camts blog

Commission on Accreditation of Medical Transport Systems

Resilience During Times of Change

March 31,2020

by Eileen Frazer

reprinted from Air Medical Journal : http://www.airmedicaljournal.com/

In the Commission on Accreditation of Medical Transport Systems (CAMTS) 11th Edition Accreditation Standards, we included resilience training as part of stress management in the list of didactic education for managers and crewmembers, and we also included post−critical incident counseling in section 04.00.00 for communications specialists. In the current health care and economic change environments, care providers are not only challenged by adapting to change but also the “ordinary” stressors of dealing with emergency and life-critical situations.

It is more apparent than ever that managers (who also have to deal with a higher stress value) need to recognize and address employees who may not have resilience or the capability to “bounce back” after traumatic and tragic situations they deal with on a regular basis, often resulting in posttraumatic stress disorders.

In the CAMTS publication Safety and Quality in Medical Transport Systems: Creating an Effective Culture, the chapter entitled “Provider Resilience” was written by John Overton, MD, Laurie Shiparski, BSN, MS, and Philip Arthier, RN, MPH.1 The authors presented a self-assessment tool to identify the 10 symptoms of your capacity for resilience that is worth sharing.

Symptoms of low resilience Absent Present

  1. Forgetfulness and inability to access information you have
    learned to respond in the situation
  2. Inability to focus on individuals and the bigger picture of the situation
  3. Overwhelmed with emotion, uncontrollable crying, outbursts
    of anger, or frustration
  4. Complete sadness, sorrow, depression, despair
  5. Hopelessness, cynicism
  6. Inability to act on priorities
  7. Self-doubt about ability to impact the situation effectively
  8. All issues seem big and overwhelming
  9. Feeling alone and isolated Low energy, fatigue, exhaustion

According to the authors, if you answered “present” to any of the questions, it is time to focus on your resilience and stop any further progression of energy-draining behaviors.

In my opening paragraphs, I also talked about change. We know we do not function at our best when we are stressed and tired, and, on top of that, we are in the environment of constant change. When we consider the many changes we encounter, planned and unanticipated, it is even more critical to manage how we navigate through changes. The authors referenced earlier asked many health care providers how they effectively manage change in their personal and professional lives.

The following are the top responses they received that may sound familiar or interesting to our readers:

*I believe in myself and know I can handle any situation.
*The more I tap courage and act on it, the stronger I feel.
*I get enough rest and take care of myself.
*I find people I can talk to and find support.
*I recognize when I am feeling stressed & take a break, reassess, & adjust.
*I offer help to others and have an attitude of gratitude.
*I realize everything happens for a reason and I may not know why.
*I remind myself why I choose this profession & identify what brings joy.
*I know I make a difference in the lives of many with the work I do *Humor and fun help me get through tough times.
*I learn from every situation and seek challenges that grow me.
*When something feels overwhelming, I remind myself that I can break it
down into smaller manageable steps.
*I know time heals and sometimes I need to detach, think, and come back
to issues.
*I show up every day with all my talents and flaws, knowing it is all needed.
*I remember to have patience with myself and others as we adjust to new
things.
*I resist engaging in judgment and blame of myself and others.
*I notice now if I am in a downward spiral of negative thinking or being and remind myself to engage in energizing behaviors.

We are all called on to deal with stress and change. The Executive Staff of CAMTS recently recognized that we also need to be aware of site surveyors who may be asked to visit a program that experienced a recent fatal accident where interaction with management and staff can be very emotional. Having an open and caring culture is always our goal and we encourage surveyors to relate situations that dealt with difficult and
emotional situations. Storytelling is always a way to release stress.

Helicopters & Tents. DO NOT MIX!

Don’t set up Emergency COVID -19 Triage “Tents” Too Close To Your Heliport

March 27, 2020

by Rex Alexander

Helicopters produce a significant amount of downwash (rotor-wash) during takeoff, landing and hovering operations.  The velocity of this rotor-wash is directly proportional to a  helicopter’s size and weight.  Even a small helicopter’s rotor-wash can cause serious damage and inflict injury under the right circumstances. 

