Air Medical Resource Management Thoughts

A pilot’s perspective of a patient’s medical emergency during a critical aspect of flight.

Not long ago I was on duty as the pilot for a helicopter air ambulance at a traditional program, so as the pilot I work for a part 135 helicopter operator and the medical crew works for the hospital we have a contract with.  We received what sounded like a rather routine call to a hospital about 50 minutes away.  The flight north was pretty typical for a crew that has worked together for quite a while.  The nurse/paramedic and I have worked together for over 10 years and the paramedic has been with us for about 6 months but worked on ground ambulances for our program longer than that and is also an RN  working in the local ER when not on flights.  The weather was clear, about 25 deg F and the winds were gusty with a little turbulence out of the south east as opposed to the prevailing northwest winds we see most often.  I knew that the return flight would be longer and rougher than usual due to the winds.

The trip back from my perspective was fairly routine again if watching the fuel flow and confirming I would be landing with the expected amount of fuel on board was considered routine.  Watching airspeed and arrival times on a windy turbulent day is always interesting.  Turns out I landed exactly as expected.  59 minutes after takeoff, and with 35 minutes of fuel, but enroute the GPS was giving me everything but an accurate enroute time.  Quite often I was watching the enroute time on the GPS increasing instead of decreasing due to turbulence and changing winds aloft.  Changing from lake effect winds near Lake Superior to the inland winds, 100 miles south is always interesting.  I am often accused of finding headwinds in both direction.

Enroute patient care was fairly normal as I listened to the med crew ask the patient where his pain level was at, did he feel nauseous, I felt bad about the turbulence, etc.  I was surprised with some of the answers from the patient as he often said the pain was a 10 out of 10 but he did not sound like he was in that much pain.  He also seemed to not be in too much distress from nausea despite the turbulence.  I was under the impression that he was over stating his pain number.  As we got closer to the receiving hospital the crew radioed in the patient info and asked for a hot off load.  I informed them that we would be landing to the east due to winds in the teens and gusting from that direction.  This direction meant that I would be landing facing away from the crew waiting on the ground for us and require them to circle around the front of the helicopter to unload the patient.  We have done this before so not a problem in and of itself just required more vigilance and was the original plan.  This was also our primary hospital and the ground help have done this before so not a show stopper.  Another option that I have done in the past when doing a hot unload with ground help was to make my approach into the wind but then do a 180o pedal turn putting the tail into the wind before setting down but allowing for a safer operation on the helipad.  This also meant we would be getting exhaust fumes in the cockpit on shutdown and startup. Something we tried not to do too often.

About 3 minutes out everything changed from a somewhat routine monitoring and administering of pain meds to #@#^*%#*@.      It started with the med crew turning on the patient’s mic and I heard a very desperate “I have to puke”, followed by movement in the back as I suspect the crew were getting an air sickness bag to him. Turned out to be two bags at least but I remember them asking him if he needed the bag anymore and he said no.  It sounded like the crisis was over.

Then it got even more intense when I heard, V-fib, we might have to shock him.  I can’t tell you much of the medical problem but what came next was a huge increase in stress.  One of the crew called for shocking the patient, Charge, Clear, shock, another called the hospital to tell them that we were charging and then shocking.  For this crewmember who I have flown with for over 10 years, this was not a normal call and his voice got significantly more excited, he was talking a lot faster and clipped the end of his sentence off. The reply from the hospital I remember was, in comparison, an amazingly calm, “I’ll tell the doctor.” There was an unreal feel to that short conversation, then the other crew member did the same thing with the same results when they shocked him again.

“Sir, Are you OK? Can you hear me? need to shock him again, Ken (me the pilot) stay clear of the patient, Clear, Shock”, feet jump, BEEEPWhat was that? That’s in my headset!  BEEP! What did that shock do to the helicopter, “Clear”, feet jump, coming over the back of the ridgeline into the hospital, BEEP, “Caution Terrain”, “Sir, Are you OK? Can you hear me?  Tell me your name”, BEEP, Instruments are fine, what is that noise?  Slow down, Relax, everything is OK, BEEP, what is that? Normal approach, good approach, “Caution terrain”, “warning obstacle”.  Good approach, BEEP, ignore, over the pad, “turning tail to right, landing” ground crew is here, a little tail wind but expected, down and safe. Idle, “your clear to get out”.  “Stay with us, we are on the ground and will get you to the cath lab shortly”.  I got him here.  But is he alive?

