Air Medical Safety

In depth

The one-page summary above is what the PDF prints. These sections go further.

Patient and equipment restraint

CAMTS requires air patients to be held by at least three cross straps, at the chest, hips and knees. A patient loaded head forward also wears a shoulder harness in both helicopters and airplanes, so a sudden stop cannot slide him toward the bulkhead; for patients loaded feet forward in a helicopter a foot bag is encouraged. Belts must be adjustable along the stretcher so they can be placed around an injury or a pregnancy: the belt is moved, never dropped. In late pregnancy the hip strap goes low across the bony pelvis, below the uterus, so a hard landing loads the pelvis instead of the fundus. A pelvic binder likewise changes where the hip strap sits, not whether it is used.

• Children under 40 lb (18 kg) ride in a restraint sized for height and weight that is itself locked down; 10 to 40 lb (4.5 to 18 kg) in a five-point device that allows access from all sides and the head raised 30 degrees; infants under 10 lb in a pod, car bed or heated bed; a car seat needs an approved safety label
• The stretcher must carry the 95th percentile adult full length (CAMTS estimates 177 cm and 110 kg, 242 lb), be rigid enough for CPR and raise the head at least 30 degrees
• Program policy states the maximum gross weight on the stretcher, patient and equipment together, per the manufacturer. A patient whose weight alone exceeds it needs a bariatric-rated platform and vehicle; extra straps or moving monitors off the stretcher do not change what the frame and floor locks are rated to hold
• Equipment goes in its engineered mount whenever one exists, for all vehicle movement; otherwise a clamp, rated strap, weight-rated carabiner or bracket to the vehicle or stretcher
• Straps used for equipment must hold its weight to at least 5 g; Velcro is never the primary or only restraint and bungee cords are not acceptable
• Equipment never shares the patient's seat belt and never rides at the head, on the rails, or between, beneath or on top of the legs; chargers and battery packs are secured too
• Soft packs are not stored with belts through their handles (handles tear); rated cargo nets are strongly preferred for bags
• A secured portable oxygen tank with a delivery device is carried so oxygen continues into the receiving unit; it is never secured between the patient's legs or right beside the patient while moving, and it may serve as the backup supply if it is reachable in the cabin
• Helmet intercom cords are not hardwired: a disconnect allows a clean separation during egress, and the cord is kept clear of controls and equipment

Weight and balance belong to the pilot, who can only account for what the crew reports. CAMTS requires a policy that the pilot is told the weight of every person aboard, all carry-on baggage and equipment, and any add-on equipment such as a second pump module or a balloon pump console. Patient weight and extra equipment are among the few patient details the pilot is given, because they are operational; the patient's condition and age are otherwise kept from the pilot at the time of the request.

Passengers, riders and specialty crew

14 CFR 135.117 has the pilot in command make sure every passenger is orally briefed before each takeoff on smoking, seat belts (how to fasten and release them and when they must be worn), the location and opening of the doors and emergency exits, survival equipment, fire extinguishers, ditching and flotation for extended overwater flight, and the normal and emergency use of oxygen above 12,000 ft MSL; printed cards supplement the briefing. A family member is briefed like any passenger; clinical details are not part of it.

