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Sunday, August 1, 2010

HEMS on the Prairie

South Dakota’s population may be sparse, but it is sufficient to keep two Sioux Falls air-medical helicopters busy. Its operational environment is unique, and the need for night vision goggles may be greater there than it is most anywhere.

By David Jensen

On a clear day, eastern South Dakota appears to be a benevolent setting for helicopter flight. The landscape is as flat as a hospital bed, and it appears covered by a giant patchwork quilt, created by the checkerboard design of farm fields. The razor-edge horizon allows a view of blue skies as far as the eye can see.

The two HEMS operations in Sioux Falls, S.D. are Avera McKennan Hospital and University Health Center’s Careflight and Sanford USD Medical Center’s Trauma 1. Both operators have implemented NVGs recently.
But flying after dark tells a different story, as do dramatic and sudden changes in weather. Which is why the prairie heartland could contribute to the helicopter emergency medical services (HEMS)’ periodic sorry safety record (35 fatalities in the last two years) as much as any setting.

Two HEMS operations in Sioux Falls, both launched in 1986, have established plenty of experience flying in this environment. Avera McKennan Hospital and University Health Center’s Careflight and Sanford USD Medical Center’s Trauma 1 have much in common; however, their operations also differ in ways, which R&W learned when it recently paid them both a visit.

David Jensen Images

Night on the Prairie

But first, more about their operational environment. The two helicopter services primarily cover eastern South Dakota, along with parts of Minnesota and Iowa. South Dakota is a land mass larger than the states of New York, New Jersey and Connecticut combined, yet its population of about 776,000 is smaller than that of any of New York City’s five boroughs, save Staten Island. Sioux Falls is the state’s largest city with about 155,000 inhabitants.

Fanning out from the city is a vast countryside sprinkled with villages and small towns, some with modest-size hospitals. These community hospitals often have patients with special, urgent needs that call for their transfer to Sioux Falls. At least 80 percent of the two operators’ flights are inter-hospital patient transfers; the remaining missions are to the scenes of car, hunting or farm accidents. Frequently, a ground ambulance transports an accident victim to a community hospital, where, if injuries are severe, an awaiting helicopter relays the patient to one of the two Sioux Falls hospitals, both level II trauma centers.

Night flying on the prairie presents unique challenges to helicopter pilots. Which is why Careflight and Trauma 1 are both night vision goggle (NVG) operations. The pair joins a growing number of HEMS operators, according to an Association of Air Medical Services (AAMS) report, which claims more than half of the helicopter EMS operations in the United States use NVGs.

Chief pilot Bill McGinnis says “one third” of Careflight’s about 660 flights annually are at night. “Almost every night, we have a flight,” he adds. Careflight began using NVGs last year and soon encountered a dramatic incident that exemplifies these devices’ contribution to safety.

It was early evening Nov. 2, 2009. Careflight’s new Eurocopter EC145 was flying west at 1,200 feet AGL to pick up a patient in Chamberlain, S.D. Craig Hilzendager was the pilot; flight medic Terry Willis was in the left seat, and flight nurse Alicia Vermeulen and a medic in training, Ryan O’Daniel, were in back. It was O’Daniel’s first helicopter flight. Dusk was quickly giving way to darkness when suddenly, about 35 miles from departure, a projectile shattered the left windscreen and rocketed into the aircraft.

Flight nurse Alicia Vermeulen holds what is left of a mallard duck that struck Careflight’s Eurocopter EC145 on a dark South Dakota night. Damage to the windscreen is seen in the image at right. Pilot Craig Hilzendager credits the safe emergency landing to use of NVGs.
“Out of the corner of my eye, I could see it was a bird,” Hilzendager recalls. It was a duck, a mallard, that ricocheted off Willis’ knee and shoulder, then torpedoed into the cabin and slammed into the doorpost, leaving much of its about five-pound body along the route. “It took two days to clean out the helicopter,” a Careflight nurse recalls. (Waterfowl—along with South Dakota’s indigenous ring-neck pheasant—flourish in the prairie, drawing hunters worldwide, but also creating a hazard for helicopter operators.)

