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Do Smaller Aircraft Meet The Needs Of Our Patients?


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#1 NaCl

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Posted 09 August 2007 - 05:39 PM

For those who have flown, presently fly, or have compared the AS-350 to your own mode of air transportation, what are your opinions on using this aircraft for medical evacuation?

For many a ground provider, the thought of calling a flight team to take over on the really bad calls is a comforting feeling. Many feel that due to the extensive training, selection and experience, that rotor crews can perform intensive critical care en flight, like a flying ICU. I think the public and the local EMS community would actually be shocked at how handicapped providers are in the smaller aircraft like the A-Star or Bell Ranger. The confines of operating in this aircraft are understood, but I question if concerns over a diminished standard of care have ever been raised.

I grew up in the Phoenix area in the '80s when Samaritan Air Evac was literally writing the book (DOT Air Medical Curriculum) on HEMS. Those were the days of the BK-117 and BO-105, both comparatively larger ships that facilitated a dedicated medical suite and even a gurney of sorts. After the PHI acquisition, the '90s brought a shift to the tiny A-Stars and even some Ranger varieties in the Valley. This seemed intuitively like a step back. Now the patient was fanageled into the vacant space between the left rear seat and the co-pilot's area by means of a sled-like articulating backboard.

Procedures like starting another IV, managing peripheral wounds, splinting or the transportation of patients under traction, mid-flight intubation, and even chest compressions are not easily achieved if not impossible. Specialty calls like bariatric, neonatal, and cardiac-assist devices can be even more arduous if not impossible, simply due to space limitations. On more than one occasion as a ground medic in Southern Arizona, I would shuttle in a flight crew member left at a scene due to weight limitations in the hot summers there.

I understand that economy does play a large role in this. Most A-Star pilots I speak with, after coming to terms with the construction of the ship, favor the model. With variations like the B3 and Twin-Star, it does have a solid reputation as a dependable vehicle that has a decent power and range vs. operating costs. I have been told that this is the thrust of the A-Star's popularity with services.

The A-Star completely dominates HEMS is the Southwestern US. Other models like the EC-135 or 145, Bell 222, Agusta 109 or 119, and MD Explorer exist--but are the exception--not the rule. When I look at places like back East, I see organizations running S-76s and other elaborate ships for shorter flights over more favorable conditions. I have been told that certain states and EMS systems have put in regulations mandating larger or dual engine aircraft, but in absence of such, the services will not pay for these more expensive aircraft.

Are we, as a HEMS community, depriving our patients of necessary treatments, handicapping our clinicians efforts and/or prolonging scene times due to the limitations of this and other smaller helicopters? Does this become a standard of care issue? If we know that larger, more comfortably equipped ships are being employed in other parts of the country or in other countries, does a patient who is injured in New Mexico deserve a less accommodating evacuation vehicle than one in Florida or New Jersey?

I am submitting this for a systems discussion, not really trying to downplay the amazing things that the services who use A-Stars and Rangers accomplish. Please share your experiences. Thanks.
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#2 Mike Mims

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Posted 10 August 2007 - 03:19 AM

Brian B,
I'd be willing to bet every person that reads your thread would agree in some way or another.
This is an issue that has no easy explanation or quick fix though.
HEMS has increased so rapidly in the past 10 years that it's become a HUGE business and we all know in some areas are too saturated.
However, it does come down to profit.

Do I think a 206 or A-star is suitable for HEMS? for what our programs mission profile is, absolutely not.
I can only speak for us, just as I don't think ANY AC that doesn't have an air conditioner is suitable for anyone who operates in extreme heat, which these days are predominately nation wide.

If you're doing local scene flights and occasional interfacilty transfers then 206 or A-star, finacially, might be a better fit.
Do I think that a pt deserves a less accomidating AC than someone who is flown in a largers AC? No, just as I feel that a pt should receive the same medical treat at a smaller more rural hospital they would have got at a larger more urban facility.

It's not only limited to HEMS.
I know that there are alot of fire departments who would love to have a frontline pumper that flows 1500 gpm with a 50 gallon foam tank; a 750-gallon polypropylene water tank; 6,000 watt scene light system etc..... or the carbon fiber airtanks; external mics and modern turn-out gear etc.....

I guess they only thing that can keep us sane is knowing that we are doing the best at what we have.
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#3 flightnursesarah

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Posted 10 August 2007 - 04:10 AM

Coming from someone who has gone from a Bell 206, to a dual pilot S-76, to a single pilot IFR Bell 222 and Bell 230, I have to add the safety aspects to this (for pt and flight crew as well).

Is it really safe for everyone involved to only be flying with one engine? With no IFR and no autopilot? Is it safe to fly without air conditioning on weeks like this? Is it safe for your pilot to have a patient's feet right in their face?

