Medevac Decision-Making Process

[Guest alsfirefighter]

1. I agree with my brother Goose.

2. If anything we can have another discussion about medevac use and proximity to facilities.

And yes for those wondering I'm talking about the IA made earlier about an MVA on a highway that basically runs almost right by WMC.

[WAS967 97]

ALS: I know which one you mean. I wondered about it myself. Rest assured the lead agency involved automatically flags all Medivac jobs for QA/QI review.

[ckroll 101]

1. I agree with my brother Goose.

2. If anything we can have another discussion about medevac use and proximity to facilities.

And yes for those wondering I'm talking about the IA made earlier about an MVA on a highway that basically runs almost right by WMC.

Indeed. This thread needs hijacking. Per the IA it was 26 minutes from helicopter request to enroute to WMC. Obviously, time to ambulance on location, possibly an extrication, status of the airway, are just some of the unknowns, but 26 minutes, an unconscious patient and without movement is a long time.

While I am solidly in the camp of those who think helicopters ought to have a VERY small role in transports in the Putnam/Westchester area, I'd love to read a spirited defense for helicopter use when ground transport is under 30 minutes to Level 1 trauma. Anyone want to step up here?

[helicopper 1,050]

These posts were extracted from a closed thread but the topic is worthy of continued discussion.

The scene in question was 8 miles (via road not direct) from the Westchester Medical Center and since no entrapment was reported, one has to wonder why 42 minutes elapsed on scene when the travel time would be 10-12 minutes with traffic.

WAS, if this call is reviewed will it be by the ALS provider or both ALS and BLS? Since the FD requested the helicopter it is unclear if it was at the direction of EMS on scene or a decision made prior to their arrival. Any idea bout that?

NOTE - THIS IS NOT MEANT TO BE CRITICAL BUT RATHER A LEARNING PROCESS.

[firemoose827 324]

Oh oh...dont even get me started on this! LOL

This is another good topic, and one that is abused quite a few times near me. I have seen a squad call the bird for a rollover MVA before they arrive on scene to find the pt out of the vehicle already but they STILL wait...30 MINUTES for the bird to land?!?! They could have been 3/4 of the way to the trauma center but they waited and it took an additional 10 minutes for the bird to land and crew to enter the ambulance, another 15 minutes for the crew to assess and start their treatments, and another 10 minutes to load the pt in the bird...when they could have been at the trauma center and half way back to the station before the bird even landed.

Call the bird for extended extrications...special rescues like water rescue, burns, trench rescue or industrial entrapments that will require time to get the patient out but will yield injuries that require special care like burn centers or hyperbaric chamber. People abuse that service way too much, and may possibly be keeping it from another squad that may actually need it.

[STAT213 332]

I'll jump in here. Yes, there is a place for using medevac close a trauma-rama center. Will the crew bring something to the scene that you don't have or need? IE RSI, blood, chest tubes, etc. Other thoughts are for traffic, etc. I did scene calls this close to the medical center when I was there. Didn't get all of them, but hey, I was just a guy in a suit, happy to get out of the office to fly!!!

Waiting for a helicopter when you can drive to the trauma center. Bad idea. Helicopters don't save lives. Especially now that I work on a fire engine!!! Getting to the trauma center saves lives. Do it in the fastest, safest manner possible. (I will argue with you until I am blue in the face that helicopter transport is as safe if not safer than ambulance transport.)

Something I always tried to do but never was able to pull off was to land and then hop in the bus for the ride to the ED. For transports close to the hospital, that is the fastest. Eliminates the move to the a/c and the unload at the hospital.

Its a never ending process, figuring out the EMS thing. Sometimes too, you get down a road and can't see that you're taking the longer, harder road until you get to the end. I always hope that I can figure that out and not take the road twice!!!

Edited June 3, 2009 by STAT213

[WAS967 97]

WAS, if this call is reviewed will it be by the ALS provider or both ALS and BLS? Since the FD requested the helicopter it is unclear if it was at the direction of EMS on scene or a decision made prior to their arrival. Any idea bout that?

It would be by the ALS agency. If warranted, I'd imagine the QA coordinator might reach out to the BLS agency for additional information if needed. I think the only time there is any regular interactivity between ALS and BLS is at call audits.