In 2018 at Fort Hunter Liggett, California the U.S. Army had 22 soldiers injured when a helicopter landed too close to the tent that they were occupying when it collapsed. 

Even when a tent stays in place, the laws of physics and aerodynamics are destined to displace every ounce of loose, unsecured and light to medium weight material located inside to the outside in a matter seconds. 

It is not just the location of the heliport in relationship to a tent that is of importance here.  The flight path of the helicopter must be taken into careful consideration as well.  As a helicopter is landing or taking off it is producing rotor-wash below it which can stay intact for up to a hundred feet or so.

Rotor wash is also greatly influenced by the wind and will travel in the direction the wind is blowing.  

The threat is two-fold:

  1. The helicopter can ingest loose items such as towels, blankets, trash bags, jackets and even the tent itself into the main and tail rotor systems with catastrophic consequences.
  • Individuals in and around the tent can be severely injured from the blowing debris or the collapsing of the tent itself, but if the helicopter crashes as in the scenario lives may be lost.

DO’S & DON’TS

Hospitals:

  • DO locate & set up any and all tents, storage areas, triage areas far away from any landing zone or heliport.
  • DO NOT assume your tent won’t be affected.
  • DO keep the area under the approach and departure paths clear of tents, storage areas, debris and triage areas.
  • DO secure any and all loose debris such as trash, dumpsters, tarps… near the heliport or landing area.
  • DO alert all Helicopter Air Ambulance Providers that you have a tent located on your campus and where it is.
  • DO mark the heliport with a large yellow X, signaling to pilots that it is closed for operations if you intend to close the heliport. 

HAA Providers

  • DO conduct a thorough reconnaissance of all landing sites prior to landing.
  • DO NOT attempt to land near any tent.
  • DO identify and use a safe alternative landing site when necessary.
  • DO NOT assume that materials near your landing area are secure.
  • DO alert other providers when you identify a new hazard
  • DO NOT hesitate to say NO when appropriate
  • DO Provide guidance and education on safe landing area operations  

CAMTS Open Letter to Accredited Services:

3/24/2020

We are receiving many calls and emails about our official position on transporting patients with suspected or diagnosed coronavirus.  First, it is NOT our position to dictate whether a patient with suspected or known coronavirus should be transported.  Medical transport is an important part of healthcare and transport is the conduit to get the patient to the most appropriate and definitive care.

Programs have unique opportunities to address the challenges of transporting patients while keeping staff healthy and able to function with diminishing resources and greater needs.

As accredited services, there may be times when you just cannot meet the Standards. Many professionals on the CAMTS Board of Directors are themselves involved in the same situations and realize these are extraordinary times. We will not penalize programs who need to make temporary changes to continue to provide a service. As best you can, continue to meet standards, especially as they pertain to quality and safety, but do what is right for your patients. As Winston Churchill once said: “It’s not enough that we do our best; sometimes we have to do what is required.” 

Over the past week, we sent out several blogs with ideas from various accredited services and helpful tips for pilots and mechanics.  If you have developed innovative  practices that have been effective and want to share – please pass them along and I will post them on our website.  We need to help each other and stay connected during these unpredictable times. 

Eileen Frazer, Executive Director

We are NOT saying stop…

March 20, 2020

In our most recent blogs, we tried to convey ideas and practices dealing with the coronavirus from accredited programs and member organizations.

These statements are not the Official Position of CAMTS and we are not telling programs to refrain from transporting patients with the coronavirus.  We are trying to address questions and concerns by providing suggestions and practices that others have relayed to us. Every situation is different, and we feel we can learn from others’ experiences and pass those along to transport professionals.

Shortage of PPE equipment is the most immediate and serious issue, according to the phone calls I receive. One of the programs traded a case of toilet paper for N95 masks because they were in desperate need.  If you have had success in receiving these supplies or have a secret supplier that would benefit other programs, please let us know.  Share your innovative ideas that we can pass along. We are innovators and we are all in this together.

