The human element in helicopter emergency medical support

As in every industry, accidents and lessons of the past have shaped the way forward. A number of key accidents in the early 2000s led to a shake-up of the industry when a combined six aircrew and two passengers tragically never made it to their destinations. The first was in 2000 when a B206L-3 Longranger crashed near Marlborough, Queensland en route to Rockhampton Hospital in the early hours of the morning. The causes cited in the ATSB report were fuel starvation while the NVFR aircraft searched for a place to land on a night where thick fog covered most of the area. The second was in 2003 when a Bell 407 departed Mackay for Hamilton Island. The ATSB report cited probable pilot disorientation and loss of control on a dark night over water. Both accidents involved smaller night visual flight rules (NVFR), un-stabilised, single-engine helicopters. The 2003 event prompted a review of helicopter classification and minimum safety standards for helicopter EMS operations. In Australia today, helicopter EMS is now a fully capable IFR + NVIS multi-engine operation complete with stability systems and autopilots.

David Betts, director of All Elements Protection and active aircrewman, paramedic, and qualified helicopter engineer, argues that a leap in equipment and technology development has occurred to improve pre-hospital medical care capability. “What’s changed is the level of equipment, which is now smaller, lighter and better. Additions which have previously not been seen on board the helicopter include ultrasound, smaller yet more advanced ventilation and monitoring equipment, plus a broader scope of drugs,” Betts says. “Ambulance-style stretchers can also be removed from rotary wing aircraft, patient loaded and flown securely to an eventual hospital bed with minimum patient moves, an important consideration for trauma patients.”

It seems the upgrade of aircraft size and capability has been driven by not only a need for greater levels of safety, but also what is now a highly advanced critical-care platform. Dr Jeff Hooper, LifeFlight’s director of medical education and training, suggests that while flight safety was the main driver behind HEMS enhancements, medical accessibility also played a part. “The expectation of care is that if you’re in a remote centre like Chinchilla, you should receive the same availability of care as if you’re in Brisbane,” he says.

Role dynamics

Successful missions rely on aircrew working both independently and in a team. For RACQ LifeFlight Rescue bases where inter-facility transfer (IFT) between hospitals is more common, the crew often consists of a captain, co-pilot, doctor and nurse. These bases also attend a smaller proportion of primary accidents. Bases requiring capability for a larger proportion of primary accident trauma missions have crews comprised of a pilot, aircrewman, doctor and critical care paramedic, with the option of a rescue crewman if required. There are, of course, variations of these crew configurations across the HEMS sector depending on the task, aircraft, cabin set-up and maximum take-off weight.

The goal of helicopter EMS is to get the medical crew to the scene as safely as possible and to give the patient the best level of care. Crew composition and training are massive and there is an interesting crossover between aviation and medical skill sets. Both deal with and manage risk and time pressures, and both operate complex equipment with technical language. Importantly, all aircrew must have a high level of situational awareness by recognising current trends and extrapolating these to anticipate and prevent complications from occurring.

Aviation skill sets

What constitutes success from a pilot and aircrewman point of view? The Marlborough (2000) and Mackay (2003) accidents noted earlier prompted big changes. Now, pilots require a few additional ratings, including Multi-Engine Type and Instrument Ratings, plus NVIS Rating, while aircrewmen require equivalent upgrades.

Trent Owen, a training and checking aircrew officer for Westpac Rescue Helicopter Service, says virtual reality is setting the standard, allowing crew to be exposed to stressful situations in a controlled environment. In Brisbane, the Thales LifeFlight Reality H AW139 Level D full flight simulator provides exposure to such challenges as multiple emergencies in the worst possible simulated conditions. The brain cannot differentiate between quality simulation and reality, hence why CASA accepts hours conducted in this standard of simulator as if they were actually flown.