Again I will stress that the QA process for Medivac jobs such as this is automatic and routine, as it is for several other types like cardiac arrests and acute strokes. I've no idea if the call for medivac in this case was warranted or appropriate. I will leave that up to people on a higher pay grade than I.

[paratrooper75 41]

1. I agree with my brother Goose.

2. If anything we can have another discussion about medevac use and proximity to facilities.

And yes for those wondering I'm talking about the IA made earlier about an MVA on a highway that basically runs almost right by WMC.

You beat me to this one. I was going to post something like this yesterday. Yea, Medevac for a location 10 minutes from the trauma center....

[Guest EFFP411]

These posts were extracted from a closed thread but the topic is worthy of continued discussion.

The scene in question was 8 miles (via road not direct) from the Westchester Medical Center and since no entrapment was reported, one has to wonder why 42 minutes elapsed on scene when the travel time would be 10-12 minutes with traffic.

WAS, if this call is reviewed will it be by the ALS provider or both ALS and BLS? Since the FD requested the helicopter it is unclear if it was at the direction of EMS on scene or a decision made prior to their arrival. Any idea bout that?

NOTE - THIS IS NOT MEANT TO BE CRITICAL BUT RATHER A LEARNING PROCESS.

I'm thinking along the same lines as you Chris. I would have to think that maybe FD made the call for the bird and nobody that arrived on scene after that wanted to make the call to cancel it? One would think that there are those that feel they don't have the authority to override a commanding officer. I will not speculate much beyond this as I was not there, but you can be guaranteed there are always 10 sides to the story and you have to take bits and pieces of each and play the puzzle game to get the truth. I can also tell you that if I was 8 miles away from a level 1 trauma center, i would NOT be the guy that made the call for a medivac. I have even been hesitant to make the call for one being 30+ minutes away from WCMC and 25-30 minutes from the local level 2 facility. I would however take more time to consider the options between WCMC and the level 2 by ground. All options have been utilized in the past, and the outcome was not bad either way. Medical control was also consulted at the level 2 on all occasions that i recall before making the ground run to WCMC. But like I said, that's just my opinion, and the finer details and dissections are done by personnel on the QAQI committee, who are of a higher pay-grade than me, lol.

[WAS967 97]

Personally, as a medic, I have no problem canceling a helicopter if I get on scene and determine that one is not needed. I really don't care if I hurt people's feelings but in the end it comes down to what is best for the patient. Yes there are some instances where maybe the helo has something I don't (RSI comes to mind). As STAT mentioned, the crew can hop in and we can paralyze and go. Just because the crew came on the chopper, doesn't mean they have to transport on the chopper. The pilot can meet them back at the hospital. Up north Albany's helicopter program specifically says they are available for ALS intercepts if needed. Yes, with the helicopter. They right out say they will land, board ambulance, and transport by ground if needed. (Ironically a local REMAC issues a policy statement saying that helicopters are not to be used for routine ALS intercepts - go figure).

In this time and age it seems there aren't as many people that are dazzled by a Stat Flight landing as there were years ago. I remember people calling the bird at the drop of the hat, a lot of time because "it's cool". That trend SEEMS to have died off quite a bit in the last 10 years, but that's not to say that people don't still do it "just because they want to do a STAT Flight job".

But anyways, back on point. It's hard to judge the call at hand without more information so I personally refuse to say whether the decision was the right one or the wrong one or somewhere in between.

[Guest cobycaptain]

I'm fairly new to this forum, but have reviewed quite of bit of forumss, My issue is, that people need to get their facts straight before posting ANYTHING. Several things have been posted about issues in my county, and alot of them have no truth to them. This topic about Medflight. I as a Captain and ALS provider do call for the bird, if I feel it is needed. We are dispatched to "Serious MVA's" I put them on stand by, because talking with the flight medics & pilots, it taked them 10-15 minutes before they are in the air, pre-flight checks and weather conditons need to be checked, so we were told to by them to get them on stand by ASAP, but assess and see if they are needed quickly, and if not cancel them. I just get tired of people who aren't active to be bashing things that they don't have all the facts. 1 thing comes to mind was the billing situation in the county. It wasn't the County Coordinators that wanted the billing it was the County Supervisors that wanted it. The county coordinators asked for a 3rd position to help when 1 of them want to go on vacation. 12 squads in the county and 4 of them have volunteer ALS providers, and 2 full time county coordinators to covre the rest, I think they do a awesome job.