AMPA statement – Covid19

March 20, 2020

After careful monitoring of the rapidly changing situation related to COVID-19, understanding that concerns for health, safety, and the impact on meeting attendance, among other issues, are affecting our conference, the difficult decision has been made to cancel CCTMC for 2020.  We are committed to maintaining appropriate health and safety measures, and we encourage you to follow guidelines recommended by the Centers for Disease Control and Prevention and the World Health Organization.  CCTMC attendees and exhibitors will be issued a full refund or may choose to roll their registration to the 2021 conference.  Watch our websites, Facebook and www.CCTMC.net for details for 2021 as they become available in the near future. You won’t want to miss it!Best regards,AMPA, ASTNA, IAFCCP

AMPA Position Statement


AMPA is attentive to the concerns of its membership in addressing the challenges associated with the transport of patients with suspected or confirmed infection with SARS-CoV-2. Recommendations regarding the personal protective equipment required to care for these patients remain fluid, and AMPA recommends that its members remain familiar with the recommendations of the World Health Organization as well as those of their local, regional, and national health protection authorities.

• AMPA supports social distancing and recommends seeking alternatives to gatherings of greater than ten people.
• AMPA supports the WHO recommendation to employ standard, contact, and droplet precautions when caring for and transporting patients with suspected or confirmed infection with SARS-CoV-2.

⁃ AMPA recommends that patients with suspected or confirmed infection with SARS-CoV2 wear a surgical mask during care and transport.

• AMPA supports the WHO recommendation to employ standard, contact, and airborne precautions when caring for and transporting patients with suspected or confirmed infection with SARS-CoV-2 who are undergoing aerosol-generating procedures such as nebulization, mask oxygenation, high flow nasal cannula oxygenation, non-invasive positive pressure ventilation, endotracheal intubation, bag valve mask ventilation, cricothyrotomy, tracheostomy, and cardiopulmonary resuscitation.

⁃ AMPA further supports the WHO recommendation to attempt to avoid performing aerosol-generating procedures in confined spaces.
⁃ AMPA therefore cautions against transporting patients anticipated to require aerosolgenerating procedures during transport and suggests mitigating the need for aerosolgenerating procedures prior to transport.
⁃ AMPA recommends the use of a certified bacterial and viral filter in the ventilator circuit of mechanically ventilated patients but recommends airborne precautions during transport to safeguard against unanticipated aerosol-generating procedures.
⁃ AMPA further recommends the mitigating use of a certified bacterial and viral filter (1) between the bag and the endotracheal tube or between the bag and the face mask of manually ventilated patients, and (2) in the circuit of patients being provided noninvasive positive pressure ventilation, when feasible.
⁃ AMPA further acknowledges that local, regional, or national practice may be to employ airborne precautions on a broader population of patients with suspected or confirmed infection with SARS-CoV-2 and that these recommendations remain fluid.

• AMPA recommends that pilots and other vehicle operators employ droplet or airborne precautions as appropriate, utilizing appropriately fit-tested personal protective equipment, unless the cockpit and patient compartment are completely separated.
• AMPA cautions that using a particulate respirator mask while wearing a flight helmet may render the mask ineffective unless appropriate fit testing has been performed while wearing the helmet.
• AMPA acknowledges that SARS-CoV-2 may survive in the environment for extended periods of time and recommends decontamination of all surfaces and open air ventilation of the patient compartment following the transport of patients with suspected or confirmed infection with SARS-CoV-2.

AMPA acknowledges that our understanding of potential best practices remains fluid at this time and recommends careful consideration of current guidelines and continuous reassessment of the potential benefits and risks surrounding the transport of patients with suspected or confirmed infection with SARS-CoV-2. AMPA will continuously review these recommendations and provide interim guidance as necessary.

Covid19 – Medical Transport

March 18, 2020

This is today’s update. We will continue to post as new information and changes occur. We will continue to answer all your questions as best we can. We are all in this together!

