When Ground Meets Air

For more than 25 years, air medical services have been integral in EMS delivery of high-quality prehospital care. Presently, there are 270 rotor-wing services with 647 bases operating 792 aircraft.1 Air medical programs perform an estimated 450,000 helicopter transports annually.2 Partnerships between fire service and helicopter EMS (HEMS) have allowed for safe and highly effective operations that ultimately benefit patients. Although the overall objectives are similar, fire and HEMS scene responsibilities are distinctively different. Successful missions depend on teamwork, the proficiency of team members in their roles, and a clear understanding of the roles of the other team members.

WHY CALL A HELICOPTER?

The cost of an emergency helicopter transport can vary greatly, depending on distance flown, geographic location, care provided, and aircraft operating costs. Average costs in North America range from approximately $2,500 to $6,200 per flight. (2) Helicopter transport is an expensive yet valuable resource. Regionally established protocols commonly dictate their use.

(1) Inaccessible areas (such as this ski slope) indicate the need for helicopter transport. (Photo courtesy of West Michigan Air Care.)

In 1999, the American College of Emergency Physicians (ACEP) developed a policy statement regarding the appropriate use of air medical transport in the prehospital environment.3 From this general policy statement, many regional medical control authorities developed protocols regarding their deployment. General guidelines on when to call for helicopter transport are presented in Table 1. For specific criteria, refer to your local criteria for helicopter utilization.

Table 1. When to Call a Helicopter

• Extended distance or ground time between the scene and a comprehensive trauma center
• Prolonged extrication that would increase the time to tertiary care
• Multisystem trauma patients
• Evidence of airway or ventilatory compromise
• Hemodynamically unstable patients
• Patients with central nervous system (CNS) injury
• Limb amputation
• Critical burns
• Situations in which specialized services provided by the air medical crew would benefit the patient prior to arrival at the receiving center

A helicopter is dispatched based on local protocols. ALS providers or BLS providers where ALS is either delayed or unavailable generally make the decision to launch an aircraft. This is done directly or with permission from the local medical control authority and is based on the above criteria.

Of particular interest to fire departments, HEMS provides expeditious transport (on average, 130 mph ground speed) for individuals injured on America’s highways, back roads, mountain ranges, forests, lakes, and deserts. Long-ground transport times, high-traffic volumes, inaccessible terrain, or prolonged extrication can mean the difference between life and death to severely injured patients. Accepted distances where helicopters provide increased benefit over ground transport are based on geography, terrain and available roads, and distances to tertiary care.

Air medical programs also offer services that might not be routinely provided by ground EMS. Medication-facilitated intubation, central line placement, surgical airways, tube thoracostomy, and blood administration are several skills that trained HEMS medical staff can bring to the scene of an emergency. HEMS can expeditiously bring to the side of a patient procedures once available only in an emergency department. Crews are afforded this expanded scope of practice by a physician medical director who is directly responsible for training and developing the medical policies and protocols. Air medical personnel practice under the license of their physician medical director.

HEMS EXPECTATIONS AND WHAT YOU CAN EXPECT

Understanding expectations strengthens team performance. Given the environment within which fire and air medical personnel must operate, both need to rely on each other.

(2) Air medical teams can bring a variety of specialized skills to the side of critically injured patients. (Photo courtesy of West Michigan Air Care.)

Air medical personnel rely on their ground counterparts for a safe landing. This begins with clear communications, establishment of a safe landing zone (LZ), and an unambiguous description of the LZ. Landing zones are important enough that they need to be established by a public safety counterpart with formal training. An LZ coordinator and dedicated safety personnel are needed and should be provided by the department requesting a helicopter. If your department has not had a formal LZ course, your local air medical program will be able to provide this training. Most programs are very eager to provide this service since it is mutually beneficial. The general requirements for establishing a landing zone are contained in Table 2.