Block training is a relatively new concept, aligning all aviation aircrew to the same annual training schedule across four separate training blocks. LifeFlight has adopted this system, and Bashir says it works because it’s structured to include training and checking on a more regular basis and in a shared environment. “The training and team exposure lasts up to four days per quarter, resulting in competent aircrew, but also a chance to develop relationships and crew resource management (CRM).” If crews are exposed to a phase of complex high-level training missions repetitively, the job becomes easier as the knowledge and confidence to be able to execute the mission is increased. You can’t beat experience.

Medical skill sets

EMS doctors are required to be emergency medicine, ICU, or anaesthetic trained. Nurses need specific training, while paramedics are required to have climbed to the critical-care level. CASA regulations apply to medical crew members from the perspective of needing a flight crew medical, CAO 20.11 emergency procedures training, and helicopter underwater escape training (HUET). Other than that, all medical aircrew training is regulated outside of CASA. Of course, company-specific training is a necessity and there are certain key differences to standard medical roles when airborne.

Dr Hooper explains that LifeFlight has a two-week training program to enhance awareness of the new working environment so medical personnel can do it safely as part of the crew. “We don’t teach basic medical skills,” he says, “rather CRM and performing their roles under adverse conditions in a small team, and with limited resources. Training is high-pressure, scenario-based, for example multi-vehicle car accidents. It’s about how to implement skills they already have into the new environments. Ongoing teaching and training are key”.

Dr Hooper recently delivered a clinical governance talk on what constitutes a high performing aeromedical service. The Australian Commission on Safety and Quality in Health Care defines clinical governance as “a system through which organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care”. Dr Hooper highlights the key elements of quality assurance, “A lot of training occurs around in-flight emergencies and to prevent them happening in the first place before climbing on board. The medical aircrew provide high-standard clinical care and spend a lot of time reviewing cases for adverse events or near misses, but also looking at cases that are done well. Jobs can always improve, and you can always learn something. The whole idea is to feed events back into the system to either change SOP (standard operating procedure) or more likely, improve the training”.

Despite many changes since the accidents noted in 2000 and 2003, we continue to learn more about the human element, including with newer aircraft and more advanced skill sets. Refining operations applies to all HEMS operators on a continual basis, such as in the aftermath of an accident in NSW in 2011. An AW139 Primary mission, 16 kilometres west-southwest of Wollongong Airport resulted in the death of a paramedic after being winched down to retrieve an injured person from a ledge at the base of Carrington Falls. The ATSB report commented “the accident highlighted the dangers associated with modifying established procedures, in order to complete a difficult, and potentially not previously experienced rescue task”. One of the industry changes from this event includes paramedics (in their role as rescue crewman), now being required to conduct annual night-winch recency training.

Working as one – teamwork and crew resource management

Like elsewhere in aviation, teamwork in HEMS operations is absolutely crucial. For the team to be efficient, a high level of crew resource management (CRM) is vital to understand personalities, emotions, and constantly liaise with people. LifeFlight’s Bashir argues the crew in the back are just as important as crew in the front for safety. “Medical crews are trained to look out and speak up, backed up with our in-house CRM training for all aircrew.”

Interestingly, NVIS operations after dark require a curtain to partition the cabin and cockpit. Trent Owen, from the Westpac Rescue Helicopter Service, comments on the importance of how crew frame their language, include their cadence and tone of voice. This is particularly important when looking at role dynamics on board. “The nature of the roles mean more alpha personalities are drawn to EMS,” says Owen. “A key attribute is sound leadership and followership skills. The pilot needs to trust other crew members to assist, while after landing, the medical crew will take on the leadership role.”

This shared responsibility is clear, and LifeFlight’s Dr Hooper lends his thoughts on crew dynamics from the medical perspective. “We need to maintain a strong relationship between the aviation and medical side,” Dr Hooper says. “CRM is very important for open communication where everyone feels they can speak up if something is not right. A key difference in EMS is the transition from working in a hospital to working in a different environment within a small team.” Outside of EMS, he adds, interactions with road paramedics and doctors in small hospitals are not common.