EXPIRATION DATES

We received many questions about currencies such as ACLS, ATLS etc. Courses have been canceled and programs are not able to schedule staff with expired or expiring certifications. We all need to adjust to new realities and CAMTS understands delays and expiration dates will be affected. Aviation managers may be experiencing the same thing with scheduling simulators for staff. There are no penalties as we adjust and cope to carry out our primary mission: taking care of our patients and each other.

Accreditation expiration dates are also affected by the timeliness of site visits. We were able to complete all but three scheduled site visits for this quarter of 2020. Programs who are on hold for a site visit receive an approved extension to their tenure of accreditation as noted on the website listing. We are looking at scheduling site visits again in late May and June but we are all operating under the assumption we may need to change as this pandemic progresses. Contact our executive staff: eileen.frazer@camts.org, dudley.smith@camts.org or jan.eichel@camts.org    with any questions or concerns.

Visit cdc.gov/coronavirus for up to date information.

COMMENTS FROM ACCREDITED PROGRAMS

From Jason Cohen, MD, Medical Director at Boston MedFlight

“We have decided to consider RW transport for these cases on a very limited basis.  Whenever possible, these will be deferred to ground, but some of our geography would require us to fly (i.e., islands with limited available healthcare).  We don’t require crew oxygen at our usual operating altitude, unlike the mountains in Colorado.  A decision to accept requires a clinical conversation between the sending physician and myself, along with the crew, as well as a conference call with aviation management to discuss any mechanical mitigation for spread based on the environment (for example, not running the HVAC).”

“Our RW clinical crew wears full PPE including N95, with surgical mask over the patient (unless intubated).  The pilot wears an N95 mask – does not seem to interfere with radio communication.”

“We are not using FW for transport of potential COVID patients – mostly due to the required recirculation in the aircraft at pressure without ability to upgrade to HEPA filters.”

FROM CAMTS

For fixed wing services, who conduct both air medical and charter flights: We recommend complete separation of staff, pilots and airplanes.  Airplanes should be configured for a single purpose at this time. Reconfiguring the interior to meet the mission – either passenger or patient – puts patients, passengers and staff at a higher risk.

For all modes of transport

The donning and doffing procedure is a simple one for personnel to follow if in contact with the patient or aircraft with suspected or diagnosed exposure, including maintenance personnel. See the website: PPE Doffing Procedure from the Provincial Health Services Authority of Canada: http://www.phsa.ca/Documents/Occupational-Health-Safety/FactSheetPPEDoffingProcedurePoster.pdf

Patients should wear masks in addition to the medical staff. Luggage should be wrapped in plastic or in plastic bags by personnel other than the patient.   Crew members should wear masks and gloves while loading and unloading, and proper doffing procedures should apply after unloading is complete. Aircraft interiors needs to be properly cleaned and disinfected between transports.

Recommended clean-up is a mixture of 50% Sodium Hypochlorite (Clorox) to 50% warm water on solid materials. If the aircraft is lined in fabric or carpeting, we recommend you do not transport known or suspected coronavirus patients as these surfaces cannot be properly cleaned (also against CAMTS standard 03.06.01 21.  “Non-fabric sides/ceilings are strongly encouraged. Floors are not carpeted.”) 

For Communications Centers

Be creative in providing 6 feet of separation between communications specialists. This may be difficult but perhaps staggering shifts and/or relocating non-essential furnishings is possible.

Hand washing, of course, is required between starts and stops or antiseptic hand wipes. Hard surfaces should be cleaned at stations with each personnel change, especially phones, headsets, keyboard, screens etc.   

Info on Transport of Patients w/ COVID19

March 16, 2020

In these uncertain times, we wanted to get some information out regarding transport of patients who are diagnosed with coronavirus. There are many variables that could affect your decision whether to transport or not but here are some thoughts from our Board members who are actively involved in Rotorwing, Fixed Wing and Ground transport.