Table 2. Landing Zone Requirements

• Level, 100-foot by 100-foot area clear of obstacles (wires, trees, fenceposts)
• Corners of landing area marked at each corner and upwind
• Fire suppression readily available at a safe distance outside of the landing area
• Judicious use of flashers on public safety vehicles to help identify landing site from the air (not pointing upward toward aircraft)
• Reliable radio communication with incoming aircraft
• Radio description of landing area to include any obstacles close to the landing or take-off path
• Landing zone (LZ) coordinator responsibilities:

  -Continuous communication with incoming aircraft and incident command

  -Final approval of landing area

  -Minimize personnel in and around LZ area

  -Determine alternate LZ if needed

  -Coordinate fire suppression

  -Assign tail-rotor guard

Once on the ground, the HEMS medical crew relies on fire personnel to establish a safe scene to work in and around. Although air medical personnel often work in less than optimal conditions, an unsafe scene can turn a single-patient incident into a multiple-casualty incident. The critical nature of injuries on-scene, the excitement and distraction of landing aircraft, and sheer unpredictable environments are common diversions that must be overcome to maintain a safe scene.

Likewise, your expectations of the helicopter you requested are equally important. Expect nothing less than high-quality, professional service from each member of the HEMS team. Service starts with your initial call to the program’s communication center and doesn’t end until well after your patient is safely transported to definitive care.

The communications staff will take your call or your request through a local communications center, dispatch the air medical crew, and provide contact between the helicopter en route and personnel on the ground. Your exact location via global positioning satellite (GPS) and radio frequencies for communication with the helicopter crew will be provided while it is headed to your scene. Information on the most appropriate medical facility available to accept the patient, general LZ assistance, and answers to any questions you may have related to the incoming aircraft are also available from personnel in the communication center. Anticipate a professional demeanor and clear, concise dialogue when interacting with a flight program’s communication staff.

Aircraft should be well maintained and flown safely into and out of your landing area by a professional pilot. Crew safety in the air and safety of individuals on the ground are priorities for the pilot operating a helicopter in and around a scene. For the safety of those on the ground and in the aircraft, a professional EMS pilot will not land if safety is in question. Once in the air, your patient will receive a swift and safe ride to appropriate care.

The HEMS medical staff should deliver nothing less than professional and competent medical care to your patient, clear and deliberate communication with you and other members of your department, and regular updates on the patient’s condition once delivered to tertiary care. Since helicopters respond to a wide variety of critical clinical situations, the education and training required to practice in air medical services is extensive. Medical crews should understand your desire for follow-up on patient condition and recognize that fire and EMS departments can sometimes be left out of the follow-up communications loop. Expect the air medical crew to help provide feedback for you.

MISSION PROFILES

Mission profiles of HEMS programs vary by region and primary need. Helicopters can land directly at the scene of an emergency or at another hospital. Programs operating in rural areas may do a higher percentage of direct-scene work, whereas those operating out of large academic centers might do more “interfacility” transports. On average, mission profiles of air medical programs across the United States are comprised of 54 percent interfacility transports, 33 percent scene response, and 13 percent of what is considered “other” (e.g., organ procurement). (2) Regardless of their particular percentages, most air medical programs are very comfortable working in any environment.

(3) Even a well-controlled scene can appear chaotic from the air. (Photo courtesy of University of Michigan Survival Flight.)

On many occasions, a helicopter may be initially called to an incident scene and subsequently cancelled or diverted to meet ground units at a local hospital. Regional protocols may even allow the patient to be loaded directly into the helicopter without being examined by the physician at the local hospital. Established policy and judgment of the medical crew on-scene will dictate this practice.

Agreements between fire departments and their local air medical program have allowed for the establishment of “predesignated” LZs. Such LZs allow aircraft to rendezvous with an ambulance away from an incident scene in a safe, secure location. LZs are identified and agreed on jointly by local air medical programs and public safety agencies and are deemed suitable for safe transition of patient care. Missions to hospital and predesignated LZs are often described as “modified” scene flights.