• Overwater: beyond autorotational distance from the shoreline, the briefing adds life preservers, ditching and exit from the rotorcraft after a ditching (135.117(a)(9)), and each occupant wears an approved life preserver with a locator light except a patient for whom it is medically inadvisable (135.168). The briefing is given before takeoff, not at cruise, and recent egress training does not replace it
• FAA AC 135-14B suggests briefing for any overwater flight, even within autorotational distance; CAMTS strongly encourages easily reached preservers from takeoff until clear of the water and requires water egress training where routes routinely cross large bodies of water
• Medical personnel (135.621): before each helicopter air ambulance flight the pilot or a designated crew member briefs them on the passenger items plus flight physiology, loading, safety around the helicopter, in-flight emergencies, emergency landing and evacuation, and communication with the pilot. Only the items beyond the passenger briefing may be skipped, and only if all medical personnel aboard completed the operator's FAA-approved training in the last 24 calendar months
• Specialty personnel added to the regular team (CAMTS names neonatal, pediatric, perinatal and IABP teams; an ECMO specialist is in the same position) need licensure and specialty experience, ride with at least one regularly scheduled crew member, receive a safety briefing before each transport and must know the program's safety and survival techniques for that aircraft (CAMTS)
• Carry-on baggage of a patient or passenger is physically inspected before loading for weapons, sharp objects, chemicals and other hazards; a description is not an inspection. Programs also need policies on firearms and on lithium-ion batteries aboard (CAMTS). Hikers' packs often hold stove fuel, lighters and sprays
• CAMTS requires a program policy for refusing to carry any patient, family member or other rider who could endanger the flight or the crew. An intoxicated or aggressive rider cannot be separated from the crew in flight, so the decision is made on the ground; tell the family where the patient is going
• Accompanying family and other riders are identified and listed by name in the communications center; observers and media riders are covered by a policy on privacy, briefing, apparel and securing their belongings

Two patients: carrying a second patient must not compromise the airway, stabilization or emergency procedures for anyone aboard. A two-patient configuration needs access for simultaneous airway management, and programs keep written guidelines on which patients may ride where access is limited, based on weight, anticipated needs and position (CAMTS). The patient most likely to need the airway or an emergency procedure takes the full-access position; intubation does not remove that need.

Agitated and combative patients

CAMTS requires written protocols for the agitated or combative patient: physical restraints available and used for patients who may endanger themselves, the crew or the aircraft; judgment on when and how to restrain and when to medicate; the monitoring each requires; and tracking of incidents that caused a precautionary landing, a change of destination or an injury. Operational controls and communications equipment must be physically protected from interference, deliberate or accidental, by the patient, the crew or loose equipment.

• Before liftoff: a patient who is fighting on the ground is brought under control there, with restraints or medication under protocol, then reassessed; a cabin in flight offers no room to separate him from the crew
• In flight: a patient reaching for a door release or flight control is an immediate threat to the aircraft. Block the hazard physically and tell the pilot at once, then restrain or sedate under protocol; a precautionary landing is the pilot's decision
• New agitation after a head injury, or with alcohol aboard, can be hypoxia, hypoglycemia, pain or a worsening brain injury: recheck SpO₂, glucose and neurologic signs alongside sedation

Refueling

Rapid (hot) refueling, with engines or rotors running, is discouraged and allowed only for turbine helicopters on Jet A or Jet A-1 under written, trained procedures. FAA AC 135-14B and AC 91-32B: a qualified pilot stays at the controls throughout; the helicopter is bonded to the fuel source before fuel flows; patients are off-loaded to a safe location first, and if the pilot in command judges a patient must stay aboard, the engines are shut down and the aircraft is fueled with them off; nobody boards or leaves during rapid refueling; doors near the fuel ports stay closed; oxygen is not replenished while fueling; and with passengers aboard, airport rescue and firefighting is asked to stand by before fueling begins.

• AIM 10-2: no thunderstorms within 10 NM; electrical and electronic equipment placed in standby or off, and no radio transmissions (keying a microphone), remembering that radar, transponders, ADS-B, radar altimeters, DME and ELTs also transmit
• Ground power units are not connected or disconnected during refueling, and fuel servicing personnel carry no lighters or matches (AC 91-32B)
• CAMTS: refueling with an engine running, rotors turning or passengers aboard is not recommended (and is prohibited for ambulances), but programs must have rigid written procedures for when it happens
• With a patient aboard during refueling or a stopover, at least one medical crew member stays with the patient the whole time (CAMTS), so the airway, ventilator and infusions are never unattended and someone can evacuate him
• Rapid refueling is strongly encouraged only where the fuel port does not block patient and crew exits; the pilot verifies fuel quality and stays with the aircraft; gloves used for fueling are not used for patient care and fuel-soaked PPE stays out of the cabin

In-flight fire, smoke and lithium batteries

FAA AC 120-80A gives cabin crew a sequence: if flames are visible, fight the fire at once; someone immediately tells the flight crew what fire, smoke and smells are present and what is being done; if no flames are visible, find the base or source of the smoke. Smoke from panel seams or vents is a sure sign of a problem, and hot spots are found with the back of the hand. In fire tests, fires that spread into hidden areas became uncontrollable in as few as 8 to 10 minutes, and a crew may have as few as 15 to 20 minutes to get the aircraft down, so the first indication of fire should start planning for an emergency landing. The pilot can only begin that plan once told.

