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From the air to the ground: Air medical safety practices applied to ground critical care
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From the Air to the Gr ound: Air Medical Safety Practices Applied to Ground Critical Care David Ellis, CCEMT-P, FP-C, CMTE
Any air medical service interested in longevity requires a quality safety culture. This culture involves not only the obvious avoidance of hazards while flying but a proactive and deliberate safety approach to each action taken. This article seeks to transpose several of these practices on the ground critical care world, with hopes that the points made will effect change and possibly even save lives.
Crew Resource Management In the Air Crew or cockpit resource management (CRM) was developed originally in 1979 by NASA to improve safety by reducing human error.1 Although the practice of CRM is an extended topic, the basic premise is that there be formal, multi-person verification of actions being taken. For example, while in a low hover over a scene landing zone, the pilot may say, “Tail is coming to the left,” at which point the person seated on the left side of the aircraft with the best view of the tail’s path of travel looks and states, “Tail is clear to come left.” This could be accomplished with no communication whatsoever, or by the pilot using any method of verbiage he chooses; however, CRM increases safety by allowing a predetermined series of statements to be made, letting all involved know what should come next. Any variation may indicate a problem, permitting the crew to immediately stop any action, thereby breaking the chain of events that may lead to an accident. To the Ground CRM is occasionally used in ground emergency medical services (EMS) and critical care, although generally in a more loose form than is found in the air medical arena. A more formalized approach has potential to increase safety and productivity just as it does in the air. An excellent example would be communication during an emergent response to a call. When approaching an intersection, the driver and front seat passenger should each verbalize that the cross traffic is or is not clear of the ambulance’s path. Vehicles slowing in front of the responding unit, or failing to yield, also should provoke a verbal observation. Making an assumption that the driver sees the vehicle rapidly slowing in front of the ambulance, or that the vehicle failing to yield in an intersection is seen, is to tempt fate. Eventually something will be overlooked, and a potentially fatal incident will occur. Much of what is involved in CRM is redundant and even obvious. Often, 158
however, the obvious problem that goes uncorrected leads to injury or loss of life.
Walkarounds In the Air A “walkaround” is performed in the aviation world to ensure that there are no immediate, obvious issues with the aircraft prior to flying. This should be performed at the start of each shift and before each flight. This should involve both the pilot and the medical staff. Cowling latches should be felt for stability; baggage doors should be checked for security. Fuel caps, position lights, and other external equipment should be inspected for a tight fit to the airframe. An experienced crew can perform a brief walkaround in less than a minute. As with CRM, it often seems redundant and obvious, but identical to the principles of CRM, the point is to eliminate as much human-error factor as possible. If only one time in your career you find a baggage door unlatched or cowling loose during a walkaround, you have justified all your efforts and possibly even saved your own life. To the Ground Too often ambulances and equipment are damaged by doors being open while driving, shore lines not being unplugged, or items being left on the back bumper. A beginning-of-the-shift examination of the truck will reveal any immediate problems: oil leakage, tire wear, loose compartment door latches, and so forth. Before leaving the station, on even the direst emergency, a rapid walk-around can prevent leaving with a compartment ajar, back doors opened, or shore lines attached. Although this may not save your life, it could definitely prevent expensive stair chairs and spine boards from being scattered across the intersection at your first turn or tearing off a compartment door while leaving the bay.
Equipment Restraint In the Air The manner in which equipment is stored and secured on any aircraft is of vital importance. Turbulence, direction changes, or the sudden stop from a hard landing can turn innocent objects into deadly projectiles. Monitors are fastened to FAA-regulated mounts, objects that are head strike dangers are padded or moved, and helmet use is Air Medical Journal 25:4
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commonplace. Any item, including soft packs or light equipment, should be stowed, strapped, or otherwise secured to the aircraft. To the Ground Too often I get in the back of an ambulance for a ride to or from a landing zone and note that the 30 pound monitor and other heavy equipment is secured to a shelf or benchseat by nothing other than gravity. In the event of a collision or tire rupture at high speed, these objects will doubtless prove highly injurious if not fatal to anyone they meet. Although a mount or strapping system for an aircraft must endure costly testing and certification by the FAA, straps, mounts, and nets for ambulances are cheap and easy to place in comparison. For the cost of a few dollars a potentially fatal incident can be prevented.