[RSM2063 2]

The recent call on the parkway where the helicopter was used was requested by the Medic on scene and although the request came via radio from the fire chief, the request was initiated by the ranking medical person on scene. It is unfair to monday morning quarterback without full knowledge of the pertinent issues and facts that an individual case presents. Any critique should be between the agencies involved and those responsible for QA(who are privy to all of the facts and circumstances) in an effort to improve the system.

[STAT213 332]

RSM,

Thank you for reminding us not to monday morning quarterback calls. But, if you don't do that how do you learn? Remember the definition of insanity, doing the same thing over and over again and expecting a different result.

What was asked in the beginning of this thread were reasons to use a helicopter when you are SO close to a trauma center and on a major road that leads to it.

It is being critiqued here because it does not make sense. Using the helicopter will ADD time in this case, not save it - all things being equal. That's why it was asked - what would be the reasons to use the a/c. People here have been for the most part respectful and trying to learn, not just flaming the people who were involved in this call.

Like WAS said, we do not have all the info, so we can't make a decision. But, looking at it from the outside, something seems amiss. That's all.

[RSM2063 2]

Agreed!!! Its all about learning however speculation does not breed answers nor does it fill in the blanks that are left out in these forums. The people who need to learn from each instance are those involved (Q/A and peer review). In turn they then pass along their knowledge to those they work with to ensure that current and future generations of Firefighters and EMS Personnel have mentors with first hand knowledge and experience based on real world experience.

I do believe that one can learn from these forums, however its discussions must be grounded in facts as their is an exception to every rule. Mistakes will be made by even the most seasoned veterans and we need to create more of an atmosphere where factual information is shared not criticized. The sharing of experiences is critical to the learning process.

[Guest alsfirefighter]

The recent call on the parkway where the helicopter was used was requested by the Medic on scene and although the request came via radio from the fire chief, the request was initiated by the ranking medical person on scene. It is unfair to monday morning quarterback without full knowledge of the pertinent issues and facts that an individual case presents. Any critique should be between the agencies involved and those responsible for QA(who are privy to all of the facts and circumstances) in an effort to improve the system.

Simply discussing something at face value isn't monday morning quarterbacking and I saw none of that type of behavior in any post made on here. The incident you mention was only mentioned because it was current and because of the distance. No incident specifics were given and if they were they could even be further debated here. We all don't live on an island and in your thought process of keeping critiques between agencies involved and those responsible for QA lends itself to nothing. The medical professional lives and thrives on this type of discussion and study. That is why we have call audits and case reviews and in some systems grand rounds to see patients post care. You also stated that discussions should be stated on facts. Which from what I have read was the case. It is 8 to 10 miles to WMC on a major highway (from the cross street given) which runs right by the facility. Traffic was cited. Traffic is not part of the selection criteria for use of a medevac. I have never used that as an excuse and never have had an issue even during rush hour and I have to go through significantly clogged arterials. EFFP was making an instance on what could have been..not was due to the lack of information and probably based on experience. I have had many occasions where fire chiefs and sometimes police officers call for a medevac and have no medical training and often based on the appearance of vehicles. It was probably foreign to him that a provider (particularly an ALS provider) would call for a medevac that close. Extrication or not. Get them out of the vehicle rapidly and get them to definitive care.

The people who need to learn from each instance are those involved (Q/A and peer review)

Again I touched on this above..but again as an educator of both the fire service and EMS I couldn't disagree with you more. In this type of thought process the same decision (and I'm not saying whether it was right or wrong, just questionable with the distance and the total time given in the IA) could be made by many other persons in agencies within our "system." And to me with education the system is pretty big from Regional to County to State and even federal depending on the circumstances.

[Goose 188]

Couldn't agree more with ALS, education is everything. From an EMS perspective, it never stops.

Anyhow, in the midst of brushing up on some local protocol stuff for an exam i have, i figured i would take a look at the Westchester/Hudson Valley Air Medical Service protocol.

The protocol outlined by the helicopter committee is as follows:

Air Medical Services (AMS), like Helicopter Transport, is an air ambulance and an extension of

EMS. It should be considered in situations wherein:

1. The transport of critically ill or injured patient(s) to an appropriate facility will be faster by

AMS than by ground ambulance, if time is determined to be a factor in patient care.