Helicopters are routinely called to hospitals to transport patients to larger tertiary or specialty care centers. Crews will transport between emergency departments (EDs) or intensive care units (ICUs). Care and interventions similar to those provided in an ED or ICU can be performed and maintained in the air by trained and qualified HEMS personnel.

Helicopters are typically staffed by a combination of physicians, nurses, and paramedics or respiratory therapists. Crew configuration depends on the mission profile. The majority of programs across the United States use a nurse-paramedic crew configuration. This allows for great flexibility; call volume can range from an injured adult on a busy freeway to a critically ill newborn in an ICU.

Because of the wide variety of calls received, medical training includes experience in the prehospital environment, emergency department, and pediatric and adult ICUs. The Commission on Accreditation of Medical Transport Systems (CAMTS) has identified educational standards for air medical crews. Although not all air medical programs have CAMTS certification, this is a generally accepted standard. Table 3 lists Web sites that offer more information on certifications air medical crews are required to hold. Table 4 provides Web sites on air medical services in general.

Table 3. Organizations Providing Certification for Air Medical Crews

Board of Certification for Emergency Nursing

• CEN (emergency) and CFRN (flight) certifications
• http://www.ena.org/bcen/

American Association of Critical Care Nurses

• CCRN (critical care) certification
• http://www.aacn.org

International Association of Flight Paramedics

• FP-C (flight paramedic) certification
• http://www.flightparamedic.org/

UMBC Critical Care Emergency Transport Program

• CCEMT-P (critical care transport) certification
• http://ehs.umbc.edu/ce/CCEMT-P/index.html

Table 4. Information on Air Medical Services

Commission on Accreditation of Medical Transport Systems (CAMTS)

• http://www.camts.org/

Association of Air Medical Services (AAMS)

• http://www.aams.org

Air Medical Physician Association (AMPA)

• http://www.ampa.org/

Air and Surface Transport Nurses Association (ASTNA)

• http://www.astna.org

National Association of Air Medical Communication Specialists (NAACS)

• http://www.naacs.org/

National EMS Pilot’s Association (NEMSPA)

• http://www.nemspa.org/

TYPICAL QUESTIONS AND CONCERNS

Many questions and concerns regarding HEMS operations and practices pertain to local or regional policies or protocols. Following is a review of best practices, current rules and regulations, and some of the issues and concerns they raise. I hope they serve to stimulate dialogue between fire departments and flight programs.

Why don’t they just take off?

“What are they waiting for?” “Why don’t they just take the patient and go?” These are common observations by ground personnel watching their air medical counterparts. Yet, calling a helicopter merely for a “fast ride” fails to recognize the full potential of an air medical program in emergency scene response and patient care.

When assuming responsibility for a patient from ground EMS providers, air medical personnel will conduct a thorough but quick patient assessment. If a patient’s ability to protect his own airway is in question, it is imperative it be managed before loading the patient into the aircraft. Although a tension pneumothorax may be relieved with needle decompression, the chance that air could reaccumulate in the pleural space at altitude may necessitate a tube thoracostomy. These procedures can be done in the back of most aircraft, but they are more safely performed (with much more room) in the back of an ambulance.

Clearly, unnecessary procedures waste time on the scene, yet safe air medical transport requires careful forethought and planning, not just swiftness. Air medical providers are trained to always think two steps ahead and constantly keep in mind the answer to the question “what if?” In many instances, they are trained and are expected to initiate the same level of life-saving care offered at a tertiary center, thus expediting a critically injured patient’s trip to the operating room or other definitive treatment.

Additionally, air medical crews have priorities and required steps taken prior to take-off (Table 5). Crew and patient safety are of utmost importance, and a pretake-off check is a methodical and deliberate process.