I will say that those last few minutes the collective stress level in that helicopter was amazingly high.  Dealing with a dying man, making radio calls, staying clear as they shocked him, a nonstandard approach because winds were not prevailing, monitoring fuel, obstacles and buildings on the approach path, a crew that was too busy with the patient to provide any assistance like normal, all added to an increase in stress.  There was a moment on final I had to actually talk to myself and I remember telling myself to just relax and make the approach.  Ignore the rest.  Ignore the Beeps, ignore the obstacle warnings since I did not have another hand to silence it at that point.  I was aware of all the things that were increasing the stress in the cockpit and with just a thought, relax and ignore it, I was back in control.

It was obvious what was increasing the stress level of the medical crew, It was very different but not surprising.  I thought the higher pitch and stressed call to the ER was interesting and a little humorous.  It was something I could give them a hard time about once we got the patient to the hospital.  I could tell that my stress level was elevated also simply by being there listening to them.  Then it went even higher with the BEEEEEEPS! This came as a monotone beep that was regular and since it was through my headset, and therefore not a medical device, I became distracted as I sought to determine what it was.  What did they do to my helicopter when they shocked the patient?  For a critical 20-30 seconds I was on personal autopilot as I started the descent down the back side of a small ridge into the helipad.  Luckily it was our primary hospital and although it was not normal to land from this direction it was also something I have done often enough in the past to know where to come over the ridge and start my descending turn to final and the helipad.  It was after I was on short final for the approach that I remember talking to myself to calm down.  I also made the decision to turn the aircraft tail to the wind.  This was not the plan but it was something I could do easy enough to ensure additional safety on the ground while they were unloading a patient they might have to do CPR on.  When they came back to the aircraft I was informed that the patient was still alive in the cath lab with severe blockage.  What a flight!  We talked about it then as we put a new liner on the cot and wiped down everything.  That was when I found out that what that BEEP was. “So did you guys have the tone in your headset too?”  “Yea that was the Michigan 800 mghz radio, we were out of range”.

“You’ve got to be kidding!”

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This was originally posted in another blog I have on personality types ( check out – https://functionsarchetypes.blogspot.com/) but I thought I would share it here also.  

 

Paying attention is something we can control. It is actually an awareness skill, according to Deepak Chopra. According to him paying attention is a form of total engagement with the situation and lists four steps that are involved:

  • Impartial observation – Look and listen with your senses
  • Analysis – Look and listen with your mind
  • Feeling – Look and listen with your heart
  • Meditation or Incubation – Look and listen with your soul

Developing awareness on all four levels strengthens your potential for success.

I can’t say that I look at this the same way Dr Chopra does but these 4 steps still resonated with me and made connections to what we talk about when we discuss situational awareness.  It is as simple maybe as paying attention to what is going on around us.  Then without really digging into the deeper meanings of his list, I discovered my own meanings and connections.  I guess that is a part of who I naturally am.  For me it connects to the 4 temperaments inside us all like this.

Impartial observation – Look and listen with your senses – Artisans/Improvisers are all about the details and using their senses to be in the moment.  Using this temperament is about seeing things as they are, while feeling alive through their five senses.  Those with a preference for the Artisan/Improviser temperament tend to be very observant to their surroundings while recognizing people’s motives, making them very good negotiators.   Stress comes from being forced into a narrowly specific way of operating, especially if they are not a part of the solution and not given free rein to meet the standards in their own manner.

Analysis – Look and listen with your mind – is very much at the root of the Rational’s/Theorist’s temperament style. Using this temperament allows for precision and competence in everything they do.  Their need for knowledge usually assures that they are always looking for more information, but can get stressed if they feel that they are not competent in the things they do for whatever reason. This is even more of an issue if there are others around that see this happen or call them out.