2. If specialized services offered by the AMS would benefit the patient(s) prior to arrival at

the hospital.

The following criteria should be used when considering use of AMS:

• The patient’s condition is a “life or limb” threatening situation demanding intensive

multidisciplinary treatment and care. This may include but not be limited to:

• Patients with physical findings defined in the adult and pediatric major trauma

protocols1

• Critical burn patients

• Critically ill medical patients requiring care at a specialized center to include, but

not be limited to: acute stroke or ST elevation MI as defined by NYS protocol

NOTE: Patients in cardiac arrest who are not hypothermic should be excluded from

these criteria.

The following medical criteria MUST be met prior to requesting AMS at a scene of patients:

ADULT MAJOR TRAUMA

1. GCS less than or equal to 13

2. Respiratory Rate <10 or >29 breaths per minute

3. Pulse rate < 50 or > 120 beats per minute

4. Systolic blood pressure < 90mmHg

5. Penetrating injuries to head, neck, torso or proximal extremities

6. Two or more suspected proximal long bone fractures

7. Suspected flail chest

8. Suspected spinal cord injury or limb paralysis

9. Amputation (except digits)

10. Suspected pelvic fracture

11. Open or depressed skull fracture

PEDIATRIC MAJOR TRAUMA

1. Pulse greater than normal range for patient’s age

2. Systolic blood pressure below normal range

3. Respiratory status inadequate (central cyanosis, respiratory rate low for the

child’s age, capillary refill time > 2 seconds)

4. Glasgow coma scale < 14

5. Penetrating injuries of the trunk, head, neck, chest, abdomen or groin.

6. Two or more proximal long bone fractures

7. Flail chest

8. Combined system trauma that involves two or more body systems, injuries or

major blunt trauma to the chest or abdomen

9. Spinal cord injury or limb paralysis

10. Amputation (except digits)

CRITICAL BURNS**

1. > 20% Body Surface Area (BSA)

2. 2nd (Partial thickness) or 3rd (Full thickness) degree burns

3. Evidence of airway / facial burns

4. Circumferential extremity burns

**Note that for patients with burns and coexisting trauma, the traumatic injury

should be considered the first priority and the patient should be triaged to

the closest appropriate trauma center for initial stabilization.

Per the NYS BLS Protocols, if a patient does not meet the above criteria for Adult Major

Trauma, but has sustained an injury and has one or more of the following criteria, they are

considered a “High Risk Patient”:

• Prone to bleeding disorders (i.e. hemophilia, taking anticoagulants)

• History of cardiac and/or respiratory distress disease

• Insulin dependent diabetes, cirrhosis, or morbid obesity

• Immunosupressed patients (i.e. HIV disease, history of organ transplants or taking

chemotherapy treatment)

• Age >55

Sorry for the length, just thought it may give a bit of perspective.

Edited June 4, 2009 by Goose

[helicopper 1,050]

Personally, as a medic, I have no problem canceling a helicopter if I get on scene and determine that one is not needed. I really don't care if I hurt people's feelings but in the end it comes down to what is best for the patient. Yes there are some instances where maybe the helo has something I don't (RSI comes to mind). As STAT mentioned, the crew can hop in and we can paralyze and go. Just because the crew came on the chopper, doesn't mean they have to transport on the chopper. The pilot can meet them back at the hospital. Up north Albany's helicopter program specifically says they are available for ALS intercepts if needed. Yes, with the helicopter. They right out say they will land, board ambulance, and transport by ground if needed. (Ironically a local REMAC issues a policy statement saying that helicopters are not to be used for routine ALS intercepts - go figure).

In this time and age it seems there aren't as many people that are dazzled by a Stat Flight landing as there were years ago. I remember people calling the bird at the drop of the hat, a lot of time because "it's cool". That trend SEEMS to have died off quite a bit in the last 10 years, but that's not to say that people don't still do it "just because they want to do a STAT Flight job".

But anyways, back on point. It's hard to judge the call at hand without more information so I personally refuse to say whether the decision was the right one or the wrong one or somewhere in between.