Table 5. Considerations Prior to Aircraft Liftoff from a Scene

• All ground personnel clear of the rotor disk
• Doors secure from outside and no loose objects protruding from inside the aircraft
• Patient secure on aircraft litter system
• ALL loose objects inside aircraft tied down/secured
• Recheck of tube and catheter patency
• Patient-monitoring equipment intact
• PRETAKE-OFF CHECKLIST

  -Throttles and rotor speed check

  -Internal systems check

  -Aircraft caution and warning lights extinguished

  -Electrical power and oxygen available to the medical crew

  -Patient attached to oxygen

  -Crew seated and belted, cabin and doors secured from inside

  -Take-off brief by pilot, identification of any potential obstacles or safety concerns

Why won’t the helicopter transport a cardiac arrest?

It seems that if any patient would benefit from rapid transport, it would be the pulseless patient. This question most often arises in the setting of traumatic cardiac arrest.

From a legal perspective, federal regulations require that all air passengers be seated with seat belts fastened during takeoff and landing.4 Administering chest compressions necessitates being unbelted in most aircraft. Effective cardiopulmonary resuscitation (CPR) is difficult at best in most rotor-wing aircraft used in EMS.

From a clinical perspective, a traumatic cardiac arrest is usually a nonsurvivable event. Most textbooks agree that the chance for recovery from this is less than one percent. Immediate interventions include identifying and correcting obvious causes of cardiac arrest caused by trauma (hypoxia, hypovolemia, tension pneumothorax, and cardiac tamponade). After these have been addressed, action should be taken based on local protocols. Some systems allow field pronouncements by EMS. If this is not an option, ground transport to the closest hospital is usually the best and sometimes the only course of action. This decision is also based on the numbers of patients, triage priorities, and available resources. When ground transporting a patient in cardiac arrest, one or both air medical crew members will usually accompany you to the hospital if requested.

Why decline a flight because of weather?

Multiple helicopters were recently requested to the scene of a major multiple-injury crash. Both services requested turned down the flights because of inclement weather. The requesting department was confused. The sky was clear of fog and precipitation. In fact, two local news helicopters were hovering over the scene.

Aircraft operate under one of two arms of the Federal Aviation Regulations: FAA part 91 and FAA part 135. Part 91 falls under general operator regulations. Weather minimums are essentially “clear of clouds.” Under part 91, the pilot operates under “see and avoid” guidelines. (4)

FAA part 135 allows the pilot and aircraft to operate as an “air taxi.” Transporting passengers requires very strict operational guidelines and, for the purpose of this discussion, weather minimums. There are identifiable minimums for visibility (how far the pilot can see in miles) and ceilings (distance between the ground and clouds). News helicopters generally operate under FAA part 91; EMS helicopters operate under FAA part 135. Federal regulations are established to protect aircraft passengers. (4)

One factor not clearly communicated to the requesting fire department was weather conditions at the bases from which the helicopters were to depart. If weather minimums are below those required for safe operation during any leg of the flight, a pilot will not accept the mission. It is just as important to arrive safely back to base as it is to reach the patient.

Why don’t they land?

You work hard to find a safe LZ, make sure it is clear of obstructions such as trees and wires, and light it up so people can see it for miles. Yet the aircraft hovers overhead or keeps circling. Is the pilot lost? Can he not see the LZ you established?

(4) A helicopter departs a properly established landing zone. The optimal landing zone is often the nearest open area, free of traffic and overhead obstructions. (Photo by Douglas Trojanowski, courtesy of University of Michigan Survival Flight.)

It is important to understand two points about approaching an LZ. The best and most organized incident scenes appear extremely chaotic from the air. Lack of clear communication with ground personnel makes even the most experienced helicopter pilot hesitant to land, especially at night.

Keeping this in mind, pilots try to establish communications with the fire department long before approaching the LZ. The foremost piece of information will be a briefing of the LZ so the entire crew can establish a mental image of it, keeping in mind obstacles, wires, and where and how it is marked. Without a report from the ground, most pilots will circle at least a few times to see for themselves the current situation before proceeding with the landing.