• Halon is the usual first extinguisher: multipurpose (Class A, B and C) and effective when the exact source cannot be found. It is generally not harmful to occupants, though high levels in a confined space can cause dizziness and impaired coordination. Water is not used on a fire thought to be from the aircraft's electrical system
• Lithium-ion cells can go into thermal runaway: a jet of flame, heavy smoke, explosion, and spread from cell to cell so the fire flares repeatedly
• Lithium battery fire, two phases (AC 120-80A): extinguish with a halon, halon-replacement or water extinguisher; then douse the device with water, an aqueous agent or another nonalcoholic liquid to cool the remaining cells. Putting out the flames does not stop thermal runaway in the cells that are left
• Do not pick up or move a smoking or burning device, and do not cover it or use ice: covering insulates it and makes more cells run away
• CAMTS requires training in smoke and firefighting in the cockpit and cabin and a program policy on lithium-ion batteries aboard

Emergency landing, crash and survival

CAMTS requires initial and recurrent aircraft safety training for medical crews, ideally with the aircraft present: evacuation (exits and emergency releases) including emergency shutdown of engines, radios, fuel switches, electrical systems and oxygen; fire suppression in flight and on the ground; in-flight emergency and emergency landing procedures (position, oxygen, securing equipment); the ELT; and survival and egress for the program's terrain, with hands-on survival practice at least every two years. Training for an incapacitated pilot is encouraged, and FAA AC 00-64 gives the example of knowing how to turn off the battery or work the radios when the pilot cannot.

• Seat belts, and shoulder harnesses where installed, are worn for every takeoff and landing; program policy defines when they may be unfastened (CAMTS). CAMTS also requires enough access and space to keep any patient's airway and ventilate from the crew member's belted seat. A crisis on short final is managed from the seat (for example bag-mask ventilation for a dislodged tube) and fixed on the ground
• Emergency landing: tighten the harness (snug, not slack), take the brace position, secure loose items; AC 91-32B says not to unbuckle until told and not to open any door unless the pilot or a crew member directs
• Incapacitated pilot after landing with rotors turning: the trained shutdown comes first, because a running helicopter with no one at the controls can move and the rotors make every task outside dangerous; then move and assess the pilot and call the communications center
• Post-crash with a fuel smell: shift the patient to bag ventilation and close the cabin oxygen shut-off (oxygen makes things burn much faster), then evacuate. Crash recovery training for responders covers fuel tank locations, cockpit and cabin oxygen shut-offs, egress and staying away from the aircraft battery (CAMTS)
• Fire on the ground (AIM 10-2-3): HEMS helicopters burn jet fuel; water controls heat and foam over fuel keeps vapors from igniting

Survival after a forced landing (CAA New Zealand survival booklet): check injuries, make sure the ELT or a personal locator beacon is on and working, leave the aircraft only if it is unsafe and move upwind; then shelter or signal, depending on the situation. The rule of threes sets priorities: about 3 minutes without air, 3 hours without shelter in extreme cold, 3 days without water, 3 weeks without food. It is usually better to stay with the aircraft unless fire, explosion or another hazard makes it unsafe, because searchers look for the aircraft and the beacon. A 406 MHz ELT is detected almost at once by satellite, can carry position data, and lets a search start within minutes rather than hours (AIM 6-2). Fire, if safe, gives warmth, a signal and something to do.

Flight following and multiple aircraft

The communications center follows every flight. CAMTS requires communication at least every 15 minutes in flight unless continuous automatic position tracking is used (with verbal checks at set times), and at least every 45 minutes on the ground; satellite tracking is strongly recommended and required for aircraft without a 406 MHz ELT. FAA AC 135-14B recommends position reports at most every 15 minutes in flight and 45 on the ground, notes an aircraft may be considered missing after about two missed reports, and says the longer the interval, the larger the area to search. A missed report starts the program's post-accident or overdue aircraft plan.