It is all about what is best for the patient and these types of discussions may be spawned here but carry on at the firehouse kitchen table (that we hear so much about), the EMS shift change, classrooms or drills, and other venues where specific agency guidelines and policies can be discussed. Veteran providers (regardless of service) can provide info to newer members and improve their clinical insight and perhaps even judgement.

The specific incident that prompted the start of this thread is being discussed conceptually - not specifically - and nobody is bashing anyone, quite the contrary. I for one do not have any personal knowledge of this incident and stated so. That notwithstanding, my opinion is that it is the rare case where a medevac is appropriate in such close proximity to a trauma center or perhaps even a local hospital. I've been involved in situations where a helicopter is requested within 5 miles of a trauma center. Where is the logic in that? Barring extremely unusual circumstances, it will take longer to go by air in those cases and I question whether or not that is the right call.

Some questions were asked and have been answered and nobody engaged in any monday morning quarterbacking. We're discussing things generally and objectively. Please try not to get defensive or take this personally as that is not the goal here.

[ckroll 101]

I will speculate it is all part of the learning curve. If a medic calls for a bird, then from a call management perspective, it's over. That's what you do. That said, I'd been to maybe 100 stat flight landings over 15 years before I decided to upgrade to medic and there were children in my class that still had wet ink on their EMT-B cards. I don't know how a medic builds perspective about when to fly or when to drive without both some experience and listening to some lessons learned by others. There is a maxim in aviation that Good judgment comes from experience... and that experience come from bad judgment.

A scene can look just awful, and that can justify a decision to consider a helicopter, but then one has to ask, how is this helicopter going to help this patient? If there are demonstrable benefits, then by all means, fly. If the purpose is to make the patient someone elses problem, then it's time to suck it up and consider good skills enroute. In the late 80's, back before medics and before trauma centers, getting good help to the scene was a godsend. With more tools and adjuncts available in the field and more training, one should properly ask, where is the added value? Flying is dangerous. Flying is expensive. Helicopters are a limited resource. Before I ask a flight crew to take to the air, I want to feel that it is absolutely necessary.

So how do the old salts make the call on this?

[Oswegowind 17]

I used to work on the ambulance...seems like ages ago...lol

We called the bird to Yonkers once in a while...never waited with a patient we could move by ground though! A few instances I can think of are an extended extrication job on the BRP in Garth Woods, north of Harney Rd...Helo had to wait on the ground for a bit too, extrication job on warburton av recently...flight medics jumped in bus to help empress to St. John's since victim went into cardiac arrest upon arrival at LZ (JFK Marina)...and I recently made the call sitting at my desk once again (Warburton too...put em on and confirmed their response) for the job on the Bronx River Parkway with the overturned auto in the water at Woodlawn because we were calling for divers, I thought it may be needed...wasn't used as far as I know though. There are times, but they are few and far between...however, no one should ever INCREASE transport time just because they called the helo. If it looks like a tough job and you think it is appropriate, it may be...but things may change and you have to adjust your game plan in the middle of the game sometimes! Leaving for the hospital because they are 5 min away and you are 10-15 away from the H is a good idea. 5 min eta means til they are overhead, then they have to land, cool off, take over pt care, load, and take off...5 min may equal the same 15 it took you!

All I ask is that everyone uses their noggin! And if you mess up, learn from it!

[ny10570 745]

How is it that everyone agrees on the times and conditions when we should be calling for a bird, yet every couple of months we wind up with another one of these threads. Its not the same guy calling for a bird each time. There have got to be some members who either know why the bird was called or believe they should be called more frequently. Lets hear from you. If you don't want to face some of the stronger opinionated members of this board, PM me the details or your reasoning and I'll take up the cause. Otherwise, there's nothing to learn here since without debate nothing changes.

[ckroll 101]

How is it that everyone agrees on the times and conditions when we should be calling for a bird, yet every couple of months we wind up with another one of these threads. Its not the same guy calling for a bird each time. There have got to be some members who either know why the bird was called or believe they should be called more frequently. Lets hear from you. If you don't want to face some of the stronger opinionated members of this board, PM me the details or your reasoning and I'll take up the cause. Otherwise, there's nothing to learn here since without debate nothing changes.

Absolutely. Calling all bird lovers. Make the case for using helicopters. I went in one myself, actually. It was a Peekskill to Jacobi trip and the hospital didn't want to take the risk of an anaphylactic reaction in traffic to the city. That makes some sense.