Additionally, as part of the protocol for scene approaches, many programs insist their pilots circle the scene several times, performing a high and low “recon.” This is to verify the LZ, identify any potential hazards not mentioned in the briefing, and discuss the approach path. Before making the approach to land, the pilot may circle at a lower altitude to identify hazards closer to the ground.

The pilot must also take into account wind direction and speed. Typically, an approach path will be into the wind. It takes more power to land an aircraft in a tailwind, since the pilot must slow down the aircraft. Just as the medical crew must always think ahead, the pilot must consider winds, the gross weight of the aircraft (and the added weight of the patient), and the best approach and departure paths at a scene. Because of this, the approach path may end up somewhat different from that anticipated by ground personnel.

What are general aircraft safety considerations?

Different aircraft designs pose unique safety issues. Loading patients “hot” vs. “cold,” loading from the side or rear of the aircraft, and tail-rotor guards are some of the design-related safety concerns.

Generally speaking, safety considerations around rotor-wing aircraft are fairly universal: Approach from the front of the aircraft and only with the pilot’s permission. Do not, under any circumstance, approach an aircraft during initial startup or shut down, as spinning rotor blades tend to “dip.” Ensure that all loose items on your person and attached to a patient are secure. Debris and foreign objects can cause severe engine damage if allowed to enter the intake. Moreover, if something loose flies away from you because of rotor wash, don’t run after it.

With respect to “hot” or “cold” loading, preferences will be based on the air medical program. Hot loading (loading with the aircraft still running) is often preferred by programs using aircraft with extensive cooldown times. Many pilots prefer to leave the aircraft running, even for prolonged periods, on the ground. Hot loading a patient will necessitate a briefing by the medical crew. They will brief you on how to approach the aircraft, which side of the aircraft to approach, and if you will be loading the patient from the aircraft’s side or rear. As few people as possible should enter the area under the rotor disk. Once the patient is safely loaded into the aircraft, all personnel should exit from under the rotor disk in the same direction they entered.

Loading “cold” is definitely safer and less chaotic. Many newer aircraft have significantly shorter warmup times and do not need to cool down before shutting down. It is still very important to be cognizant of turning rotor blades during the start-up and shutdown periods.

What about taking on additional passengers?

Allowing additional passengers (e.g., parents, family members, armed guards with prisoners) is at the discretion of each flight program. The pilot in command (PIC) has final authority relative to who lifts off with the aircraft. If an armed law enforcement officer is to accompany the crew, the pilot must be aware of the situation. FAR part 135.119 states:

No person may, while onboard an aircraft being operated by a certificate holder, carry on or about that person a deadly or dangerous weapon, either concealed or unconcealed. This section does not apply to (a) Officials or employees of a municipality or a State, or of the United States, who are authorized to carry arms; or (b) Crewmembers and other persons >authorized by the certificate holder to carry arms. All passengers must be seated and belted in the aircraft prior to departure. If there is no additional space or issues with gross weight, the PIC will not allow additional individuals to board the aircraft, and contingency plans must be made at that time. (4)

How safe are EMS helicopters?

Discussion surrounding the safety of EMS helicopters in operation today has left many fire departments questioning whether they should even be used at all. It is no secret that the air medical service as an industry is under much scrutiny. In a January 2006 fact sheet provided by the Federal Aviation Administration (FAA), it was reported that “the number of crashes nearly doubled between the mid-1990s and the HEMS industry’s rapid growth period from 2000 to 2004. There were nine crashes in 1998, compared with 15 in 2004. There were a total of 83 crashes from 1998 through mid-2004.”5

Likewise, Baker et al performed a retrospective study of HEMS crashes over a 22-year period. The results of the study reveal that between 1998 and April 2005, 88 HEMS crashes occurred, an average of 12 per year. This was compared to the periods of 1983 to 1989 where, on average, 8.6 crashes per year occurred and 1990 to 1997, where there was an average of 4.3 crashes per year.6 This study also found that operating in night conditions more than triples the risk of fatalities from crashes and that adverse weather conditions increase this risk eightfold.

