HEMS and the Golden Hour

If you are severely injured, a helicopter flight to a top-level trauma center will boost your chance of survival over ground transport. That’s the conclusion of a rigorous national comparison of the effectiveness of helicopter versus ground emergency medical services, as published in the April 18, 2012, issue of the Journal of the American Medical Association.

Survival after trauma has increased in recent years, given improvements in emergency medical services coupled with the rapid transportation of trauma patients to centers capable of providing the most advanced care. What has not been clear until this study is the effectiveness of helicopter emergency medical services (HEMS).

According to the American Trauma Society, trauma is the No. 1 cause of death in the United States for persons under the age of 44. Trauma is defined as an acute personal wound or injury requiring immediate care. Between 140,000 and 160,000 trauma-related deaths occur nationwide every year. For each death, at least two permanent disabilities occur.

The total annual cost of accidental death and disability in the United States is estimated to exceed $110 billion. Despite the staggering cost, trauma remains “the neglected disease.” Medical treatment of trauma within the first hour, often referred to as the “golden hour,” can prevent 20–30 percent of potential deaths and reduce hospitalization times dramatically. Helicopter air ambulance programs are a key resource in delivering trauma victims to trauma centers within the golden hour.

For this article, we talked with two HEMS operators: Shock Trauma Air Rescue Society (STARS), headquartered in Calgary, Alberta, Canada; and Air Evac Lifeteam, headquartered in O’Fallon, MO.


Helicopter Maintenance– How did STARS come into being?

STARS – The helicopter air ambulance program, initially named Lions Air Ambulance Service, was established in 1985, and the first mission was flown in December of that year to transport a critically ill infant to tertiary care in Calgary. Relationships, people and the commitment to respond to the needs of the critically ill and injured are the foundation of STARS’ journey from a dream and vision to reality. From that humble beginning, more than 28 years of history is captured in the stories of the people, places and teamwork that have contributed to more than 22,000 missions flown to date.

Helicopter Maintenance – How would you describe the vision and mission of STARS?

STARS – Our vision is best stated as “Saving lives through innovation, partnership and leadership.” Our mission is best stated as “Dedicated to providing a safe, rapid, highly-specialized emergency medical transport system for the critically ill and injured.” Our core values are safety, teamwork, accountability, respect and spirit.

The STARS vision and mission are supported by four pillars of activity:

Emergency medical communications – finding the patient

Patient care and transport – transporting the patient to the medical facility

Education and research – educating the providers

Fundraising and community partnerships – raising funds and working with the community

Helicopter Maintenance– With STARS being a charitable, non-profit organization, how are you funded?

STARS – The STARS Foundation is the fundraising arm of the organization. Funding is met through donations received from individuals, service groups, business and corporations, municipalities, and through collaborative agreements with provincial governments. The incredible ongoing support of the community helps us continually enhance our innovative and leading-edge air medical programs and service.


Helicopter Maintenance – Are patients billed for transport by STARS?

STARS– No matter where STARS provides service in Canada, patients are not billed for repayment of the costs for their transport by STARS.

Helicopter Maintenance – What communities do you currently serve?

STARS– We currently operate from bases in Calgary, Edmonton, Grande Prairie, Saskatoon, Regina and Winnipeg.

Helicopter Maintenance– How many helicopters do you operate and what type are they?

STARS– We currently operate with seven BK117s and are proceeding with bringing an additional BK117 into our fleet. We also have one AW139 currently located at our Edmonton base. It is in the final stages of certification with Transport Canada, but is already flying as part of aviation and medical training. A second AW139 is anticipated to arrive later in 2013.

Helicopter Maintenance– What special EMS equipment do you carry and how does that impact your maintenance procedures?

STARS– The helicopter medical interiors include many pieces of equipment found in a typical hospital intensive care unit, including medication pumps, monitors, ventilators, ultrasound machines and more. We follow instructions for continued airworthiness, associated with the medical interior approval.


Helicopter Maintenance – From a flying perspective, under what part Canadian Aviation Regulations (CAR) do you operate?

STARS– Under CAR 702 and 703.

Helicopter Maintenance– From a maintenance perspective, are you certified under a particular Part XXX as a repair station?

STARS– Yes, that is under CAR 573, Approved Maintenance Organization.

Helicopter Maintenance– How many people are in your maintenance department by job description?

STARS– We have 18 aircraft maintenance engineers (AMEs) that also do the avionics work. There are two full-time QA persons, three parts persons, one supervisor and three managers.

Helicopter Maintenance – How many maintenance shifts do you operate?

STARS– We operate one day shift and are available on call, as STARS is a 24/7 operation.


Helicopter Maintenance– In a typical 30-day period, how many and what type of inspections do you normally perform?