Response from Mike Brunko, MD, Flight for Life Medical Director (CAMTS Board Member)

Many programs, including mine, have halted transport of patients diagnosed with coronavirus by rotor, primarily because of inability to control and to be able to protect crew and pilots from patient contact (especially in helicopters where it is not possible to  physically separate the infected patient from the pilot) and/or the inability to get adequate N95 fitting with helmets. In our case, we have the added pressure of flying above 12000 feet, with oxygen on. It is difficult to decontaminate a helicopter as opposed to an airplane or ambulance and the air flow is not as easy to control. Right now, many busy academic programs are not transporting by rotor, but are by fixed wing or ground. Some are only doing intubated patients where we can control the filtration of inhalation and exhalation and lessen/prevent the aerosol exposure.

The AMPA Board Is actively discussing the literature, experience and their institutions’ recommendations. Most programs’ crews were fitted and tested for PAPR and N95s without helmets and likely didn’t consider the importance of separate testing (a standard we will need to address in the future). Today, I feel, ground and FW should be used and rotor CONSIDERED only for time sensitive critical ARDS patients where ECMO or ventilation strategies are necessary. This truly is a dynamic situation which may change tomorrow.

Webinar from Ashley Smith – NATA representative

Specific to fixed wing transports – please see the link on the www.camts.org website to the NATA webinar that our board member, Ashley Smith, made available last week.

Safety Alert Bulletin

In the 1980s, helicopter medical transport services were just beginning to develop. By 1990, the year CAMTS incorporated, there were approximately 200 services across the U.S. compared to over 1200 helicopters operating today. In those early days, groups like ASHBEAMS (now AAMS), NFNA (now ASTNA) and NFPA (now IAFCCP) were just evolving and starting to develop guidelines for patient care during transport that included operational issues not found in other areas of medical transport. As CAMTS developed, we studied the accidents and incidents to create standards that would address the practices that were common to the NTSB’s probable causes of HEMS accidents.

Today, we have a whole new generation of medical and aviation professionals who have the advantage of time-tested standards and of technology that was not found 30 plus years ago such as NVGs, satellite tracking, glass cockpits, simulators, improved weather reporting, etc.

But, with this new generation of pilots and medical crews, we are seeing some of the same unsafe practices that lead to accidents in the 1980s. This may be because they are not aware of the dangers that caused so many accidents in the past. 

So… LET’S GET BACK TO BASICS!

HELICOPTER SHOPPING IS DANGEROUS! Helicopter shopping is still happening and even more dangerous in this highly competitive era. It is one of the reasons the FAA has operational control regulations and there are standards that address helicopter shopping. If a flight is turned down for weather or unsafe conditions, it is important to inform any other providers considering the flight. It is also important to respect the decision in the interest of SAFETY.

Train to Proficiency! 

Training is critical to safety of flight. It is important to ensure all pilots are trained to proficiency on sophisticated technology (glass cockpit), night vision goggles, instrument flight procedures in the event of inadvertent weather, mountain flying or cold weather operations. Pilots should be trained to fly the specific aircraft assigned including enhanced technology. They should also be trained to the specific mission, location (including terrain and unique weather) and the instrument procedures required to get safely return from an encounter with reduced or no visibility.

Recognize Fatigue!
We know fatigue leads to errors that humans make more often when tired.  Not only are crews and patients are at risk when the pilot is fatigued but medical errors can be life ending. Pilots have duty time regulations, but it is difficult to regulate sleep habits on off-duty time. Medical crews are more frequently scheduled 24, 36, 48-hour shifts. Unless downtime is planned, emergency services must be available 24/7 so there is no guarantee how much sleep they will get. “Reducing fatigue-related accidents” was on the NTSB’s 2019-2020 Most Wanted List (see www.ntsb.gov).

Another safety recommendation on that list was “Eliminate Distractions”.

Avoid Distractions!

There are more distractions today than ever imagined. Cell phones may provide temptation to send a brief text when the crew’s full attention should be on assisting the pilot in looking for obstructions. Drones, laser and bird strikes are more and more prevalent and can be deadly. 

So, let’s get back to basics!

