Flight Ops - The Anatomy Of A Scene Flight

Scene safety is one of the first things we learn in EMS, and interestingly, it’s often one of the first things forgotten. Human nature drives us to rush in and help as quickly as possible, sometimes leading us into dangerous situations. While tunnel vision might be an overused phrase, it captures how urgency can blur judgment when risk is highest.

We approach patient care through a hierarchy of priorities: assessment, intervention, and operational steps that stabilize the patient and get them to the right facility. Aviation is no different. While there is always an inherent level of risk in climbing into an aircraft, specific systems are in place to mitigate and control as many of those risks as possible.

Let's take a look at the anatomy of a scene flight.

There is a lot of work being done behind the scenes before an aircraft can launch. When the comm center receives a flight request, they will alert the closest, most appropriate air asset with the type of flight (scene vs IFT) and the location. The nature of the call is not initially provided to maintain non-biased, objective decision-making when checking to see if the weather is currently and forecasted to allow the crew to complete the transport safely. Depending on the size of the flight program, an individual in the operation command center (OCC) will be evaluating weather and potential risks separately from the flight crew. The FAA requires an OCC if an air ambulance program (Part 135) has 10 or more air assets. Read more about how OCC operates here.

It is not uncommon for the pilot, med crew, and OCC to all hop on a call together and discuss the forecasted weather to determine if the flight can be safely completed. If the decision among the pilot, OCC, and the med crew is to accept the flight, we move to the next phase of the process, and patient information is then provided to the crew.

It is important to note that while the pilot in command (PIC) has the final say in accepting a flight, this only applies to turning down a flight. If any person in the chain states they do not feel comfortable taking the flight, they have the right to refuse. This is often expressed as "3 to go, one to say no." This is sometimes changed to include OCC (4 to say go, one to say no).

After accepting the flight, the pilot will submit a risk assessment. This includes items such as:

• Pilot fatigue level (hours awake, duty time, sleep in last 24 hrs)

• Illness or medication use (IMSAFE check)

• Recency of flight experience (hours flown in last 30 / 90 days)

• Proficiency in type / NVG currency

• Crew composition (single vs dual pilot, new crew member, recent training)

• Stress or distractions (personal or operational)

• Type of mission (scene flight, interfacility, specialty team transport)

• Time pressure / perceived urgency

• Known hazards at LZ or departure site

• Weight and balance margin

• Fuel reserve / alternate planning

• Crew duty day length / cumulative flight hours

• Availability of alternate transport options (ground, fixed-wing)

This risk assessment is submitted to OCC for approval. The crew will begin preparing for the mission by pulling the blood from the refrigerator and placing it in the portable cooler, doing a 360 around the aircraft to ensure all doors are closed and secured.

Before the crew can lift, the pilot will need to confirm that OCC has approved the risk assessment. Typically, this comes back as a green indicator on the tablet that can be shown to the crew for confirmation that the flight is a go.

As the team begins the flight to the scene, the next important step is to establish ground contact. The comm center will typically provide the flight team with the radio frequency and department you will be contacting. Depending on terrain and radio, how far out you can actually reach the ground crew is variable.

The person on the ground who has taken responsibility for setting up the landing zone (LZ) is known as the LZ Coordinator. Flight programs spend a lot of time meeting with local fire departments and teaching LZ classes to ensure they understand how to select and prep a landing zone.

LZ coordinators know that the flight team needs a 100-ft x 100-ft space prepared and clear of debris that could kick up and enter the rotor system upon landing. If the aircraft will stay running, a tail rotor guard will ensure nobody gets even remotely close to the tail rotor. The LZ coordinator must be visible to the pilot and is typically positioned at 10 or 11 o'clock to serve as a liaison between the tail rotor guard and the pilot. Helicopters land into the wind to improve lift, stability, and control during approach and touchdown. Facing the wind increases airflow over the rotor blades, allowing them to generate more lift with less power.

Radio Etiquette

One of the first things first responders learn is proper radio call-out etiquette. When trying to contact an entity over the radio, the phrase you should hear in your head is "hey, you, it's me."

This initial contact with the LZ coordinator is designed to allow communication regarding where the LZ is, potential risks, and any additional updates to ensure a safe landing. Here are a few of the items the LZ coordinator should communicate.

Ideally, helicopters land on level, firm ground. However, sloped terrain around the aircraft is not uncommon. Always move downhill to maximize rotor clearance when exiting under the rotor system.

