Category: SAFETY MATTERS: An Online Magazine

“Safety Matters” is an online magazine created and authored by both MedFlight and HealthNet Aeromedical Services.

Sentry and Safety

Meade, Bev
Bev Meade, Flight Nurse, MedFlight

The granite & metal memorial dedicated to flight paramedic Shawn Baker, who passed away unexpectedly in 2010 from medical complications, stands like a sentry at the entrance to MedFlight 3’s base in Pomeroy, Ohio.  For me, it is a reminder, and a caution, of the fragility of life.   As I enter the base it also serves as a profound incentive to move situational awareness to the forefront of my actions for the coming shift.

MedFlight 3's memorial to Shawn Baker.
MedFlight 3 Base’s Memorial to Flight Paramedic Shawn Baker.

When we consider safety in critical care transport, we think of vehicle walk-arounds, safety belts, sterile cockpit, speed limits and more.  But do we consider that safety also involves listening, looking, and being aware when our team members are not at the top of their game?

Safety by definition is “the state of being safe, freedom from the occurrence or risk of injury, danger, or loss” (Webster Dictionary, 2019).  We complete an individual Risk Assessment (RA) during crew briefing at the beginning of our shift that includes our activity level, restfulness, previous 12 hours’ mission hours, and work days in a row that helps us identify the potential dangers associated with our cognizant and physical needs during our work hours. In addition, we need to listen to our colleagues during our conversations and observe indicators of their physical well-being.

Recently, I came to work with a nagging sinus issue that had not resolved after some home remedies (after all, I AM a seasoned nurse!).  I was not in pain or otherwise compromised but was just not feeling 100%.  After 20+ years of flying and ground transport, I had adopted “push forward, push forward” as my mantra and I continued my shift.  We received a mission request. We responded as usual with our safety walk-arounds and Crew Resource Management (CRM) in all phases of our flight. As we flew back to base following the mission, I experienced a pop in my left ear that quickly turned to intense discomfort.  We landed safely at the base, and I continued with the post-mission associated responsibilities even though I had essentially lost the hearing in my left ear by this time.  The paramedic I was partnered with for the shift had noticed the change in me and said “you seem a little off today. Are you okay?” That was all I needed to reevaluate my situation and be aware that I was giving less than my usual 100% to not only my team and organization, but perhaps to my patients as well.

The paramedic had acted as the “sentry” to my team member performance, and that brought safety to the forefront of my CRM contribution. I took some time to reevaluate what I was doing to myself and my team in terms of safety and wellness.  I announced to the pilot and paramedic that I was going home and needed to care for myself before I could care for our patients.

I suggest transport clinicians not only use risk assessment tools as a numerical identifier of “the risk of danger”, but also as an opportunity of listening, awareness, and observation of each other as well.

As I continue to be part of the MedFlight 3 team and Mobile ICU teams in our organization, I will hold the “sentry of safety” close to my heart.  Listen to each other and HEAR each other during your mission conversations and casual conversations, which helps fulfill a “Safety First” mission at your workplace.

mf3 sam
MedFlight 3’s base in Pomeroy, OH.  Partners For Life.  Photo Credit: Sam S.

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Better Lucky Than Good?

Justin Koper, M.S., GSP, MTSP-C, FP-C

Safety Officer, HealthNet Aeromedical Services

While attending the Safety 2019 conference in New Orleans, I had the opportunity to interact with some of the nearly 6,000 safety professionals in attendance.  During all of the networking, I was asked about the type of industry I worked in, to which I replied “air and ground ambulance services”.  Predictably, everyone remarked about the precarious nature of air medical operations, but very few made remarks about the dangers of ground ambulance operations.  Unfortunately, I feel this is an all too common misnomer even among our own ranks.  Yes, the consequences of a helicopter related incident are far more severe than ground incidents, but thankfully air incidents are far less frequent.

During routine ground EMS operations, crews are exposed to a multitude of hazards not commonly present in the aviation industry such as distracted drivers, impaired drivers, road rage incidents, drivers violating traffic laws, and the list goes on and on.  Despite these external threats that come at us day in and day out, I still routinely see crew members partake in at-risk behavior such as speeding, use of a mobile device behind the wheel, not using seat belts, etc.  There is an adage from law enforcement which says that for a criminal to not be caught, he or she must be lucky every single time, whereas the officer only has to be lucky once. This mindset holds true with complacency and at-risk behavior where the complacent individual has to be lucky every single time they engage in at-risk behavior in order to avoid a bad outcome whereas the threat or hazard only has to be lucky once to get through all of our defenses to cause a bad outcome.