  • Take care of yourselves and each other.
  • Proper rest, diet and exercise
  • Don’t take short cuts.
  • Do the pre-flights, do the walk-arounds, use the checklists
  • Speak up – ask questions – if you see something- say something!
  • Stay Situationally Aware
  • Be alert – Stay alive!

NTSB’s Most Wanted List of transportation safety improvements for 2019-2020

Feb 06, 2019

The National Transportation Safety Board (NTSB) published its 2019-2020 Most Wanted List of Transportation Safety Improvements, during an event held February 4 at the National Press Club in Washington DC.

First issued in 1990, the NTSB Most Wanted List of Transportation Safety Improvements serves as the agency’s primary advocacy tool to help save lives, prevent injuries, and reduce property damage resulting from transportation accidents.

The top 10 items on the NTSB’s 2019-2020 Most Wanted List of Transportation Safety Improvements are:

  • Eliminate distractions
  • End alcohol and other drug impairment
  • Ensure the safe shipment of hazardous materials
  • Fully implement positive train control
  • Implement a comprehensive strategy to reduce speeding-related crashes
  • Improve the safety of Part 135 aircraft flight operations
  • Increase implementation of collision avoidance systems in all new highway vehicles
  • Reduce fatigue-related accidents
  • Require medical fitness screen for and treat obstructive sleep apnea
  • Strengthen occupant protection

 “The 2019-2020 Most Wanted List advocates for 46 specific safety recommendations that can and should be implemented during these next two years,” said NTSB Chairman Robert Sumwalt. “It also features broad, longstanding safety issues that still threaten the traveling public.

Sumwalt issued a call to action during the February 4 event saying: “We at the NTSB can speak on these issues. We board members can testify by invitation to legislatures and to Congress, but we have no power of our own to act. We are counting on industry, advocates, and government to act on our recommendations. We are counting on the help of the broader safety community to implement these recommendations.”

There are 267 open NTSB safety recommendations associated with the 10 Most Wanted List items and the NTSB is focused on seeing 46 of those implemented within the next two years. The majority of these recommendations, roughly two-thirds of the 267, seek critical 
safety improvements by means other than regulation. Of the 46 safety recommendations the NTSB wants implemented in the next two years, 20 seek regulatory action to improve transportation safety.

SHARING THE AIRSPACE

There was a discussion at the 2018 HeliExpo and at the recent CAMTS Board meeting regarding hospital helipads and Unmanned Aircraft Systems (UAS).  The development of UAS technology in the private sector and the FAA’s limitation in developing airspace regulations to ensure that they will not interfere with air medical operations is an issue of concern, especially with the number of private and business UAS increasing every day.

The FAA has Operational Limitations (PART 107) for UAS that limit the altitude to 400 feet AGL and operations around Class B, C, D, and E airspace with ATC permission. There are also Flight Restrictions over Sporting events with a seating capacity of 30,000 or more (FDC NOTAM 4/3621) but there is no FAA separation rule governing operations around a hospital helipad.

MW-DU845_drone__20150922153227_ZH

One of the reasons is that the FAA’s database on the location of hospital helipads is probably, by their own estimation, only 50% accurate. Since hospital helipads are considered private and therefore subject only to Advisory Circulars, many hospitals do not register the “Airport Master Record” – FAA Form 5010-3 – in the first place – when it is built.   Most also do not turn in a Notice for Construction, Alteration, and Deactivation of airports FAA Form 7480-1 when the helipad is moved, deconstructed or altered. We all know that hospitals add, change and rebuild frequently.  The FAA puts out the location of hospital helipads to the public – but this information only has a 50% chance to be correct.

CAMTS site surveyors visit hospital helipads that are either in the control of the air medical service or if an independent service bases its aircraft on a hospital helipad. In these cases, the site surveyors are asking to see the FAA Form 5010 or Form 7480 to determine if this is current and accurate.  This is one way to assist the FAA with correct information so that as new regulations catch up to an exploding UAS population, we can help to stipulate airspace around hospital helipads.  This is one way to help improve the safety and protection of our airspace as the UAS technology and popularity continue to expand.

Mr-Dyson-wanted-to-build-a-helipad