As for doing procedures in the back of smaller aircraft-- I really don't remember how I did it! You have to be quite the contortionist. I generally work on the offense, anyway, and do every possible procedure on the ground--but there are always those "oops" and "oh sh#%!" And fitting an isolet or a patient with a traction splint in some of those models---forget it.

Those of us who do not have the constant discussion of financial gain shoved down their throats don't realize how good we have it.
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Sarah RN BSN CFRN
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#4 lems1169

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Posted 10 August 2007 - 04:26 AM

This a universal problem...medecine and economy don't mix together. Just like a good olive oil and water,
beat them as hard as you want, they'll separate as soon as you stop. I agree 100% /c Mike and his arguments-comments.

Part of the problem is that a good bunch of the folks who manage the $$ aren't in touch /c the work that goes on.

Now that being said doesn't mean that only creappy/greeddy are at the decision level, but there are few...

My 0.02 $ :mellow:
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#5 flightnursesarah

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Posted 10 August 2007 - 04:44 PM

Does anyone ever get a chance to take those $$$ guys on flights? We have done it a few times and it is an eye-opener for them.
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Sarah RN BSN CFRN
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#6 GregBeaty

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Posted 11 August 2007 - 08:42 PM

I've only ever worked on an AS-350 B2/B3. The posts above are correct, it's tight. I'd love to work in a blackhawk or huey. You know, something I could roller skate in between the pts in, but that's just not realistic. Brian you do make a good point though. I moved to the Southwest to fly. Most of the services back home in the Midwest are flying the Bk-117, EC-135, Dauphines, there are a few 407's but there are a lot of larger aircraft. As a newbie not only to the industry but also the Southwest USA I figure it’s “the norm.” But I wonder why? Oh well even if we do end up with the big, sexy, fast, ****** (insert your favorite aircraft,) the AStar will always be my first!
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Greg Beaty NR/CCEMT-P
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Posted 11 August 2007 - 09:23 PM

I have to agree. I understand that this topic has been covered in past threads; however, I have to agree with the other posts. The A Star is IMHO a suboptimal platform for the mission. In my non pilot opinion, I have several issues with the AStar: restricted patient access, weight limitations, single engine, single hydraulic pump, and limited space for storage are some of my concerns.

I also understand that HEMS is much like any other industry, and money is on of the most important aspects to consider. The AStar is much cheaper than its twin pack counterparts and maintenance is cheaper. So, I can understand why companies opt to go with the AStar or other similar platform. However, this does not mean that I agree with the practice.

With the accelerated growth of flight services, I can foresee many more regulation and policy changes at the federal, state, and local levels. Perhaps this will lead to positive changes.

With all of the AStar faults, I continue to fly and care for patients in AStars. So, I suppose this is a scenario where "the pot calls the kettle black." I will however continue to voice my opinion that twin engine aircraft should be a HEMS standard. I am not sure about configurations such as IFR equipped and certified aircraft; however, I would support policies that mandate enhanced safety.
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#8 NaCl

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Posted 11 August 2007 - 11:31 PM

The responses thus far have been enlightening. Thanks everyone.

I suspected it was tied to economies of scale, but I bet if I researched the laws regarding the licensing of HEMS in those states with the big, fancy ships, they are often there by mandate, not just altruism.
Hopefully it will not take the thumb of government pushing down on the industry to see upgraded aircraft. Pardon my optimism.
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#9 NaCl

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Posted 11 August 2007 - 11:37 PM

I'd love to work in a blackhawk or huey. You know, something I could roller skate in between the pts in, but that's just not realistic.



Hi Greg! Speaking of Blackhawks, thanks to your Silver City-based crew for getting our aircraft out of a bind a few weeks ago. I'm going to post a pubic thanks to ya'll on the the General Discussion forum.
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#10 Gila

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Posted 11 August 2007 - 11:51 PM

Brian B. are you with the 717th out of Santa Fe? I was a SGT with Det 4 and CATC and I know a few people from the 717th.

Oops, it looks like I posted as a guest above.
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#11 GregBeaty

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Posted 11 August 2007 - 11:59 PM

You're more than welcome Brian. I've really got a good group of professionals up here. Glad we could help. Feel free to drop in anytime!

Fly Safe.
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Greg Beaty NR/CCEMT-P
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Silver City, New Mexico

#12 NaCl

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Posted 12 August 2007 - 12:41 AM

Brian B. are you with the 717th out of Santa Fe? I was a SGT with Det 4 and CATC and I know a few people from the 717th.