Traffic Control

Shortly after the crew lands, they will be directed to the patient, who may be at the accident scene or in the back of an ambulance if the patient has already been extricated. If the accident occurred on an active highway or street, the flight crew needs to know best practices for emergency temporary traffic control.

The ultimate goal is to place as much metal (emergency vehicles) between oncoming traffic and the accident scene as possible. The diagram below shows some best practices when an accident occurs on a highway.

Police, EMS, & Fire are trained and familiar with temporary traffic control, but safety is everyone's job. Here are a few things to be on the lookout for:

• Warning signs should be placed well before the taper to one lane.

• Vehicles in the "fend off" position to protect emergency workers on the scene.

• Accident + One Lane Buffer

• Ideally, the ambulance should be positioned at the end of the taper to allow for easier delivery.

Before entering a vehicle, confirm that it has been properly stabilized and that the rescue team has declared it safe to approach. Vehicle stabilization is the first step in preventing secondary injury to both the patient and the responders working around or inside the wreckage. A vehicle that shifts even slightly can trap rescuers, shear hydraulic lines, or worsen patient injuries.

Stabilization techniques depend on vehicle type and position but commonly involve chocks, step cribbing, and tensioned buttress struts. The team responsible for stabilization should clearly communicate when the vehicle is secure before any patient contact.

If entry is necessary, ensure you’re wearing full PPE appropriate for the environment. This includes: helmet, eye protection, cut-resistant extrication gloves, a protective jacket, steel-toe or puncture-resistant boots, and high-visibility outerwear. Consider respiratory protection if glass dust, smoke, or battery off-gassing is present.

The examples shown above demonstrate the use of struts and cribbing systems to prevent movement during extrication. Notice the use of lateral tension and base cribbing to distribute the load and to avoid rebound.

Loading The Patient

After the patient has been extricated & stabilized, the next step is safely loading them into the aircraft and getting them to definitive care. Before approaching the aircraft, the flight crew must ensure that any loose items, such as hats, blankets, or wrappers, are secured so they do not get sucked into the rotor system. Typically, the crew will look at the pilot for a thumbs-up and wait for the pilot to either give a thumbs-up or flash their light indicating it is safe to enter beneath the rotor system. The illustration below shows best practice when approaching the helicopter.

Before lifting, a crew member should ensure that all doors are properly latched, no bags have been left on the ground, and no seat belts are hanging out the door. Even though there is still clinical work to be done, it is essential to assist the pilot in ensuring a safe take-off from the scene. This includes sterile cockpit technique, watching for powerlines, trees, or people/vehicles approaching the aircraft.

The Debrief

After the patient has been successfully transported to the hospital, the crew will debrief the mission, discussing what went right, what went wrong, and ideas for improvement. This conversation includes not only the flight team but also the comm center and OCC. Any safety issues must be expressed early and reported to improve the system. These debriefs are also documented after each mission. The crew will complete an additional fatigue assessment after each flight to ensure they are "green" for the next mission.

Additional Considerations

Night Vision Goggle (NVG) Operations

NVGs have significantly assisted in the safety of night operations. They work by amplifying available light (moon, stars, artificial sources) to improve visibility, but it is also essential to recognize their limitations. The LZ coordinator knows to avoid bright scene lights, high beams, and high-intensity light bars near the LZ.

Advantages

Enhanced ability to detect terrain, obstacles, and wires

Better LZ evaluation under low light

Improved situational awareness during approaches and departures

Limitations

Reduced depth perception and peripheral vision

Susceptibility to light “blooming” from bright sources

No color perception (everything is in shades of white or green)

Poor performance in fog, smoke, or precipitation

Difficult transitions between lit and dark environments

The LZ perimeter can be illuminated with commercial LZ lights.

MCI & Incident Command

A mass casualty incident occurs when the number of patients exceeds the local providers' and resources' capacity. Flight crews are an integral part of the MCI response and can help provide critical care and expedite transport to the appropriate hospital without overwhelming a single center. Understanding how the incident command system (ICS) works can help improve the flow of injured patients rather than clog it. My buddy, Rommey Duckworth, did a great job breaking this down.

Final Thoughts

There is an industry saying: "Safety never happens by accident." It is our job as first responders to create a space between call and action. Systems that expect human error and do their best to control for it. I personally think ground EMS should adopt more of the systems used in flight (fatigue assessments, risk assessments, after-action debriefs) to optimize safety and ensure everyone goes home at the end of the shift.