STARS– We do inspections every 100 flying hours and average 50 flying hours a month.

Helicopter Maintenance– What maintenance tasks are outsourced to an MRO or back to the OEM and why?

STARS– We outsource dynamic component overhauls as STARS does not have the infrastructure to support them, nor would it be cost effective for us to do so.

Helicopter Maintenance– From start to finish, what is your procedure for doing a maintenance repair or inspection?

STARS – It begins with work orders and a chief engineer coordinating all aspects of initial maintenance activity with maintenance personnel at each base.

Helicopter Maintenance– Of all the maintenance tasks that you perform, which have you found to be the most labor intensive and time consuming?

STARS– The A9 check on the BK117 is most labor intensive and time consuming, as we need to completely disassemble the helicopter to perform this inspection.

Helicopter Maintenance – Who assigns the maintenance tasks to be done each day?

STARS– The maintenance tasks are computer tracked and the forecast is monitored by the chief engineer and base engineers.

Helicopter Maintenance – Who has the responsibility for assigning aircraft to flight operations?

STARS– The STARS engineering staff release the aircraft to flight operations after any maintenance activities.

Helicopter Maintenance – Has STARS started any initiatives regarding the push towards a safety management system (SMS)?

STARS– Yes, the engineering department is beginning to harmonize with the STARS incident reporting system.

Helicopter Maintenance– If you were looking to hire a new mechanic, what skill sets would you be most interested in?

STARS– The ability to work well independently and twin-engine transport category helicopter experience.

Helicopter Maintenance– How important to you are appearance and communication skills during the interview process?

STARS– STARS has a professional culture which is reflected in all areas of the organization.

Helicopter Maintenance– Describe what takes place during a typical day in the life of the maintenance department.

STARS– Let’s take a look at a day in the life of one of our AMEs, Kim Heidel.

People’s lives depend on the work that Kim completes throughout his day. The aircraft maintenance engineer arrives at the STARS base every morning ready to make a difference.

8 a.m. Heidel reaches the base. His first priority is to talk with the pilots who are on duty, discussing how many hours were flown on the helicopter, changes to inspection times and training agendas, and if there are any problems to report. Doing so helps schedule maintenance tasks for the day.

Communication with the pilots is very important. We have to stay diligent when planning our day and making sure the helicopter is safe to fly. Our goal is to minimize any downtime and keep STARS up and running.

8:30 a.m. Heidel prints off a daily task list and heads to the hangar to get to work. On this particular day, he is checking oil pressure inside the engine, making sure that various components are receiving the lubrication they need to function safely. If a call comes in, the helicopter will be good to go.

“You have to be constantly managing time and changes,” says Heidel. “The pilots and crew are focused on the mission and it’s our job to make sure a helicopter is airworthy. The engineers are required to make some really important decisions on whether a particular aircraft can fly or not.”

11:30 a.m. After completing the maintenance tasks, Heidel joins the pilots in the helicopter for a test run to check operations and make sure the job was done right.

1:30 p.m. A special component on the helicopter is removed and replaced with a functional unit. Heidel is now tasked with fixing the older part so that it can be used again in the future.

“There are a lot of behind the scenes jobs that need to be done when not doing inspections,” explains Heidel. Whether it’s fixing a part, building special tools, touching up some paint or replacing a decal, there’s always something important to do.”

3:30 p.m. A call has come in and the STARS helicopter is out flying a mission. This is an opportune time for Heidel to sort some hardware, saying that doing so will increase the effectiveness of the engineering team. “We can’t be wasting time looking through washers or bolts to find a specific one,” he says. “Having things catalogued and organized allows us to do our job more efficiently.”

4 p.m. Heidel is flight following on a special computer program; he is able to track the helicopter’s location, airspeed and direction. By doing so, he and the engineering team can know exactly when the aircraft will be back and be prepared to work when it arrives.

5 p.m. A day of work is now complete for Heidel. He heads home to spend some time with his family, feeling good about what he accomplished throughout the day. “I leave with the gratification of knowing I played an important role in keeping STARS flying and saving lives today,” says Heidel.

There you have it, a good look at one of Canada’s HEMS organizations. STARS is dedicated to providing a safe, highly specialized emergency medical transport system to fight trauma and get patients where they have to be within that golden hour.

Air Evac Lifeteam

The Air Evac Lifeteam is supported by an expanding community of more than one million members who pay an annual fee and are entitled to be transported free of charge for life- or limb-threatening medical emergencies. Membership support enables the company to provide its services in rural areas that otherwise might not be capable of supporting an air ambulance service.

We talked with Dennis Cleaves, senior director of maintenance for the Air Evac Lifeteam.