Yeppers. But it's not the much-fabled 717th anymore... The Army is "transforming" its aviation assets and we took on a much less sexy unit designator last year:
Charlie Company MedEvac, First of the One Hundred Seventy-First General Support Aviation Battalion.
Say that on one breath!
Or, C-Co. 1/171st GSAB (AA) for short. :rolleyes:

Same guys, "new" name.:blink:
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#13 Mike MacKinnon

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Posted 12 August 2007 - 12:46 AM

hehe

what an interesting thread

well i have spoken on this topic on a number of occasions.

I think that I can 'get it done' in the A-Star. Im from Sam. Air Evac and got to see the BK -> Astar as well as the EC135. I think that the days of large ships are going away. Its all about profit now as they are all in it for profit.

I am not picking on PHi/Sam. Air Evac, they have been nothing but good to me. However, these changes always start somewhere. Many feel that other companies which came into the valley are the ones who dropped the standard. I tend to agree. They brought in crappy aircraft with extremely low operating costs in comparison to the BK or BO. In AZ, anyone can drop an aircraft next to anyone else, effectively splitting the calls instantly. Its impossible to compete with aircraft which are 3-4X as expensive.

Now some would say thats just smart buisness by these incoming companies. Thats hard to argue against as it IS a buisness. However, it really is harder with less access to work in these smaller machines. Does it make a huge difference in pt care... thats really hard to quantify. What it does do is make a huge different in provider comfort which may well impact pt care indirectly.

Again, hard to say. Everyone wants the ferrari but it isnt always practical or needed. I guess the question is where do you draw the line?
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#14 wyomed

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Posted 12 August 2007 - 02:48 AM

Really, that's the key question. Where do you draw the line? I have yet to work in an aircraft where I couldn't figure out a way to ge done what I needed to get done. In that respect, we're our own worst enemies. As long as we continue to be able to effectively do what we need to do, we will continue to operate out of smaller aircraft.

You can't argue with profit margins, like they say... money talks!

Steve
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#15 jbflightnurse

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Posted 12 August 2007 - 06:56 AM

I have, like some of the rest of you, flown in a 206/AS/407/222/230. Call me crazy but the AS350B3 is my fav. I think it's all whatever you can adapt to. I don't feel like I gave any "better" care in a 222 than I did in an AS. I'm sure there are some small facility ER folks that wish they had the big, state of the art, trauma rooms that some facilities have too, but you adapt and do the best you can. As far as the safety factor, I would like the pilots opinion on single vs dual engine RW. I think there is an illusion of being "safer" in a dual engine AC. In fact, I'll put a post out for the pilots so we can get their opinion. Anyways....my 2 cents is that I think you can do a good job anywhere.....it just depends on how determined you are.

Jan B.
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Posted 13 August 2007 - 01:28 AM

My history in A/c includes the UH-1, UH-60, BK, and various fixed wings from Lears to King-Airs. I have flown in the 206 but not during pt care (Heck of a Grand Canyon tour). I have, however, been around the medical variants of the 206 and A-Stars. Yes, I do believe that they are ill-suited for the HEMS mission. I have always had the best possible access to the patient(s) and continue to enjoy that luxury today. I could not see myself having to work around that bulkhead in the 206 (don't know if thats even possible). Have no experience with it. I do believe the A-Star is a much better platform than the 206 with the much better access but is still limited.

With regards to the issues of twin vs. single, I have been in the a/c when we lost an engine. Trust me, it is a feeling you do not want to have. Because we were in a twin, it was an uneventful controlled landing in an open area of our pilots choosing much further from where an autorotation would have occurred. Believe me, you want that second engine.

The A-star does present favorable opinions from pilots and crews in that it has good power and a short start/cool down time. I don't think I could ever give up my BK though. Especially with our cot system so we dont have to depend on the crappiest bed a receiving facility has sitting on the pad. You know the one I mean. The one that is a step away from the dumpster that hospitals leave by the pad for the incoming crews.

Just my humble opinion. I can understand the money flow options of some programs (or the money grubbers, your call) but in my opinion the line from top to bottom would look something like this - S-76, Bk/EC-145, EC-135, A-Star/EC-130, then way down the line would be a 206 only one step up from a Korean era Bell 47. I don't hate the A/C just don't believe it should be a HEMS A/C. Almost like having a medically interiored R-44.
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#17 justapilot

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Posted 13 August 2007 - 06:10 AM

Single vs Twin. Lots of agendas and lots of propaganda. Maybe on both sides of the issue. Here's a tip......follow the money.

I fly a twin. A well equipped, modern twin. I like it. It provides me with many effective tools and options that are designed to help me deal with various unforeseen situations that may arise during the course of a flight. It's not just an extra engine, it's an extra hydraulic system, fuel system, electrical system, fire suppression, autopilot, etc. Redundancy.