Crew Restraint In the Air Crew restraint devices in aircraft are generally more substantial than those found in other modes of travel. A five-point harness is the standard, and all crewmembers are expected to remain restrained throughout the flight with exceptions for patient care. In the event that a medical crew member needs to release his or her harness, the proper CRM action is to ask the pilot whether it is safe to come out of the harness, followed by a verbal notification of when the crewmember comes out of the harness and when he or she is back in place in restraints. To the Ground The lack of seatbelt use in the patient compartment of most ambulances is appalling and inexcusable. In the same accident in which the unrestrained monitor is traveling at high velocity toward the bulkhead of the unit, the unrestrained crewmembers will find themselves traveling at roughly the same speed on an intersecting course. Although at times free movement is required in the back of an ambulance, these instances can be made as few as possible by proper preplanning and good equipment placement. As in the air medical field, any time a crewmember is unrestrained in the patient compartment, the driver should be notified, allowing him or her to use extra caution.
July-August 2006
Weather In the Air Weather is an obvious and important safety concern with any aircraft. Air medical bases are provided with on-site access to up-to-date weather information and forecasting. On receiving a flight request, the first consideration pilots take is whether the weather is suitable for flying. While in flight, the pilots have access to various radio weather reporting stations, allowing them to make continuous decisions regarding the safety of continuing the flight. To the Ground Often, in ground critical care and EMS, weather is little more than an annoyance and rarely a consideration in initiating or continuing a trip. Although few weather conditions exist that totally preclude a ground unit response, a working knowledge of the weather in the area, at the expected destination, and in the forecast can significantly increase the crew’s and patient’s safety. This information may not always be readily available to the crew in the field; however, dispatchers can check and notify crews of potential weather hazards. This is especially relevant in the winter months and on trips that require the crew to travel a long distance into possibly changing weather systems. Conclusion A safety culture is not just an idea or a set of policies. A safety culture requires practice and a lifestyle change in the way we approach our work. Although tragic accidents occur in both the air and ground annually, with proper vigilance and practice, we can eliminate many of the issues that lead to injury or death. Safety is not just a goal; it is a daily act.
Reference 1. Crew (or cockpit) resource management. Available at http: en.wikipedia.org/ wiki/Crew_resource_management. Accessed June 13, 2006.
David Ellis, CCEMT-P, FP-C, CMTE, is a flight paramedic and base educator for Emory Flight 1 in Griffin, Georgia. 1067-991X/$32.00 Copyright 2006 Air Medical Journal Associates doi:10.1067/j.amj.2006.03.003
159
6/27/06
9:50 AM
Page 158
From the Air to the Gr ound: Air Medical Safety Practices Applied to Ground Critical Care David Ellis, CCEMT-P, FP-C, CMTE
Any air medical service interested in longevity requires a quality safety culture. This culture involves not only the obvious avoidance of hazards while flying but a proactive and deliberate safety approach to each action taken. This article seeks to transpose several of these practices on the ground critical care world, with hopes that the points made will effect change and possibly even save lives.
Crew Resource Management In the Air Crew or cockpit resource management (CRM) was developed originally in 1979 by NASA to improve safety by reducing human error.1 Although the practice of CRM is an extended topic, the basic premise is that there be formal, multi-person verification of actions being taken. For example, while in a low hover over a scene landing zone, the pilot may say, “Tail is coming to the left,” at which point the person seated on the left side of the aircraft with the best view of the tail’s path of travel looks and states, “Tail is clear to come left.” This could be accomplished with no communication whatsoever, or by the pilot using any method of verbiage he chooses; however, CRM increases safety by allowing a predetermined series of statements to be made, letting all involved know what should come next. Any variation may indicate a problem, permitting the crew to immediately stop any action, thereby breaking the chain of events that may lead to an accident. To the Ground CRM is occasionally used in ground emergency medical services (EMS) and critical care, although generally in a more loose form than is found in the air medical arena. A more formalized approach has potential to increase safety and productivity just as it does in the air. An excellent example would be communication during an emergent response to a call. When approaching an intersection, the driver and front seat passenger should each verbalize that the cross traffic is or is not clear of the ambulance’s path. Vehicles slowing in front of the responding unit, or failing to yield, also should provoke a verbal observation. Making an assumption that the driver sees the vehicle rapidly slowing in front of the ambulance, or that the vehicle failing to yield in an intersection is seen, is to tempt fate. Eventually something will be overlooked, and a potentially fatal incident will occur. Much of what is involved in CRM is redundant and even obvious. Often, 158
however, the obvious problem that goes uncorrected leads to injury or loss of life.