Helicopter Maintenance– How did the Air Evac Lifeteam come into being?

Cleaves– The Air Evac Lifeteam was established by a group of local citizens to provide air medical transportation and ensure access to emergency health care for their remote community in West Plains, in the Missouri Ozark region. Although air ambulances were primarily based in metropolitan areas at the time, the company founders believed that the people who needed air medical transport the most were those living in rural areas, often far away from a hospital. That was in 1985.

Today, the Air Evac Lifeteam has grown to be the largest independently owned and operated membership-supported air ambulance service in the United States, operating more than 110 bases across 15 states. As the company has evolved since 1985, it has remained true to its original mission and patient-first focus through an unwavering dedication to:

• Remaining an independent provider, which makes it possible to impartially work with other health care providers, including more than 1,700 diverse referral sources representing more than 1,000 hospitals and more than 700 EMS agencies, to ensure patients are cared for and transported to the most appropriate medical facility;

• Providing service to the medically under-served areas of rural America, often in rural areas that other air ambulance companies may not adequately service;

• Responding rapidly through a contiguous footprint of mutually-supporting bases in collaboration with numerous hospitals, physicians, 911 centers and EMS agencies;

• Taking an active role in the advancement of health care services in the communities it services, through local interest in, knowledge of and relationships in each community;

• Providing superior patient care and aviation operations associated with substantial financial resources, a professionally managed, common infrastructure and standardized, centrally controlled operations.

Helicopter Maintenance– How would you state the Air Evac Lifeteam’s mission statement, vision and values?

Cleaves– Our mission statement is, “To save lives and positively impact outcomes during life- and limb-threatening medical emergencies by providing rapid access to definitive emergency health care for people in rural America.”

Our vision is to “establish a network of membership-supported cooperative helicopter ambulance operations throughout rural communities across America.”

Our values are “Safety for patients and our people. Quality patient care and a professional environment of honesty, integrity, and respected hard work with an unwavering dedication to the mission.”


Helicopter Maintenance – Tell us a little bit about your helicopter operations.

Cleaves– Twenty-eight years, we started with one helicopter in West Plains, MO. The community didn’t have immediate access to a trauma center; the closest was 1.5 hours away by ambulance. Flying patients to the trauma center was the only option, Air Evac was born, and this has been our business model ever since.

Today we operate a fleet of 130 helicopters that are comprised of Bell 206 Long Ranger and Bell 407 aircraft. Air Evac Lifeteam’s instrument-rated pilots are skilled aviators who become proficient air medical pilots by training under its proprietary and FAA-approved program. Each certified pilot meets FAA standards and has flown, on average, more than 5,700 hours.

Only pilots who meet or exceed their respective state’s requirements are considered by the Air Evac Lifeteam. Before a pilot can fly for Air Evac, the candidates must demonstrate instrument proficiency in a dedicated flight training simulator. Air Evac Lifeteam is among the few air medical companies with this stringent requirement.

Pilots must also achieve standards established in Air Evac Lifeteam’s proprietary, FAA-approved training program. The 18-day course delivers operational and procedural instruction, as well as aircraft- and mission-specific training in the Bell 206 LongRanger and Bell 407 helicopters.

As part of their continuous improvement program, all pilots are required to complete recurrent training, which includes a Part 135/NVG check-ride on an annual basis. Mission-specific training includes flying at night and landing on unimproved rural terrain, such as pastures and fields. Base assignment requires rigorous local flight orientation training to become an authority on local terrain, hospitals and landmarks.

Helicopter Maintenance– Does the maintenance department have a mission statement?

Cleaves– Air Evac’s maintenance department’s mission is to promote integrity and professionalism, to assure the safety of our customers by setting and enforcing high professional standards and encouraging continual improvement in workplace safety, while providing an airworthy aircraft to support our company’s missions and goals.

Helicopter Maintenance– From a flying perspective, under what part FAR do you operate?

Cleaves– We operate under FAR 135.

Helicopter Maintenance– From a maintenance perspective, are you certified as a repair station?

Cleaves– Yes, we are a Part 145 certified repair station.

Helicopter Maintenance – How many people are in your maintenance department by job description?

Cleaves– On the 135 side, we have 154 technicians working in the field. We divide the U.S. in half; we have one regional director of maintenance for each half. He, in turn, has two regional maintenance mangers reporting to him. Each manager has a super regional maintenance office (SRMO); this is where we do our heavy maintenance. It is staffed by eight technicians. Each SRMO is surrounded by approximately 26 bases. Each base has a base mechanic permanently assigned.

On the 145 side, we have 67 technicians working in the shop. We have a director, chief Inspector, floor inspectors and managers that support five subgroups: paint, avionics, structures, overhaul and assembly.