These statistics force the question, What can be done to improve air medical safety? The industry as a whole has listened to the FAA and public concern. Per the FAA, immediate focus has been placed on the following:

• Encourage flight crews to take risk management training so that they can make more analytical decisions about whether to launch on a mission.
• Improve training for night operations and responding to inadvertent flight into deteriorating weather conditions.
• Promote technology such as night vision goggles, terrain awareness and warning systems, and radar altimeters.
• Provide airline-type FAA oversight for operators. Identify regional FAA HEMS operations and maintenance inspectors to help certificate new operators and review the operations of existing companies. (5)

What is the air medical community’s approach to safety?

The main causes of HEMS crashes, according to the FAA, include controlled flight into terrain (CFIT), inadvertent operation into instrument meteorological conditions [i.e., unintentionally flying into adverse weather conditions, requiring the pilot to fly with instruments (IFR)], spatial disorientation, and a lack of situational awareness by the pilot during operations. (5) This is consistent with the industry, which, as a whole, is beginning to address these issues with aircrew resource management training, increased training for pilots that would improve decision making at night, instrument training, and implementing new technology such as night vision goggles (NVG) and terrain avoidance warning systems (TAWS).

Air Medical Resource Management (AMRM) is a concept that originated with commercial airlines in response to surges in airliner crashes. Formerly known as Crew Resource Management (CRM), it is a training program designed to enhance the safety culture within an organization. It recognizes that no one particular factor is involved in air medical crashes. Discussion focuses around improving communication among all members of the team (pilots, mechanics, medical staff, and administration/program management), problem solving, decision making, and maintaining situational awareness.7 It is not presently mandated by the FAA but is implemented by many flight programs in an effort to strengthen their team. Decisions made by a cohesive team are stronger decisions. This is of particular importance in the high stress environment of HEMS.

An improved decision-making algorithm is another idea that will improve safety within the industry. Protocols designed to use some forethought prior to launching for a mission allow for the entire team’s input concerning potential hazards. Such decisions are much easier to make while on the ground. A similar approach is used by the U.S. Coast Guard, where command endorsement is required prior to the undertaking of what would be considered a “high-risk” mission. (6) The decision making might include such factors as pilot experience, familiarity with the destination, weather, and day or night operations.8

Night operations are especially risky. As previously referenced, the chances for a fatal crash triple during night flying. For this reason, our air medical colleagues in Europe greatly restrict night missions, especially when ground transport or postponing the mission until daylight hours is a feasible alternative.

The use of technology that makes operations safer at night is an area getting increased focus. Although data to support their effectiveness in preventing crashes are not conclusive, it should be noted that there have been no HEMS crashes secondary to a controlled flight into terrain while night vision goggles have been used. (6) Although expensive (goggles, training, retrofitting avionics in existing aircraft), we will see many programs invest in these items in the future.

What can fire/EMS personnel do to improve helicopter safety?

To think that the lone firefighter or fire department in general has no impact on air medical safety is to discredit the emergency service provider. HEMS services greatly rely on ground personnel to make decisions that will keep helicopters flying long after the scene is clear and patients are stable in a trauma center. Launch criteria, establishing safe LZs, and deciding on appropriate alternatives when aircraft are not flying all lie solely in the hands of professional ground personnel.

All fire departments that use helicopters have a professional responsibility to seek appropriate training in establishing and maintaining the safety of LZs. If your department has not had LZ training, consider a mutual-aid agreement with a department that does, or seek out LZ training. The air medical service you routinely work with is probably very eager to help. As previously stated, this is a mutually beneficial endeavor.