For EMS as a whole to move past a reactive safety mindset to one that is focused on prevention, each employee must have an appreciation of the problems and hazards we face. They must also reinvest themselves into their organization’s safety culture.

Since the beginning of 2018, HealthTeam Critical Care Transport has closely monitored any and all vehicle related incidents so we can carefully analyze trends within our organization. The data listed below shows the total number of at-fault incidents from January 1st 2018 to May 31st 2019.

Base At Fault Incidents
Beckley (Opened Nov. ’18) 0
Charleston 16
Martinsburg 3
Morgantown 6
Moundsville 2
Petersburg 1
Total 28

Just looking at total number of incidents does not truly paint a picture of where our opportunities for improvement are at. During this time frame our program’s ambulances have logged more than 2.7 million miles so just looking at sheer number of incidents makes it difficult to identify trends or problem areas. Listed below are each of the bases incident rates per 100,000 miles driven. Please note that even though Moundsville Ground has the highest incident rate, they had not yet accumulated 100,000 miles in this time period.

Base At Fault Incident Rate
Moundsville 2.02
Charleston 1.67
Petersburg 0.98
Morgantown 0.63
Martinsburg 0.53
Beckley 0.0
Company Average 1.02

With this data in mind, it is important to remember that each one of these incidents were preventable and many were the result of complacency.  Backing incidents, overhead strikes (driving under awnings) and sideswiping objects (cutting corners too close) accounted for 83% of our overall at-fault incidents.  It is also important to note that this data does not include the two at-fault collisions which occurred in July 2019.

What we have experienced within HealthTeam Critical Care Transport is like the rest of the EMS industry in terms of causal factors and preventability of incidents. According to NIOSH, backing incidents were the cause of 25% of all vehicle accidents even though we drive forwards 99% of the time.

Now that the extent of the problem is known, the next logical question is what we can do to make things better. Considering all the at-fault incidents were the result of unsafe actions or complacency, the answer is simply personal accountability. You have a responsibility to yourself and your partner to operate in accordance with the law and policy and failure to abide by them places everyone at an unacceptable level of risk. If you notice your partner taking unsafe actions, you need to hold them accountable in order to ensure everyone’s safety. We, as a program, have tried to instill the principle that safety is fundamental to our culture, but it only works when people are accountable for their actions and don’t rely on blind luck for a good outcome.

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Are YOU Making Your Patients Sick?

Karen Swecker

Infection Control Liaison, MedFlight

 The cost of healthcare acquired infections is great.  A Boeing 747 crash once a week for an entire year is equal to the number of people dying from a healthcare acquired infection (HAI).  The latest statistics show approximately 23,000 people die each year due to an infection, such as pneumonia, bloodstream infection or a urinary tract infection contracted while receiving healthcare.  Adding healthcare costs, lost wages, legal costs and other patient factors the annual cost of an HAI is between $96 to $147 billion.

Three of the most common HAIs are ventilator associated pneumonia (VAP), catheter related bloodstream infection (CRBSI) and catheter related urinary tract infection (CAUTI).

A VAP is defined as a pneumonia that develops 48 to 72 hours after intubation.  Chart reviews estimate VAP as being the cause of 50% of all hospital acquired pneumonia, occurring in up to 27% of ventilated patients.  Mortality rates vary ranging from 33% to 50%.  A 2017 meta-analysis showed the average cost of an ICU stay was $19,000, compared to $80,000 for an ICU patient with a VAP.  Bacteria begin to form biofilms on the ET tube within hours of insertion.  The type of bacteria most frequently causing VAPs include Staphylococcus, Enterococcus, Enterobacteriaceae, Pseudomonas and Acinetobacter.  Bacteria migrates from the oral cavity to the stomach then to the esophagus and is aspirated into the lungs.

Costs for a CRBSI range between $17,896 to $48,108 with an increased 10 days length of stay.  A CRBSI increased mortality rates to 150 deaths per 1000 central line patients.  In 2017 there were an estimated 119,247 CRBSI due to Staphylococcus aureus with an associated 19,832 deaths.  Staphylococcus, including MRSA, is the number one bacteria causing CRBSIs followed closely by Pseudomonas, Enterococci, Klebsiella and AcinetobacterInfections are due to bacteria migrating down the IV catheter or central line, contamination of the catheter at insertion or contamination of the IV tubing ports. All may lead to the formation of biofilm on the catheter.  Intraosseous devices cause bloodstream infections approximately 0.6%.  IO infections are typically due to prolonged use.