Feeling – Look and listen with your heart – this is the realm of the Idealist/Catalyst. These are the people persons. Decisions will always include concern for the others on the team.  Are they OK with the decision, are they a part of the decision, are they going to be affected by the decision. The idealist is a natural mediator or arbitrator, being able to see both sides of a conflict with a natural empathy.  It is that same heart that drives the idealist to take on causes that match their own values.  Stress is significantly increased when others could possibly be affected or harmed in some negative way especially if it is because of the idealist’s decision.

Meditation – Look and listen with your soul – a good decision for a Guardian/Stabilizer can be said to follow this simple (common sense) rule.  If it is legal, moral and ethical it is a good decision. This is more than a mantra, it is something that is deep down at the core.  Guardians seem to be natural leaders and will typically work for the good of the group or organization. Decisions however, often come without consulting with others because they already know that they make good decisions using objective and logical reasoning. Stability being their strength, in an organization they can become stressed when change is introduced and the Guardian is not given a good explanation why or it does not seem to meet the common sense rule.  They can also be stressed when others on their team do not follow what they know objectively to be right or rules are broken or severely stretched.

This does not mean that we have to act in one specific way.  I talk all the time about the fact that we are all of these temperaments.  I can’t emphasize this enough.  We naturally prefer some over the others and when we focus on our most natural or preferred ways of doing things we can often overlook a better way if there is one. We should work to be comfortable being uncomfortable.  When we need to act a different way, a way that may not be most natural for us, we should be able to get out of our own comfort zone, or most comfortable temperament and switch to a more appropriate way of handling the situation. What this means to leadership can be significant as we look at why one person or another may not make what the leader feels is a natural decision. Instead they don’t seem to recognize what others see as obvious.  Our natural tendencies may draw our attention to decisions that only meet one or two of the four techniques for paying attention and making good decisions.

What do you think?

 

 

Recently I was fortunate enough to present Safety classes at HAI’s Heli-Expo in Dallas and AMTC in Charlotte. What awesome experiences they both were allowing me to meet some super people.   Toward the end of each class I asked for assistance from the participants as I am conducting a study into the risk personality types and general risk tolerance of helicopter pilots and more specifically air medical crew members. I believe, and preliminary findings are supporting this, that this study could easily lead to a better understanding of cockpit communications and improved CRM/AMRM, especially in the Helicopter Air Ambulance Industry where non pilot crew members are an integral part of the flight crew.

If you are either a helicopter pilot or an air medical crew member, your participation would be invaluable. I have been conducting this study for over a year now so if you have already taken it, thank you so much. If you would like a copy of your report for the Risk Type Compass just let me know when you have completed it and I can send it to you. If you have a crew or team take it, provide their names once they are complete and I can even send a team report.  If you have any questions please feel free to contact me directly.

Thank You and please complete BOTH STEPS below;

Step 1. Click here (https://www.surveymonkey.com/r/Helicopterrisks) to take the Demographics Survey.  Study Instructions — To participate, start with taking this short survey to help me gain some basic demographics. At the end you will be asked to provide an email address to connect the survey with the questionnaire. If you DO NOT wish to provide your email address and name, you may replace them in both the survey and Risk Type questionnaire with a unique PIN number of your choosing. It should be at least 4 digits long and exactly the same in both the survey and questionnaire so that when they are both complete we can match them up for statistical comparison. However, if you would like your results I will need your email address and name, but that is the only thing they will be used for. Also if you want your results of the Risk Type Compass please email me to let me know that.

Step 2. Click here  (http://www.psy-key.com/) to take the online Risk Type Compass®.    Please follow the instructions below and again use the same unique PIN, or your email and name, as you did in the survey.

Enter access code: RTCKCPILOTS then click continue.

Follow the on-screen instructions

Completing just the survey does not provide enough information and will be discarded without the Risk Type Compass being completed. The survey and questionnaire together should take between 20 to 30 minutes so please ensure that you have sufficient time to devote to uninterrupted completion of the assessment.

Thanks ahead of time for your participation. I appreciate it very much and I am excited about how we can use this data to enhance training and safety.