Helicopter Maintenance – How many maintenance shifts do you operate?

Cleaves– Our heavy maintenance facilities (SRMOs) have two shifts, while all other support departments have only one.

Helicopter Maintenance– In a typical 30-day period, how many and what type of inspections do you normally perform?

Cleaves– On average, we will complete 125 inspections. Since we operate under an Approved Aircraft Inspection Program (AAIP), we have developed our own inspection process much like OEM 100-hour-type inspections.

Helicopter Maintenance– What maintenance tasks are outsourced to an MRO or back to the OEM and why?

Cleaves– We only outsource engine overhauls and small subcomponents. We are unable to justify a return on investment (ROI) by doing these items in house. If I can show that we can do it quicker, more cost effectively and with better quality, we will support this task in our facilities.

Helicopter Maintenance – From start to finish, what is your procedure for doing a maintenance repair or inspection?

Cleaves– There are so many variables. In order to assist with the complexity, we have implemented a FAR 121-like maintenance control organization.

From a 30,000-foot overview, a base mechanic will discuss with his regional maintenance manager (RMM) about any upcoming maintenance. We look for bad weather days and make sure another base close by isn’t going out of service (OOS) at the same time so we don’t have two bases out of service at once. The aircraft is placed OOS through our maintenance control center and a notice is sent out through our notification system. The maintenance is performed and our maintenance control will issue all the approval for return to service paperwork (43.9 and 43.11) to the base mechanic to review and sign. All records will be updated prior to the pilot returning the aircraft to service.

Helicopter Maintenance– Of all the maintenance tasks that you perform, which have you found to be the most labor intensive and time consuming?

Cleaves– Troubleshooting noises and/or vibrations. Unlike a gauge that fails hard, noises or vibrations tend to be subjective in nature and are very difficult to duplicate and analyze.

Helicopter Maintenance– Who performs pre-flight and post-flight inspections on the aircraft?

Cleaves– Our pilots do, but I do ask each base mechanic to look over the aircraft every day they are on shift.

Helicopter Maintenance– Who has the responsibility for assigning aircraft to flight operations?

Cleaves– Our communication center and operations control center perform this task.

Helicopter Maintenance – Who assigns the maintenance tasks to be done each day?

Cleaves– Our base mechanics are required to monitor the status of their aircraft; working in conjunction with the RMM, maintenance is scheduled either at the base or the SRMO.

Helicopter Maintenance– Please describe what takes place during a typical day in the life of the maintenance department.

Cleaves– For me, I come to work with a game plan, but in most cases it is out the window by 9 a.m. I like this, as crazy as that sounds. Every day is different. But a typical day for the department would be, on average, five to eight inspections are being performed in the field and we work on unscheduled maintenance as well. Aircraft are being moved to SRMO locations for heavy maintenance and plans are being made for upcoming aircraft upgrades — remember, this is happening 24/7, 365 days a year.


Helicopter Maintenance – Has Air Evac started any initiatives regarding the push towards a safety management system (SMS)?

Cleaves– Yes, we have for the last four years. We are currently in level three, looking to exit sometime this year into the last level four. This has been an interesting journey — very process driven and a collaborative effort with our certificate management unit (CMU) FAA. If you were to ask me a few years ago, ‘What are your thoughts regarding SMS?’, I would have given you a negative answer, but I believe SMS has value. It really makes you look at proactive hazard identification, risk management, information control, auditing and training.

Helicopter Maintenance– Do you have any lessons learned or tips you can share with our readers on a particular task that you found can improve on the maintenance process in the way of saving time, cost, materials, etc?

Cleaves– Troubleshooting — it is a pet peeve of mine. I don’t like the shotgun style of troubleshooting. What I mean by that is this: if you have a problem in a system, let’s say the fuel system. Replacing the fuel gauge, fuel transmitter, fuel harness and sending units all at once doesn’t really solve anything. I agree the problem is gone, but what fixed it? Furthermore, we have just depleted inventory of four other items. What I like is for our mechanics to spend a little more time troubleshooting down to the root cause. We replace only what is needed and the mechanic gets a better understanding of the system and we can truly track real problems looking for systemic issues.

Helicopter Maintenance – If you were looking to hire a new mechanic, what skill sets would you be most interested in?

Cleaves– Our minimum requirements are two years as an A&P with two years rotorcraft experience. Communication, in my opinion, is the most important skill set a mechanic can have. I can teach technical skill, but I cannot teach someone how to communicate well. This is a trait that I feel is diminishing with young A&Ps.

The Air Evac Lifeteam is out there saving lives and providing positive outcomes to life- and limb-threatening emergencies for the folks in rural America.