Another common cause of HAIs is urinary catheters. The incidence of CAUTIs in the US is approximately 4.40 per every 1000 urinary catheter days.  The cost of a CAUTI ranges from $800 to $10,197 depending on location of the patient, increased length of stay and comorbidities and complications such as sepsis due to the CAUTI.  Gram negative bacteria – E. coli, Pseudomonas, Klebsiella along with Candida species were the most common pathogenic causes.

What you can do to protect your patients:

  • Hand hygiene with frequent glove changes. Remember to change gloves between tasks and between patients
  • Elevate the head of the bed at least 30o for ventilated patients if not contraindicated by:
    • Spinal fracture or injury
    • Open abdomen
  • Perform subglottal suctioning when adjusting the tube or balloon
  • Insertion of an IV or IO is a sterile procedure – you are introducing a sterile product (IV/IO cath) into a sterile site.
    • Make sure to prep the site as thoroughly as possible
    • Do not use tape that’s been in your pockets or thrown in a bag. Tape is easily contaminated with bacteria
  • Scrub the hub – don’t just do a promissory swipe with an alcohol pad. Use friction for at least 10 to 15 seconds
  • Keep the urinary catheter bag below the level of the bladder. This may take some creativity – at the very least do not place the collection bag on the abdomen or carry it above the cot
  • Do not “break” the system – do not separate the catheter from the collection bag
  • Empty aseptically – clean the spigot with and alcohol wipe; do not touch the spigot to the container

 

These are simple, easy to accomplish methods to protect your patients from a healthcare associated infection.

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Transporting Infectious Patients

by Karen Swecker, RN, Infectious Control Liaison at MedFlight.

Would you be able to recognize an infectious patient?  At this time outbreaks of vaccine preventable diseases such as chickenpox, measles, diptheria, and polio are occurring in several countries in Europe, Asia, the Middle East and the African continent.  In the U.S. the evening news has been reporting an ongoing outbreak of measles – more than 465 cases as of April 4, 2019.  A health threat anywhere is a health threat everywhere” is the statement from a 2018 conference of infectious disease physicians from across the world.  In today’s world of frequent international travel previously eliminated disease outbreaks in the U.S. are increasing.  Your chance of seeing a case of the measles, diptheria, chickenpox or even polio are increasing.  Would you be able to identify and protect yourself and others from one of these diseases during a patient transport?

 

Measles is a very contagious, acute viral respiratory illness that was eliminated in the U.S. from 2000 to 2008.  Before vaccine availability, the U.S. averaged 549,000 cases of measles with approximately 500 related deaths annually.  (The CDC states due to unreported cases the count of measles cases was in actuality closer to 3 to 4 million.)  Of the reported cases, 48,000 were hospitalized and 1000 people developed chronic disabilities due to acute encephalitis.  Signs and symptoms of the measles include:

  • Fever – may be up to 105oF
  • Malaise
  • “3 C’s” – cough, coryza (runny nose) and conjunctivitis (pink eye)
  • Koplik spots – white spots inside the mouth that look like tiny grains of sand surrounded by a red ring.
  • Maculopapular rash that appears about 14 days after exposure. Spreads from the head to the trunk to the extremities.  The immunocompromised typically do not develop the rash.

 

measles 1
Measles

Chickenpox is a very contagious, vaccine preventable disease.  Before the vaccine approximately 4 million people in the U.S. got chickenpox each year, more than 10,500 of those were hospitalized and 100-150 died each year.  Side effects of the disease include skin infections (may have more than 500 blisters), dehydration, pneumonia and encephalitis.  Symptoms last 7 to 10 days and include:

  • Infectious 1 to 2 days before rash begins
  • May start as “cold” symptoms – runny nose, sneezing, cough before rash begins
  • Itchy rash of blisters, appears as very small red pimples that rapidly spread
  • Fever
  • Headache
  • Malaise
cp1
Chickenpox