Hilzendager quickly snapped his helmet-mounted NVGs into place and began looking for a safe landing zone (LZ). Knowing Willis could be seriously injured, he sought an LZ close to Interstate 90 to facilitate a fast ground-ambulance response. Naturally, he wanted to avoid wires, but he also hoped to steer clear of water standing in farm fields, the result of unseasonable rainfall. Hilzendager spotted an ideal LZ, a high spot in a newly harvested cornfield near the major highway. He attributes the safe emergency landing to use of NVGs.

The incident demonstrated the Careflight crew’s professionalism as well. Seconds after impact, flight nurse Vermeulen contacted dispatch, which immediately reported to the hospital. Another aircraft was sent to Chamberlain, and McGinnis and a maintenance technician quickly sped down I-90 to the downed aircraft. Willis sustained minor injuries. Despite a harrowing first flight, O’Daniel continues his career as a medic.

‘It’s Dark!’

Reported in the local newspapers, the collision with a duck did not go unnoticed by the staff at Trauma 1, which already had plans to equip with NVGs. Helicopter pilots in South Dakota are well aware of nighttime’s hazards.

“When I flew around Washington [D.C.], I could see forever at night,” says Trauma 1 pilot Jack Diehl, recalling past HEMS missions in a well-lit, urban environment. “But when you leave Sioux Falls, it’s dark!”

Darkness combined with unpredictable weather can create a perilous circumstance. “When you turn the searchlight on, you may see clouds below you,” Diehl warns.

During R&W’s visit, Trauma 1’s Bell 230 had just returned from Hill Aero in Lincoln, Neb., where its cockpit was painted to be NVG compatible. Its four pilots were awaiting the arrival of Boise, Idaho-based Aviation Specialties Unlimited, contracted to provide NVG training and install cockpit lighting (sans infrared) appropriate for NVG operations. Trauma 1 began night vision goggle operations this spring.

When Careflight lifts off at night, the pilot and medical crew all wear NVGs. “The hospital bought four sets, knowing we would use three all the time,” says McGinnis. “When the nurse and medic are with a patient, they may not have them [before their eyes], but otherwise they ‘goggle up’ and help the pilot by scanning for traffic, wires and obstacles.”

To become an NVG operation, Careflight pilots and medical personnel took classroom instruction, then the pilots performed a proficiency flight and the medical personnel took a two-leg night flight. To maintain NVG proficiency, nurses and medics must go on two night flights every 60 days, and the pilots must periodically carry out a list of tasks—takeoffs, landings, hovers, etc., with NVGs—as directed by FAR 61.57, paragraph F, which FAA updated Oct. 20, 2009.

Trauma 1 personnel have yet to decide who, other than the pilot, will wear NVGs. “The medic sits up front on the way out, and there’s a good chance we’ll have him or her wear goggles,” says Mike Christensen, Trauma 1 director. However, in March, he said the decision will be made after the pilots are trained, and added, “the flight nurse in the cabin will not be wearing NVGs.”

What’s the Weather?

The prairie is known for its extreme weather. Winter brings blowing snow and freezing temperatures. Summer sees thunderstorms, even tornadoes. And a thick fog can appear any time of year. “We have a lot of ceiling issues,” McGinnis adds.

Making matters worse is South Dakota’s limited weather reporting. “We have only 17 weather reporting points in South Dakota,” says Diehl. “Meanwhile, Minnesota has hundreds.”

“Weather reporting is sparse,” McGinnis agrees. “We only get an altimeter and winds report out of Chamberlain, no ceiling or visibility readings, and we have big open areas where weather is not reported at all.” Consequently, both HEMS operations in Sioux Falls have adopted conservative minimums. Careflight’s are 1,000-foot ceiling and three miles visibility during the day and 1,500/five at night. Trauma 1 takes a two-tier approach, with local (within 30 nm) minimums of 800/two daytime, 1,000/three at night, and cross-country minimums of 1,000/three daytime and 2,000/five at night.