Walkarounds In the Air A “walkaround” is performed in the aviation world to ensure that there are no immediate, obvious issues with the aircraft prior to flying. This should be performed at the start of each shift and before each flight. This should involve both the pilot and the medical staff. Cowling latches should be felt for stability; baggage doors should be checked for security. Fuel caps, position lights, and other external equipment should be inspected for a tight fit to the airframe. An experienced crew can perform a brief walkaround in less than a minute. As with CRM, it often seems redundant and obvious, but identical to the principles of CRM, the point is to eliminate as much human-error factor as possible. If only one time in your career you find a baggage door unlatched or cowling loose during a walkaround, you have justified all your efforts and possibly even saved your own life. To the Ground Too often ambulances and equipment are damaged by doors being open while driving, shore lines not being unplugged, or items being left on the back bumper. A beginning-of-the-shift examination of the truck will reveal any immediate problems: oil leakage, tire wear, loose compartment door latches, and so forth. Before leaving the station, on even the direst emergency, a rapid walk-around can prevent leaving with a compartment ajar, back doors opened, or shore lines attached. Although this may not save your life, it could definitely prevent expensive stair chairs and spine boards from being scattered across the intersection at your first turn or tearing off a compartment door while leaving the bay.
Equipment Restraint In the Air The manner in which equipment is stored and secured on any aircraft is of vital importance. Turbulence, direction changes, or the sudden stop from a hard landing can turn innocent objects into deadly projectiles. Monitors are fastened to FAA-regulated mounts, objects that are head strike dangers are padded or moved, and helmet use is Air Medical Journal 25:4
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commonplace. Any item, including soft packs or light equipment, should be stowed, strapped, or otherwise secured to the aircraft. To the Ground Too often I get in the back of an ambulance for a ride to or from a landing zone and note that the 30 pound monitor and other heavy equipment is secured to a shelf or benchseat by nothing other than gravity. In the event of a collision or tire rupture at high speed, these objects will doubtless prove highly injurious if not fatal to anyone they meet. Although a mount or strapping system for an aircraft must endure costly testing and certification by the FAA, straps, mounts, and nets for ambulances are cheap and easy to place in comparison. For the cost of a few dollars a potentially fatal incident can be prevented.
Crew Restraint In the Air Crew restraint devices in aircraft are generally more substantial than those found in other modes of travel. A five-point harness is the standard, and all crewmembers are expected to remain restrained throughout the flight with exceptions for patient care. In the event that a medical crew member needs to release his or her harness, the proper CRM action is to ask the pilot whether it is safe to come out of the harness, followed by a verbal notification of when the crewmember comes out of the harness and when he or she is back in place in restraints. To the Ground The lack of seatbelt use in the patient compartment of most ambulances is appalling and inexcusable. In the same accident in which the unrestrained monitor is traveling at high velocity toward the bulkhead of the unit, the unrestrained crewmembers will find themselves traveling at roughly the same speed on an intersecting course. Although at times free movement is required in the back of an ambulance, these instances can be made as few as possible by proper preplanning and good equipment placement. As in the air medical field, any time a crewmember is unrestrained in the patient compartment, the driver should be notified, allowing him or her to use extra caution.
July-August 2006
Weather In the Air Weather is an obvious and important safety concern with any aircraft. Air medical bases are provided with on-site access to up-to-date weather information and forecasting. On receiving a flight request, the first consideration pilots take is whether the weather is suitable for flying. While in flight, the pilots have access to various radio weather reporting stations, allowing them to make continuous decisions regarding the safety of continuing the flight. To the Ground Often, in ground critical care and EMS, weather is little more than an annoyance and rarely a consideration in initiating or continuing a trip. Although few weather conditions exist that totally preclude a ground unit response, a working knowledge of the weather in the area, at the expected destination, and in the forecast can significantly increase the crew’s and patient’s safety. This information may not always be readily available to the crew in the field; however, dispatchers can check and notify crews of potential weather hazards. This is especially relevant in the winter months and on trips that require the crew to travel a long distance into possibly changing weather systems. Conclusion A safety culture is not just an idea or a set of policies. A safety culture requires practice and a lifestyle change in the way we approach our work. Although tragic accidents occur in both the air and ground annually, with proper vigilance and practice, we can eliminate many of the issues that lead to injury or death. Safety is not just a goal; it is a daily act.
Reference 1. Crew (or cockpit) resource management. Available at http: en.wikipedia.org/ wiki/Crew_resource_management. Accessed June 13, 2006.
David Ellis, CCEMT-P, FP-C, CMTE, is a flight paramedic and base educator for Emory Flight 1 in Griffin, Georgia. 1067-991X/$32.00 Copyright 2006 Air Medical Journal Associates doi:10.1067/j.amj.2006.03.003
159