Diptheria is very infectious bacteria whose toxin causes tissue death which creates a thick grey membrane.  This membrane may cover the back of the throat, tonsils, or larynx which leads to difficulty breathing, swallowing and speaking.  The bacterial toxin may also go systemic and cause damage to the heart, nerves and kidneys.  Before the vaccine (tetanus/diptheria/pertussis) there were more than 200,000 cases in the U.S. annually with more than 15,000 deaths.  Although still rare in the U.S., many countries continue with cases – more than 7,000 cases occur worldwide annually.  The overall death rate from diptheria is 5%-10%, with a fatality rate of 20% for those under 5 and over 40.  Diptheria is transmitted person to person via respiratory droplets from coughing or sneezing and via contact with contaminated surfaces or objects.  Symptoms begin 2 to 10 days after exposure, can involve any mucus membrane including the tonsils and include:

  • Weakness
  • Sore throat
  • Fever
  • Swollen glands in the neck
diptheria 1
Diptheria

Polio is an infectious disease that is crippling and potentially deadly.  It is caused by a virus that easily spreads from person to person mainly via fecal/oral route, although it is also transmitted through contaminated food or water.  Polio multiplies in the intestinal track then invades the nervous system where it can cause permanent paralysis within a few hours.  In the pre-vaccine years of the 1950s, polio outbreaks caused more than 15,000 cases of paralysis each year.  Due to vaccination there have been no polio cases originating in the U.S. since 1979.  In 1993 there was one case imported into the U.S. via an unvaccinated person who traveled to a country with wide spread polio.  Due to vaccine, the number of cases worldwide has dramatically decreased (33 reported in 2018).  However, as long as there is one case the unvaccinated are at risk.  There is no cure for polio and 1 in 200 infections will result in permanent paralysis.  Symptoms include:

·                     Fever ·                     Fatigue
·                     Headache ·                     Vomiting
·                     Stiff neck ·                     Pain in the limbs

 

What you can do to protect yourself and others from these diseases. 

  • Make sure you and your family’s vaccines are up to date.
  • Familiarize yourself with signs/symptoms of rarely seen communicable diseases.
  • Use airborne precautions If a patient has any of these signs/symptoms – wear a fit tested N95 mask, place a surgical mask on the patient if tolerated.
  • Use contact precautions which include gowns and gloves. Remember not to touch surfaces with contaminated gloves.
  • Thoroughly disinfect surfaces and equipment. Use EPA approved disinfectant wipes or sprays to clean surfaces.  Change wipes frequently as the wipes quickly become contaminated and will spread the germs instead of removing them.

Sources:  www.cdc.gov; www.who.org

 

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A Lynyrd Skynyrd Case Study in Safety

by Amanda Ball, MedFlight Safety Officer

 

lynyrd-skynyrd-crash-d345126c-fe0d-4fde-8f0d-a9ce89f8ea3a
What can we learn from this rock band’s fatal plane crash?

While on their way to a show in 1977, the band’s chartered private plan ran out of fuel, and both engines failed… Causing a freefall from 4,500 ft cruising altitude.  Several on-board were killed on impact, including the band’s lead singer, shocking their friends, family, and fans… as well as the aviation industry.  What happened?  Why?  How?

The band’s management had advised that the plane they normally chartered was being replaced with a newer, more “trustworthy” aircraft after this concert.  But this concert was going to be a big one, and the pressure was on to be there.

 

BAND STATEMENTS PRIOR TO FLIGHT:
“The flames shooting out of the engine 2 days earlier didn’t make me very confident.”
“We were afraid to get on the plane, but didn’t know any better.”
“Something’s not right.”
“Aerosmith previously used this plane, and the pilots had questioned its flight worthiness.”
“I didn’t see the pilots check it out before they climbed in.”
AND FINALLY…
“Let’s go anyway, man.  We’ve got a gig to do.”

 

NTSB FINDINGS:
Inadequate fuel planning.
Aircraft was last checked 2 days prior to flight.
High, and unnoticed, fuel consumption by one of the engines during the flight.
Poor flight path planning prior to takeoff.
Continued flight with minimal fuel, overflying several airports with fuel resources.
Negligence or ignorance in regards to engine instruments.
Passengers entering and exiting cockpit.

 

SURVIVING BAND MEMBER STATEMENT AFTER THE CRASH:
“There were a lot of people on the plane that knew something was wrong, but we all kind of followed each other, and that’s where we made our mistake.”

 

There have been many speculations on what led to this incident… Pressure on the pilots to get the band to their destination, a rowdy culture that quite possibly caused distraction in the cockpit, lack of accountability in maintaining the plane’s airworthiness, and more.