Kerry Berg, Trauma 1’s chief helicopter pilot, estimates Trauma 1 misses about 200 flights annually due to weather. “We had 1,200 requests [for helicopter pickup],” says Brian Erickson, Avera McKennan’s emergency services manager. “Because of weather, we completed about half of them.” Both medical centers operate IFR fixed-wing aircraft, which are commonly summoned to back up the rotorcraft. Avera McKennan has a Beech King Air and Trauma 1, two King Airs.

Careflight and Trauma 1 are VFR operations, but both have the intent of adopting instrument flight rules. “We fly single-pilot VFR,” says McGinnis, “but we have an IFR aircraft.

The Eurocopter EC145 has dual autopilot and Garmin’s GMX 200 multifunction display (MFD) plus the GNS530W and GNS430W nav/comm systems capable of WAAS (wide area augmentation system) navigation using GPS.

The pilot can overlay on the MFD imagery from a moving map display, Honeywell weather radar and a Garmin GDL 69 data link that provides NEXRAD, METARs and current weather conditions. The MFD also can show warnings symbols from the EC-145’s Honeywell Mk21 enhanced ground proximity warning system (EGPWS) and Avidyne traffic alert and collision avoidance system (TCAS).

According to Hilzendager, Careflight is the first EMS operators in the U.S. to use satellite mobile phones. The Flight Cell DZM phones also provide backup flight following.

Careflight’s helicopter also is fitted with an omni-directional camera that can record up to eight hours of activity in the cockpit and cabin. Hilzendager explains that it mainly contributes to crew training and claims he does not find it to be intrusive. “We’re getting paid to be professionals, and if we’re not [professional] in some way, then that should be addressed.”

The EC145 is Careflight’s first IFR-equipped aircraft. “In the next year, we very well will fly IFR. It’s only a matter of training the pilots,” says McGinnis.

Trauma 1 has the distinction of owning one of only two Bell 230s not equipped with an autopilot and therefore not fit for single-pilot IFR operation. It is the second 230 (No. 23002) Bell Helicopter Textron delivered, after using it as a demo aircraft. All succeeding 230s have been factory equipped with autopilots.

“I’m an IFR check airman,” says Berg. “We do our training for IFR and are ready for IFR.” Christensen asserts that Trauma 1 will take the next step by acquiring an IFR helicopter, but couldn’t say when.

Though minus an autopilot, the 230 is well appointed with Rockwell Collins nav/comm, Honeywell EGPWS and weather radar, SkyWatch TCAS, Bendix-King weather radar and an MFD that presents XM weather and a moving map display along with other data. Trauma 1 employs EMS Sky Connect for its satellite flight tracking and satellite phone service.

Both HEMS operations utilize the South Dakota Interagency Communications System, a statewide digital trunked radio network operating on VHF-highband. It allows the helicopter to communicate with law-enforcement units, ground ambulances and government agencies within the state.

Alike, but Different

Both Sanford and Avera McKennan are part of a hospital network, a factor contributing to their need for fixed-wing and helicopter transport. Both hospitals own their helicopters, too, but the histories of these HEMS operations reveal fundamental different choices made.

Sanford Medical Center initially contracted Rocky Mountain Helicopters to provide a total HEMS operation. Rocky supplied an Alouette III in 1986 and then an Agusta A109, followed by a Bell 222. The hospital broke from Rocky in 1998, purchasing the 230 and attaining its own Part 135 air carrier certificate. Sanford’s total air operation is called Intensive Air; Trauma 1 is its rotary-wing component.

At the hospital complex, Trauma 1 has a rooftop helipad and a 60-by-80-foot hangar built four years ago. The hangar houses a couple of ground vehicles, a spares inventory, sheet-metal equipment and an office for two maintenance technicians, along with the helicopter. Fuel in a 10,000-gallon tank is available at one end of the helipad. There is a communications center in the hospital for dispatch and for flight following that receives updates every two minutes via EMS Aviation’s Sky Connect satellite communications system.