Good CRM undoubtedly enhances the safety of the mission. This is paramount because the fallout from an accident may be a lot more than one patient. Damage to an aircraft would also put it out of future missions. Bashir argues the crew and aircraft must always be the most important elements on every mission, in that order. “The patient is our purpose and our business, but does not drive the mission,” he says. This is a necessary point of view and puts the community and customer first by ensuring that more lives can be saved in future. It’s also an example of why Safety Management System (SMS) mandated by CASA, following earlier accidents, are so important.

Holding it all together

There are so many contributors to a successful EMS operation outside of the aircrew alone.

Whereas tasking of assets was previously solely completed within an organisation, the move towards tasking agencies has seen efficiencies improve. Operational control is an area Bashir feels is essential for an organisation the size of LifeFlight to be successful. At LifeFlight the control and coordination are provided by “C3’’, aptly abbreviated from “communication, control and coordination”. Craig de Gee is a duty tasking manager within C3 and is passionate about communication, “C3 brings planning to fruition while also pivoting and adapting to inclement weather, engineering requirements, and sick crew to get the job done. Effective teamwork and communication allow us to service the community.”

de Gee suggests inter-agency communication with state departments, Retrieval Services Queensland (RSQ) and Queensland Health is also important. “C3 has a good relationship with RSQ, which fields 000 calls and determines the best asset available for dispatch to the emergency. C3 are constantly in touch delivering information to RSQ so it has the required knowledge.” The quickly changing landscape and time-critical nature of EMS means efficiency in the passage of information is vital. This goes equally for engineering departments which C3 also liaise with frequently. As an active aircrewman and qualified engineer, Betts from All Elements Protection says anything that can bring the two professions together is positive. “Communication is vital and having positive relationships between all personnel is very important.”

At LifeFlight, areas such as health, safety, security, and the environment (HSSE) are combined into a single department which provides oversight of the organisation’s safety management system (SMS). Within the SMS sits the quality management system (QMS) which directly contributes to successful safety outcomes. Employees are key elements to ensuring continued safe operations by working together with management to identify and manage risk. Hazards can be identified with checklists and audits, however, it’s the informal observations of staff that truly get the whole team involved.  This pro-active approach to identifying potential threats and errors allows HSSE to make changes before these become incidents. Ongoing improvements to the SMS occur as this kind of data is continually fed back into the system as part of a just culture.

Luke Peyton is the director of HSSE at LifeFlight – a role which also doubles as the safety manager in the eyes of the regulator. “Having a good safety culture is a constantly evolving strategy. The reporting can always be improved. Within a just culture we’re looking for the best ways to do things, that’s where the gold is. [Through reporting], the mistake you make is a mistake the other base isn’t going to make.” Peyton also hails the importance of teamwork element and everyone having a common goal, as well as an understanding of human factors. “We’re mindful of the emotional element. The other side of getting the job done is what’s going on in the mind. Is a decision being made based on emotion or SOP through a measured approach? Emotional elements need to be put in check”.

Crew wellbeing

The contribution of crew wellbeing to the performance of individual skill sets and teamwork in HEMS is undeniable. Non-technical skills can be enhanced with practice; however, a healthy mind and body sets the baseline. These include skills such as lookout, situational awareness, task prioritisation, decision making, and effective communication. “Flight crew need to think on their feet. There are so many variables. Sometimes you don’t know what’s going to come in the next minute,” describes Bashir. This is one reason why LifeFlight has invested in the wellbeing of personnel with a subsidised fitness passport for employees and their families.

Dr Toby Ford is the CEO at Ford Health, a corporate health and employee wellbeing company. He says companies must view personnel as their greatest asset. “Managing personnel like this contributes to a sustainable business, risk management, enhanced customer service and retains staff in a competitive workforce. Personnel last a lot longer, it’s just like maintaining an aircraft. The key is to understand that wellbeing and resilience are value added propositions in the workplace.” Some of this value is seen in the ability of aircrew to perform non-technical skills to a higher standard, thus adding to the safety of the operation.