If you have any questions or want to know more, please contact me below.  If you call please leave a message if I do not answer, as I may be out on a flight myself.  I will get back with you as soon as possible.

 

If there is anything else I can do for you or your flight program, please let me know.

 

A diverse team at work at an accident scene.  Every individual here, EMT's, firefighters, bystanders, ground and air responders bring different personalities to the scene and have to find a way to work together.

A diverse team at work at an accident scene. Every individual here, EMT’s, firefighters, bystanders, ground and air responders bring different personalities to the scene and have to find a way to work together.

Air Medical Resource Management (AMRM) or Crew Resource Management (CRM) is something that is done daily, on every flight, and every transport. AMRM/CRM is how we communicate and make decisions in the helicopter or vehicles with our crew members, and how we communicate with others that impact the flight or transport like mechanics, communication specialists, administrators, emergency room personnel and the patient.

AMRM/CRM Training is the yearly requirement. The difference is significant and the confusion is something that I hear and see often when talking to individuals about AMRM. There are a lot of people who feel AMRM is something that we do once a year in a classroom and then we are done with that requirement for another year. This came to my attention recently when I was asked in an email for my opinion on whether or not AMRM is the training we get every year. The writer states;

“many people say that this knowledge is just part of AMRM and already covered. I think the application of this knowledge is AMRM, but not how the knowledge is acquired. What is your thought on whether AMRM includes the knowledge acquisition?”

Here is my response.

I think a lot of people, especially administrators, feel that AMRM is another task needed to meet FAA and certification requirements.  When treated as a task or required class it is nothing more than knowledge without application.  It is the application of that knowledge that is so important.  AMRM and CRM are ways of communicating not a class on communication.  You stated “I think the application of this knowledge is AMRM, but not how the knowledge is acquired.”   You are absolutely correct in the statement that the application of the knowledge gained is AMRM. But the second half of the statement can actually be labeled as AMRM TRAINING.  It seems we always want to shorten things and in this case AMRM training simply gets shortened to AMRM.  Therefore most people equate AMRM with the training or way of gaining knowledge and as instructors we tend to forget to focus on teaching how to apply that gained knowledge. 

So to answer your last question, AMRM does not include the knowledge acquisition per se, but instead is the actual application of that knowledge.  Here is another way to look at it.  I can bring a video on how to play soccer and teach a class on it but we are not playing soccer until we go out and apply that knowledge.  AMRM is not the same as AMRM training for the same reason. 

AMRM and CRM are integral in an organization with a strong safety culture. AMRM training is a small but important part of AMRM that should never be treated as just another yearly requirement or catch phrase. It is the application of that training that becomes a way of life for a group of professionals that not only talk the talk but walk the walk of safety.

One of the best things about my military career has been the variety of assignments that I have experienced. When I retired from the Army I started a small consulting business utilizing my training in leadership, team and personality training experience and built upon my final assignment as the Chief of Leadership Training for  the Army Reserve’s Readiness Training Command.  Unfortunately it did not take off well and in a short time I was looking for an actually paying job.  Fortunately with a Sunday morning phone call the day before I would have accepted a full-time job an old Army buddy asked me if I was interested in flying again.   A couple of months later I started flying helicopters again although this time it was for a hospital instead of the Army and I was able to put to use flying skills I had learned in the Army that I did not think I would ever use again.  Now, over 6 years later I am bringing skills from both of these divergent lives together in something called Crew Resource Management (CRM) or Air Medical Resource Management (AMRM) training.

CRM and AMRM are both fancy names for team communications skills.  This is nothing new and has been around for quite some time.  What I believe is different is my approach to it.  You see for the past six years I have continued my quest to gain experience and knowledge in the areas that I pulled together originally to do business as a consultant; communications, team dynamics, conflict resolution, interaction styles, group decision-making and the like.  I have attended workshops and certification courses, earned a master’s degree in Education, and become certified in a diverse collection of personality assessment tools. Assessment tools that look at a person’s core values and behaviors, cognitive/decision-making processes, emotional intelligence, conflict/interaction modes, need for inclusion or control, and more.  More important than an assessment though is the ability to bring an understanding of how to apply the theories behind these assessments without worrying about the results.