Avera McKennan’s Careflight, South Dakota’s first HEMS operation by a month, began with Omniflight Helicopters, providing crew and a Bell 206L. The LongRanger was traded for a 222UT in 1992 and served until last year. Like Sanford, Avera McKennan acquired its own helicopter, the EC145, but unlike its counterpart, it continues to contract Omniflight for crews, technical support and the Part 135 certificate. “We have a good relationship with Omniflight and see no reason to change,” says McGinnis.

Omniflight provided Careflight’s NVG training, sending an instructor from its headquarters in Addison, Texas. Eight of Omniflight’s 11 flight instructors are authorized to provide such training. The 45-year old HEMS operator has equipped nearly half of its about 100 air medical helicopters with NVGs and plans to have all equipped by year’s end.

The Careflight helicopter is based at Sioux Falls Regional Airport with the King Air. However, the operator plans to emulate Trauma 1 by building a rooftop hangar at the hospital, next to the helipad. It will shelter the helicopter and two maintenance technicians and coexist with an above-ground 10,000-gallon fuel tank. Construction of the about 60-by-100-foot structure was to begin in March.

For dispatch, radio communication and flight following, Avera McKennan contracted a multi-operation communications center in Rochester, Minn., home of the well-known Mayo Clinic. “We use that communications center for economy of scale,” says McGinnis. “We found it is more efficient to have them do [dispatch and radio communications] rather doing it in-house.”

Also following Careflight’s flight operations is Omniflight’s operations control center (OCC) in Addison. Aircraft positions are reported to both Rochester and Addison every three minutes via the OuterLink satcom system. The system includes a mayday switch; when activated, transmissions of the aircraft position are hastened to every 30 seconds. The OCC tracks all of Omniflight’s air-medical helicopters, located on 72 bases. OuterLink also accommodates voice communications, which can be critical when operating in remote areas, beyond the UHF signal’s effective range.

Because it is part of Omniflight, a large multi-helicopter operator, Careflight must adopt a different policy than Trauma 1 regarding the decision to go on a mission. FAA requires that large helicopter operators have an OCC and that a coordinator in the center and the pilot assigned to a mission both agree that the flight should be made. While the pilot becomes aware of the local weather and type of mission, the OCC coordinator calls up the aircraft’s maintenance status, pilot’s proficiency and a “big-picture” view of the weather, thanks to data from WSI, the National Weather Service and other sources. Together they make the go/no-go decision; either person can nix the flight. A medic or flight nurse also can halt a mission. “It does a patient no good if we risk our lives getting to him,” says McGinnis, explaining a discreet policy that also includes not telling the pilot about the patient’s condition because it may influence his decision to fly.

For the EC145 to takeoff, the Careflight pilot must first receive a go-ahead in the form of a release number that Omniflight’s OCC sends on-line to the communications center in Rochester. Omniflight has issued some 150,000 released numbers over the past three years, indicating the operator’s fleet-wide activity.

At Sanford Medical Center, “anyone [of the assigned Trauma 1 crew] can cancel a flight; only the pilot can accept it,” says Christensen. The pilot makes his decision after checking conditions from weather briefs and the National Weather Service on a computer in the pilot’s quarters.

Friendly Competition

Is there room for two comparable HEMS operations in Sioux Falls? The common use of NVGs, concordant plans to acquire IFR aircraft, and decision to both have on-site hangars indicate a clear “keeping-up-with-the-Joneses” rivalry.

But it appears to be a friendly one, and both operations, located only several miles apart, would seem to be busy. Careflight posts more than 600 flights and about 900 flight hours annually. Berg reports that Trauma 1 logged 468 missions and about 500 flight hours last year.

“We compete, but if they can’t complete a flight, they will turn to us for backup and, in turn, we will do the same,” says Berg. In fact, when Careflight’s collision with a mallard forced the EC145 to land in a cornfield last November, it was Trauma 1’s Bell 230 that flew to Chamberlain to complete the mission.

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