MD, an AMPA founding member, who was just elected president of AAMS at AMTC.
        All of us are probably tired of winter by this time. I know I am not enjoying the thoughts of cold, snow, and ice as I write this, but for many of us, winter is a large part of our year, whether we like it or not. Winter brings with it many challenges for those of us involved in air medicine and EMS. Increased numbers of requests because of the weather often result in conditions that make responses slower and, at times, require turndowns as a result of weather limitations. This can be a frustrating time for many.
        As we suffer through the bad weather, let's all remember to keep safety in mind at all times. As medical directors we need not worry only about our patients, but our crews as well. I think it is important that we mind their mental health and their physical health. The bad weather, seasonal affective disorder, financial down times, and all the other stressors that exist can do a lot more harm to our crews than flu. We need to be very vigilant for changes in level of care, attitude, and activity in crewmembers that can be a clue that they are in trouble and need our help.
        Don't forget that there are some important meetings coming up soon: NAEMSP in Phoenix, AZ, January 7–10; CCTMC in San Antonio, TX, April 12–14; and AMTC 2010 in Fort Lauderdale, FL, October 11–13. Start paying attention to information regarding AirMed 2011 in Brighton, England, too.
        CCTMC in San Antonio will again feature AMPA's Critical Care Skills Day, with the assistance of VidaCare. Please pass the word around to your crews and colleagues. This is one of the best opportunities to practice life-saving procedures, including intraosseous access, chest tubes, central lines, surgical cricothyroidotomies, cut downs, and what ever else we can squeeze into our lab time. Everyone who has attended in the past has thoroughly enjoyed it—don't let this opportunity pass.
        Remember, AMPA is the association comprising physicians and professionals involved in medical transport who are committed to promoting safe and efficacious patient transportation through quality medical direction, research, education, leadership, and collaboration.
        I need to finish with a sad ending. It is with great sorrow that I heard of the death of Gerhard Kugler, the founder of European HEMS and Air Ambulance Committee and a huge advocate of air medical transport. He will be remembered for his commitment to safe medical transport and, ultimately, better patient care.
        Safe transports!
        Jack B. Davidoff, President



        As we close out another year in the history of our profession and began fresh in 2010, this is time to take a moment and remember those we have lost. While this past year was better than the previous, we still have a long way to go. I hear people in other healthcare fields tell me that, when we have a year without any deaths, we will know that our job is done. I disagree. While my hope and desire is that this year is a great year to be in air medical transport, without any serious crashes or fatalities, our job will be harder than ever to continue doing the right thing.
        From the forefathers of our profession in DUST OFF to the flight personnel who just received their wings, we owe them and our patients an obligation to keep alive the tradition that air medical transport provides fast, safe, efficient, and the highest level of care possible in the out-of-hospital setting. This tradition is changing as we welcome more ground critical care transport personnel to our house. They will be hearing more about flight safety and critical care in the field. We should remember that those in the air are not the only ones injured or suffer the loss of colleagues and loved ones. No pressure and Safety first are not just catch phrases but words to LIVE by.
        While we all have traditions, especially during the holidays, it is especially hard to alter or change them. I was recently told a story about the origins of tradition with the following example. A newlywed couple was making their first holiday dinner when the wife cut the ends off the roast and placed them in the garbage. When her husband asked her why she cut off two perfectly good pieces of meat and threw them away, she replied that this was her mother's recipe. “That is the way to cook it,” and if he did not like it, then…(you know how the rest of the cooking and conversation went). At the holiday dinner this eager young husband asked his mother-in-law about the recipe, and she quickly she replied that it was not his concern. After a few tense bites of food, she followed up with, “because that is the way my mother taught me.” Still not content with that answer, the husband visited grandma the next day with the rest of the family and posed the same question to her. After an awkward silence, she explained that her mother taught her to do the same thing. “That's right young man, this is a family tradition. And until they make casserole dishes big enough to hold a piece of meat like that, you have to cut the ends to make it fit.”
        Tradition and routine can be essential parts of our business when they are productive and prevent us from forgetting an import step in the process. However, when tradition forces us to make the same mistakes over and over again, it is time for a change.
        Everyone makes New Year's resolutions every few years, if not every year. We are all gung ho to lose that weight, pay off debt, etc. Within a few months or weeks, however, that resolution is either forgotten or we get so busy that other projects and tasks take priority. My New Year's action—action, not resolution—is to do my small part to make 2010 a year that will be remembered as the first of many years in air medical transport without a black page on the internet. My hope is that, when I write my last installment for the IAFP this year, I can proudly say that this year went down in history for all the right reasons. My resolution for 2010 is that every flight paramedic, nurse, pilot, mechanic, communicator, respiratory therapist, and physician safely goes home to their family at the end of their shift. I will neither forget that resolution, nor will I allow it to be put on the back burner because something more important came up. There is nothing more important than our safety and the safety of our colleagues. Let's each do our part to make this a year for the history books.
        Jason Hums, President