• Communications specialists ask the requester whether another aircraft is already coming to the same scene or hospital (CAMTS)
• Where no common frequency was arranged, inbound aircraft announce in the blind on 123.025 MHz or another agreed frequency from 10 minutes before arrival (CAMTS); AIM 10-2-4 has later helicopters call on 123.025 at least 10 NM from the LZ, monitor it throughout, and recommends 500 ft of altitude separation when orbiting
• Before leaving a scene or hospital the crew and pilot agree on diversion hospitals; one medical crew member watches for obstructions during the critical phases of flight
• Laser, drone or bird encounter (CAMTS policy): limit further exposure by leaving the area or other countermeasures, report promptly to local police or the FAA with a named person responsible, assess anyone struck by a laser for medical follow-up, and track every event for the safety committee

Preflight risk analysis and aviation weather

14 CFR 135.617 requires every helicopter air ambulance operator to use an FAA-approved preflight risk analysis covering route obstacles and terrain, landing zone conditions and fuel; human factors such as fatigue and life events; weather at departure, en route, destination and forecast; a procedure for finding out whether another operator refused the flight; and mitigation, including management approval when risk passes a set level. The pilot completes and signs it before the first leg. CAMTS extends risk assessment tools to every patient transport and to search and rescue, public relations, training, maintenance and repositioning flights, because the aircraft, weather and crew risks are the same with or without a patient.

• Turn-downs: AC 135-14B says ask why another operator declined and factor the reason in; a decline for maintenance or an unavailable pilot is not counted. CAMTS has programs ask requesters about prior turn-downs, share weather turn-downs, and tell the on-duty pilot at once of a weather turn-down. Patient condition stays out of the analysis
• Weather minimums: CAMTS requires day and night, local and cross-country visual minimums; 135.609 sets Class G minimums for helicopter air ambulances. Minimums are never launch criteria; the pilot has final authority and any crew member uncomfortable may ask to return to safer conditions
• Local flying area: up to 50 NM from a base, defined by features the pilot can identify; its lower minimums are available only to a pilot who passed the operator's examination on that area within the preceding 12 calendar months (terrain, obstructions, minimum safe altitudes, fog-prone areas, lighting, communications). Otherwise the cross-country minimums apply, even inside the area; an exam at another base does not carry over
• New and relief pilots: higher minimums strongly encouraged and their experience tracked (CAMTS); a decline by a newer pilot in weather a senior pilot accepted is the system working
• Weather is obtained by policy (routine checks, checks in marginal weather, trending), and current and forecast weather is part of a formal shift-change briefing among pilots, medical crew and communications specialists (CAMTS)

Fog forms when temperature and dew point become nearly equal and seldom forms when the spread exceeds 2 °C (4 °F), so a narrow spread on a clear, calm night makes fog likely at a valley scene even when the base is clear; AC 135-14B flags ground fog for off-airport scene flights. Structural ice forms when supercooled drops strike the airframe and freeze; on a wing, frost or ice no rougher than coarse sandpaper can cut lift about 30% and raise drag up to 40% (FAA-H-8083-28B). 14 CFR 135.227 bars taking off with frost, ice or snow on the rotor blades, and bars flying a helicopter under IFR into known or forecast icing, or under VFR into known icing, unless it is certificated and equipped for icing. A pilot report of ice on the route is icing already found there, so treat it as known icing; urgency changes nothing, and ground transport is the alternative.

Landing zones and ground hazards

LZ selection and ground-crew preparation are on EMS Operations. For the flight crew: the pilot normally orbits the scene at least once (high reconnaissance) to check wind and obstacles, and helicopters normally land into the wind (AIM 10-2-3), so the final approach can come from a direction the ground crew did not expect. An overflight is a survey, not a rejection: the zone stays exactly as the pilot saw it, and any change is asked for by radio. CAMTS requires programs to train public safety agencies in LZ preparation, high and low reconnaissance, approach and departure paths and crash recovery.