I won't enter the statistics/accident rate debate. (because it's too easy to skew) Suffice it to say that if I believed a single was safer, I'd be flying one tomorrow. I've got plenty of time in singles. Actually, I could make that change without even leaving my current employer. (In fact, I may have to change industry sectors (or at least employers) to stay in a twin if this current HEMS trend continues)

Does it not challenge common sense to claim that redundancy is undesirable or dangerous? It defies logic. Redundancy is a basic concept used in mechanical things to improve reliability. Machines break. Redundancy gives you a plan B. Pretty simple.

Twins do pose their own challenges and are not the "be-all, end-all" in and of themselves. Their systems tend to be more complex and they require an appropriate level of experience and "real" recurrent pilot training to proficiency. Do not try to run an IFR twin on a VFR single training budget. It will not end well.

I'm certainly not going to claim that a modern single engine turbine helicopter is unsafe or not capable. We typically don't hear that. Instead, what we do tend to hear is that a single is "just as good" as a twin, or something to that effect. The idea that a twin's redundancy only provides an "illusion" of safety is not something that I would agree with. A well maintained modern IFR twin with a proficient crew is a pretty good place to be.

The least expensive option is not always the best choice. It is, however, always the cheapest.


I have, like some of the rest of you, flown in a 206/AS/407/222/230. Call me crazy but the AS350B3 is my fav. I think it's all whatever you can adapt to. I don't feel like I gave any "better" care in a 222 than I did in an AS. I'm sure there are some small facility ER folks that wish they had the big, state of the art, trauma rooms that some facilities have too, but you adapt and do the best you can. As far as the safety factor, I would like the pilots opinion on single vs dual engine RW. I think there is an illusion of being "safer" in a dual engine AC. In fact, I'll put a post out for the pilots so we can get their opinion. Anyways....my 2 cents is that I think you can do a good job anywhere.....it just depends on how determined you are.

Jan B.


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#18 jbflightnurse

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Posted 13 August 2007 - 04:22 PM

Thanks for your input. As medical people (with or without common sense :rolleyes: ) we need your knowledge and expertise. Thank for sharing!!

Jan B.
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#19 Mike MacKinnon

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Posted 13 August 2007 - 07:16 PM

Nice post!

I love to see pilot input on these threads.

I would love hear what you think about the old twins vs the new ones. It is my understanding that old twins (like the BK) were not able to manage well on a single engine and thats what skewed the safety stats suggesting they were not any safer as singles. Now, however, the EC 135 can manage on a single engine. Is this correct?


Single vs Twin. Lots of agendas and lots of propaganda. Maybe on both sides of the issue. Here's a tip......follow the money.

I fly a twin. A well equipped, modern twin. I like it. It provides me with many effective tools and options that are designed to help me deal with various unforeseen situations that may arise during the course of a flight. It's not just an extra engine, it's an extra hydraulic system, fuel system, electrical system, fire suppression, autopilot, etc. Redundancy.

I won't enter the statistics/accident rate debate. (because it's too easy to skew) Suffice it to say that if I believed a single was safer, I'd be flying one tomorrow. I've got plenty of time in singles. Actually, I could make that change without even leaving my current employer. (In fact, I may have to change industry sectors (or at least employers) to stay in a twin if this current HEMS trend continues)

Does it not challenge common sense to claim that redundancy is undesirable or dangerous? It defies logic. Redundancy is a basic concept used in mechanical things to improve reliability. Machines break. Redundancy gives you a plan B. Pretty simple.

Twins do pose their own challenges and are not the "be-all, end-all" in and of themselves. Their systems tend to be more complex and they require an appropriate level of experience and "real" recurrent pilot training to proficiency. Do not try to run an IFR twin on a VFR single training budget. It will not end well.

I'm certainly not going to claim that a modern single engine turbine helicopter is unsafe or not capable. We typically don't hear that. Instead, what we do tend to hear is that a single is "just as good" as a twin, or something to that effect. The idea that a twin's redundancy only provides an "illusion" of safety is not something that I would agree with. A well maintained modern IFR twin with a proficient crew is a pretty good place to be.

The least expensive option is not always the best choice. It is, however, always the cheapest.


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Mike MacKinnon MSN CRNA
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It's what we know for sure that just ain't so" - Mark Twain

#20 safltrn

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Posted 14 August 2007 - 12:09 AM

Our program in Southern California has always used Twin Engine Aircraft such as the Bell 412, Bell 222 (B and U models) as well as the MD902's and even a BK at one stage. The counties that we serve in SoCal, insist that the aircraft that are used for the transport of patients ,are twin Engine. The bases that are located in the coastal areas need to be IFR twin engine aircraft to service calls further in the interior as well as out to sea where IFR approaches are utilised.
Many large corporations are looking at replacing many of the twin engine aircraft accross the country with the smaller Single engine AStars or similar. Hopefully though, the local regulations will ensure that we continue to fly larger more spacious airframes in the future. Looking forward to the new Bell 429's.
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