While I personally like talking  and discussing CRM/AMRM, I have always felt that the HEMS industry in general are focusing on the wrong part of CRM/AMRM while many individuals see AMRM as just another mandated class turned into a yearly requirement.  What we are in fact trying to deal with is the difficult task of combining several individual personalities into one crew without giving them the knowledge( or even talking about it in a meaningful way) of how to do this.  The problem I see here is a lack of training and understanding in how much individual personality types affect a crew decision.

Advisory Circular 00-64 is the FAA’s Recommendation to the HEMS industry of what should be talked about in AMRM.  While not an overly large document, they spell out what topics should be addressed without mandating how to actually go about it.  But within the 18 page (approximately 6000 word) circular, is just one sentence and a smattering of inferences that talk about personality types.  The very next paragraph has all of two sentences on group dynamics, which should be addressed as much as individual personality types.  The topics of these two paragraphs influence almost every other topic of discussion in the circular.  So that you do not need to go look it up here are the two paragraphs or three sentences.  (Go here to see the actual AC 00-64)

Understanding of Basic Personality Types.  The type of personality defines “what” is important to an individual and significantly influences the way one makes a decision.

Understanding of Group Dynamics. The “group” may have its own way of making decisions. The group should be aware that perhaps their “informal” structure does in fact work in a formal organization.

My contention is simple here; I believe that these two paragraphs should be the focal point of a meaningful AMRM/CRM program and not just an “Oh, by the way…” This program is not about an annual “check the block” requirement that has to be met.  This program is not about how to fly, how to drive, how to administer to a patient, or how to be a communication specialist or a mechanic.  This program is not about pilots, ambulance drivers, medics, nurses, doctors, mechanics, comspecs, or administrators.  This program is about people.  About individual personalities that HAVE to come together as a group and deal with their varied and unique personalities in a meaningful way so the group dynamics on the crew can be such that they complete each and every patient transport, reposition, static display and demonstration safely.

This past fall I decided that I was going to stop standing on the sideline and became an AMRM instructor for the company I fly for.  More importantly this coming fall at the 2014 Air Medical Transportation Conference in Nashville TN, I have been selected to give two presentations on incorporating personality type and group dynamics as the focal point and not an afterthought of a meaningful AMRM/CRM training program.   The first one will be a six-hour pre-conference workshop incorporating a personality assessment and looking at how personalities affect the crew dynamics.  The second will be a one hour  education session and discuss how personalities affect team building in this industry. I recognize that this is a very new approach to an industry wide training program and a lot of education needs to be done yet. While I may not know where or how this will look 5 years from now, I do know that individual lives are at stake and it is those individual personalities that will either make a safe team or fail in that attempt depending on how they approach team dynamics.  I also know that we can no longer afford to have everyone learn about how they might best fit into a team through trial and error.

We as an industry cannot expect everyone to learn and treat the topic of AMRM the same way, although that is the goal.  It was one thing when we mainly concerned ourselves with one profession.  Pilots in general tend to be similar in personality or have figured out how to deal with training and certifications as just the way it is.  AMRM encompasses a whole new group of professionals that do not normally deal directly with the requirements of flight and yet they have been made an active and meaningful part of the crew.  Medical crew members have learned to speak a different language and have very different backgrounds and experiences from professional pilots. Likewise when actually performing the tasks they are hired to do, they often have very little time to focus on the flying business.

Thankfully, using a simple model of personality as a bridge between the various groups of professionals involved allows for a common language that can easily be learned.  The one thing we all have in common in the air medical industry is that we are all different.  As an aviation unit operations officer for the US Army I was once told that I had a personality conflict with an individual that I absolutely had to work with daily, and that I should get over it.  So instead of ignoring this or writing it off as something for you to get over, I am proposing that we stop ignoring the individual personalities that are present in any team or crew.  Stop telling your teams that there is no “I” in team – The “I” is every individual team member.  What we should be teaching them is how we can turn a group of “I’s” into a cohesive team that they can proudly refer to as “we”.  Especially when they get done with a flight or transport, and in their post transport debrief can claim that “WE made a great decision tonight”.