Dr Ford promotes a balanced view of employee health and wellbeing where key areas of our lives such as connection, medical, resilience, work, lifestyle and sleep, all hold significance. Anyone who has worked in a HEMS role knows that sleep needs to be managed well to minimise fatigue. This is again a personal responsibility, plus CASA mandates organisations to possess their own fatigue risk management system (FRMS). With a standard HEMS roster consisting of two days on, two nights on, four days off, CASA suggest an FRMS is “designed to create a flexible operating environment in which potential fatigue risks can be highlighted and managed”. LifeFlight aircrew complete an Individual Fatigue Likelihood Score (IFLS) record at the start of every shift. This will flag scenarios where insufficient sleep renders a crew member unable to fly due to “scoring” on their IFLS record. Medical crew comply with additional fatigue requirements. Safety nets also exist during pre- and post-flight briefings where an open forum facilitated by the aircraft captain allows crew members to speak up with any issues across the board. Operations and coordination centres such as C3 and LifeFlight Retrieval Medicine (LRM) also monitor aircrew movements to consider fatigue and FRMS considerations, while the HSSE department provide education in this area. The priority is safety above all else.

Peer support

HEMS organisational support to aircrews extends further than the general health and wellbeing construct. Exposure to some potentially traumatic events and the cumulative effect of seeing these scenes on a semi-regular basis have necessitated an outlet to nurture employee mental health. Organisations like LifeFlight currently utilise wellbeing services such as the Converge International Employee Assistance program (EAP), which provides 24/7 counselling services. Peyton says the eventual goal is to move towards a comprehensive in-house mental health and wellbeing strategy. “The nature of the job is we attract high performing people, and this sometimes means people don’t want to reach out for help.”

As an additional service, members of the Australian Federation of Air Pilots (AFAP) can also reach out to that Member Assistance Program which is designed to assist aircrew after serious incidents or accidents. More commonly, people seek support for everyday pressures that can result from a stressful life. AFAP suggest “access to psychological treatment can and should be part of any pilot’s maintenance of their overall health and wellbeing”.

Dr Hooper explains that peer support programs are important to medical crew, however other avenues are also beneficial. “Clinical leads at the bases are the first point of call and this catches the wider issues. Having highly experienced clinicians as leaders to reinforce when individuals have done a good job is important. Also available to people are the anonymous services, this is something that is evolving but could be done a little better in the industry. It is important to have wellness outside of work which can be self-driven by employees. Work-life balance is very important and should be encouraged.”

COVID-19 has also changed the landscape of organisational peer support. Dr Ford says it dramatically changed the nature of people in what they need. “The most stable state of sovereignty people belonged to [throughout the pandemic] was their workplace,” says Ford. “Everything else was in a state of flux. A few years ago, work was just one place we belonged to. COVID has suddenly shifted that dynamic. Giving workers general life skills creates a feeling of belonging. In return, they give back discretionary effort, innovations (improve processes), and ingenuity (ability to cope with issues). Employees highly regard life skills. Maslow’s hierarchy of needs used to prioritise safe and secure accommodation. Now [workers prioritise] connection, valuing belonging and creativity.” Personnel working in EMS roles care greatly about the communities within which they work and live, while developing relationships in the workplace. A human desire for connection means we all want to be part of something larger than ourselves.

Conclusion

The human element of helicopter EMS is what makes it. Interaction and connection between many individuals mean the whole is greater than the sum of its parts. Flight nurse Chris Eustace describes it best, “Part of the crew dynamic is everyone’s willingness to do their best. We’re all there for the patient we’re treating.”

The thing is, synergy occurs not only between aircrew, but also between organisational departments, and inter-departmentally. Optimising human relationships across the board starts with individual skillsets and wellbeing or peer-support, so we may show up as the very best versions of ourselves within the team dynamic. “Always fluid, we never get to a point where we’re the best we can be,” says Bashir. “That comes from daily experience and doing more missions”.

Andrew Boniface is an AW139 EMS co-pilot and mindfulness facilitator. Prior to beginning his aviation career, Andrew worked in the health industry performing both clinical and corporate roles. Human Factors represents the coming together of his two passions.