• Blinded by dust or a blowing object near the aircraft: stop and crouch lower, or better, sit down and wait for help (AC 91-32B). Walking blind can take a team toward the tail rotor or a low blade tip; backing up blind with a loaded stretcher is as dangerous
• Dust: firefighters wet down an extremely dusty LZ when available; ground personnel wear eye protection, hats come off and helmet chin straps are fastened (AIM 10-2-3). Brownout takes away the pilot's visual reference close to the ground
• Rapid (hot) loading and unloading need a written program policy, and everyone who helps wears hearing protection (CAMTS)
• Hazardous materials: the LZ is a safe distance from any downwind danger, the crew is told the material, and contaminated patients are decontaminated before loading (CAMTS, AIM)

Heliports

• Hospital helipads need at least two unobstructed approach and departure paths, 90 to 135 degrees apart and oriented to the prevailing wind, plus a lit windsock and required signs (no smoking, heliport warning, high noise, eye protection)
• Changes such as construction, cranes and new obstructions are communicated to every pilot who uses the pad, through a pilot memo book or a communications center database, with each acknowledgment recorded; photos of the pad give a baseline and train new pilots (CAMTS)
• Security: at least one person to keep bystanders from approaching the helicopter as it lands or lifts off, or a perimeter such as nonhazardous fencing or vegetation. A pad the public can reach is also monitored, by direct watch or closed-circuit TV; video recording is strongly encouraged. Signs supplement security, they do not replace it
• The route from pad to hospital is short, smooth and level; patient monitoring continues without interruption from helipad to hospital, and the crew carries what it needs for emergent care on the way. Keep the transport monitor on until the bedside handoff rather than switching on a windy pad or in an elevator
• Programs have policies for more than one aircraft at a heliport, staging, permission to land and lift off, and coordination with other air medical services

Debrief and safety culture

Under CAMTS every transport ends with a debrief. Communications staff join it when the problem involved communication, and maintenance when it involved the vehicle; the debrief is documented on paper or electronically and fed into the program's quality reporting system. Programs also identify and analyze adverse events and near misses, with a non-punitive way for staff to report hazards and root cause analysis of incidents. The aim is the system cause (a coordinate format, a missing read-back), not a person to blame, and a near miss counts even when the patient did well.

Critical care ground transport safety

• Surface weather: CAMTS requires a written policy on conditions that prohibit transport, such as zero visibility, high winds, weather advisories and highway patrol road closures, and on who may abort a transport for safety. Surface weather is scored in the risk assessment too; a stable patient waits at a hospital that can keep treating him rather than travel a closed or fogged-in road
• Seating: crew are belted whenever the vehicle moves unless an emergent patient condition prevents it; front seats always belted; overhead grab rails required. CAMTS strongly encourages individual seats that face forward or backward and advises against side-facing benches; where a bench is used, its belts are mounted at pelvic level and shoulder harnesses on it are discouraged
• Cot: the stretcher must lock into the vehicle so it cannot move in a crash; a flight stretcher that does not fit the ambulance's mount is swapped for that ambulance's cot rather than tied down. NIOSH-backed SAE crash test methods treat the patient cot, its floor mount and restraints as one system (J3027), separate from worker seating (J3026) and equipment mounts (J3043)
• Supporting ground ambulance (used when the aircraft is grounded or unsuitable): a checklist for working equipment and enough oxygen, a locked stretcher, bags and equipment secured, lights and siren only when the clinical crew asks, hands-free communications, everyone belted, EVOC training at least every two years (CAMTS)
• Crashes: written policies for coming upon a crash, for any accident with damage or injuries, and a mandatory drug test of the operator after any accident, regardless of fault. Operators complete an emergency vehicle operations course with defensive driving, and managers review driving records at least yearly; lights-and-siren use is tracked (CAMTS)

Crew motion sickness: CDC lists habituation as the most effective countermeasure, along with a view of the horizon, avoiding reading, limiting head movement and fresh air; sleep loss and alcohol make it worse, and the drugs that treat it sedate. Traveling rearward raised motion sickness in a crossover study (Salter 2019), so a crew member who becomes sick while charting facing backward faces forward if a seat allows, looks out at the horizon and stops reading.