Landing an aircraft at the scene of an incident is never without risk, but it becomes increasingly hazardous at night. A safe alternative is to establish a “predesignated” LZ. It is easier and much safer to land in a familiar area than in one that is unfamiliar. Working together with your local air medical program to designate safe LZs throughout your service area is one of many ways to establish effective relationships between agencies. It is a good way to build trust and to make emergency scenes safer and less chaotic.

There generally is also a certain amount of inherent risk associated with the liftoff of a fully loaded helicopter with crew. A helicopter should be called for an appropriate reason. The criteria for using a helicopter have been previously discussed, and local protocols will guide specific decisions on when to call for an aircraft. If conditions on-scene change or if a helicopter is no longer needed or if its use is no longer appropriate, it may be cancelled at no cost to the department or patient. Air medical services save lives and definitely have a purpose for the community they serve. However, the suitability of their use should be analyzed.

An unsafe practice that has come under recent scrutiny by federal and state agencies is the process of “helicopter shopping.” This involves calling, in sequence, various operators until an operator agrees to take a flight assignment without sharing with subsequent operators the reasons for which the previously called operators declined the flight (as defined in a letter the FAA recently sent to state EMS directors).9 This can create a risky situation: A flight program may launch a flight that it would have turned down had it realized all of the factors involved.

Many state air medical associations have formulated processes for keeping all programs advised of requests that have been declined and the circumstances surrounding the request (weather, mechanical issues, unsafe landing areas, for example). The information is disseminated by phone, fax, or instant e-mail notifications. Once a program has all of the information it needs to make an informed decision, it decides whether it can accept the mission. Ground personnel have an obligation to provide clear information to each service if multiple services are called and to develop contingency plans if air transport is not an option.

•••

My hope is that this short discussion will stimulate dialogue between your department and the local air medical program. To enhance team performance, all members must share the same thought process. It is important to train together and understand each other’s roles in an emergency.

References

1. Atlas and Database of Air Medical Services. National Air Medical Services GIS Database (4th ed.). Available at http://www.adamsairmed.org/pubs/AMTC06_poster.pdf. Accessed November 3, 2006.

2. Association of Air Medical Services. “Frequently Asked Questions.” Available at http://www.aams.org/Content/NavigationMenu/AboutAAMS/FrequentlyAskedQuestions/default.htm. Accessed November 6, 2006.

3. American College of Emergency Physicians. “Appropriate Utilization of Air Medical Transport in the Out-of-Hospital Setting,” Annals of Emergency Medicine; September 1999, 34(3):420.

4. U.S. Department of Transportation. “Federal Aviation Regulations.” FAR: Aeronautical Information Manual. Aviation Supplies and Academics Inc., 2006.

5. Federal Aviation Administration. Fact Sheet: “EMS Helicopter Safety.” Available at http://www.faa.gov/news/fact_sheets/news_story.cfm?newsId=6763. Accessed November 11, 2006.

6. Baker SP, et al., “EMS Helicopter Crashes: What Influences Fatal Outcome?” Annals of Emergency Medicine; April 2006,47(4): 351-356.

7. Federal Aviation Administration. Advisory Circular: “Air Medical Resource Management” (AC: 00-64). Available at http://www.airweb.faa.gov/Regulatory_and_Guidance_Library/rgAdvisoryCircular nsf/MainFrame?OpenFrameSet. Accessed November 10, 2006.

8. Federal Aviation Administration. Helicopter Emergency Medical Services Operator Risk Assessment Programs. Available at http://www.faa.gov/library/manuals/examiners_inspectors/8000/. Accessed November 12, 2006.

9. Indiana Association of Air Medical Services. “Dangers of Helicopter Shopping.” Available at http://www.inaams.com/INAAMSMediaNews.html. Accessed November 8, 2006.

PAUL MAZUREK, RN, BSN, CCRN, CEN, CFRN, NREMT-P, is a flight nurse for University of Michigan Survival Flight and an EMS instructor in southeast Michigan. He has worked as a critical care nurse and an EMS provider in New York and Michigan.