 

Discuss with your transport team:  Do you see similarities to the pressures and challenges in our industry?  What factors may have played into this incident?  What measures does your organization have in place to enhance safe operations, reduce distraction, maintain vehicle quality and remove customer and financial pressure when reviewing transport requests?

 

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ECHO Safety Team

By Jeff White, M.S., MTSP-C, FP-C.  Director of Safety, HealthNet Aeromedical Services

Every Coast Helicopter Operations (ECHO) has evolved into a driving force for our industry.  The organization was created by flight crews as an opportunity to collaborate on safety, training, and come together to share ideas to become better clinicians and patient care providers.  ECHO encompasses all public safety aviation, which includes law enforcement, search and rescue, and military members and provides free to low-cost education, high quality training programs, crew member and program support, and networking opportunities to public safety aviation members around the world.

As an added service for the industry, ECHO has developed a safety team to travel the country to assist agencies with an unbiased mindset to build internal safety management systems, complete safety and crew resource management training for agencies, etc.

Driven by CAMTS and the FAA, companies are now required to have their own safety programs that integrate into their operator’s safety program. This will create a more controllable safety program for a company’s specific area and hazards encountered.

This team will continue to grow and drive safety bringing it to the forefront of the industry and is another service for the aeromedical industry provided by the aeromedical industry.

The ECHO Safety Team is comprised of members from across

the country and includes:

Veronica Marzonie, Team Director: RN, LifeFlight of Maine

Ron Folse: Pilot, Orange County Florida Sheriff’s Office

Rachel Tester: Pilot/Paramedic, Tennessee

Brian Ceraolo: Business Development Manager for LifeForce, Tennessee

Justin Koper: Flight Paramedic and Safety Officer for HealthNet Aeromedical Services, West Virginia

Joey Loehner: EMS Planning Officer and Flight Paramedic for Humboldt General Hospital EMS, Nevada

Jeffrey White: Flight Paramedic and Director of Safety for HealthNet Aeromedical Services, West Virginia

Rhett Draehn: Safety Director of Air Division for CareFlite, Texas

ECHO Safety Team

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Crew Resource Management in IIMC

by Dave Corbi, MedFlight 4 Pilot

Inadvertent Instrument Meteorological Condition (IIMC) is a potentially deadly situation that flight teams may encounter while operating in marginal weather conditions.  According to a recent FAA study: “Tests conducted with qualified instrument pilots indicated that it can take as long as 35 seconds to establish full control via instruments once visual reference to the horizon is lost.”  While MedFlight operates under visual flight rules (VFR), each pilot is instrument-rated and trained to fly in IIMC conditions.

The pilot is always in command of the aircraft.  However, safe operations is everyone’s responsibility, and everyone on-board the helicopter should have a vested interest in the safe completion of every flight. These crew resource management (CRM) actions during an IIMC event may assist the pilot and ultimately the safe completion of the flight:

  1.  A clinical team member’s actions should always support the pilot’s actions.  Keep the pilot situationally aware of deteriorating weather conditions. An example could be telling the pilot, “I can’t see the horizon any longer from the 2 o’clock to 5 o’clock position”.
  2. If the pilot is task-saturated, they may need you to make radio calls for them or perform other duties as requested. You may be asked to select and program frequencies or request assistance with air traffic control. Calls to your program’s communication center or operational control center are secondary to this radio traffic and should be completed following primary calls to local ATC.
  3. Assist in setting the aircraft GPS or communication radios as requested.
  4. Access information from the aviation resource manual or tablet and provide the pilot with requested information, such as frequencies, instrument approach plates and sectional charts.
  5. Ensure there is clear and concise communication between all team members on-board, and remain situationally-aware of the conditions you find yourself operating in.

It is important for crewmembers to understand IIMC avoidance and recovery procedures. Every crew member’s experience and knowledge can be helpful in the successful outcome of any in-flight emergency..  Take time regularly to train as a team, know where to locate and how to operate the above resources on your aircraft, and ask your pilot questions during your shift about these procedures.

Good crew resource management REQUIRES that you speak up when you have a concern.  Do not let lack of experience, or pressure to accept a flight in less-than-ideal weather, influence your decision-making.  Always trust your gut.  Remember: “Three to go, one to say no.”

corbi
Author Note:  Dave Corbi has worked as a helicopter pilot for MedFlight since 2001.  He also currently serves as the Battalion Standardization Pilot and Instrument Examiner with the Ohio Army National Guard.

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