The last time I called for one was 3 years ago, maybe. It was a 12 foot fall backwards through a deck railing onto a walkway with pointy brick edging and deeply unresponsive but clenched. I foresaw airway issues, but by the time we were packaged the patient was somewhat responsive and it was looking more like drunk as a skunk. [ And likely really banged up as well.] Helicopter resources were probably unnecessary, but it was on the ground before that was clear. My bad.

[NWFDMedic 58]

I have never been in the position to be 10 minutes from a level 1 trauma center and had a call that would potentially require a medevac. In my short time at Sloper, I never did any calls out in Medic 4 that was a hop, skip, and a jump from Danbury that may have met the trauma criteria (call me a white cloud).

I have, however, been that guy in regards to a level 2 trauma center and my decision was questioned by the Monday morning QB's (not by my agency's QI committee because they actually read my report). I was a 10-12 minute drive from a level 2 trauma center and I came upon a car wrapped around a telephone pole basically into the driver's compartment. For 30-45 minutes, the only visible contact I had with the patient was one hand and audible contact revealed a conscious but confused patient. There was blood everywhere around the scene and I knew from the start that this was going to be a difficult extrication.

To make a short story long, the helicopter was on the ground and at my side when we got access to the patient, only to find out that the patient had some significant injuries but was not significant enough to warrant transport past the level 2 to the level 1 trauma center. I made the decision to bring the helicopter based on limited information and a long extrication in the best interest of the patient, should they need a level 1 trauma center. People could question that around the table at the station all they want, but I still feel it was the correct decision.

My decision to call for a medevac in most situations is a combination of the availability of the patient (ie. need for extrication), the condition of the patient (if I am limited in access, I will presume worse rather than better), and distance to a trauma center. I must say though, as my experience has grown, I'm more comfortable transporting the patient by ground than calling for a medevac that can be better used somewhere else. It also helps that I have RSI available to me if needed.

[WAS967 97]

Helicopter resources were probably unnecessary, but it was on the ground before that was clear. My bad.

I disagree. As you said, you foresaw issues and called in the resources you thought necessary at the time. No harm done.

I made the decision to bring the helicopter based on limited information and a long extrication in the best interest of the patient, should they need a level 1 trauma center. People could question that around the table at the station all they want, but I still feel it was the correct decision.

THIS

Edited June 4, 2009 by WAS967

[ckroll 101]

Thanks, but I will respectfully disagree with your disagreement. 'No harm done.' is a starting place but it shouldn't be the standard. EMS needs to be outcome oriented. When a 'good' decision doesn't ultimately end up where it ought to, that is reason for evaluation, and for threads like this.

The craft in EMS comes in both making good decisions AND in those good decisions also being the right ones.

As someone pointed out, the same type of thread emerges regularly and regularly we read of decisions that on their face do not make sense. The sensitive combatant replies something along the lines of 'Well, you weren't there!".....No Shi[p], Sherlock. I wasn't there and the only way I can understand a decision is if people who know more than I do step up. Interest in what happens on calls to which we are not party is not an opportunity judge, but an opportunity to learn.

How does a decision get made? I'm surprised this hasn't gotten more traction. Why don't we all step up with a helicopter call that went the way we wanted it to and one that didn't. Surely we all have been in charge of one of each. Or am I the only medic who has ever been repacking the gear while muttering 'That could have gone better..'?

[ny10570 745]

ckroll and NWFD, those are excellent examples of when to call for the bird. What matters is what you did when you realized the flight was not necessary.

[ckroll 101]

ckroll and NWFD, those are excellent examples of when to call for the bird. What matters is what you did when you realized the flight was not necessary.

Once it's on the ground, the resources are committed and sending it back empty or full isn't that much of a savings, and local resources get back in service faster. At some point one has to pick a strategy and stick with it. The down side is that we so seldom get feedback about nature of the injuries. It would be so much easier develop a good game if we knew when we sent someone out in a helicopter if timing mattered or if they were a treat and release. I recall a story from long ago that a significant number of patients ended up being treat and release.

On the other side...It's a story twice told and not mine, but a woman 7 or 8 months pregnant hit a tree and couldn't remember the accident. The medic insisted on a helicopter for her, got some heat locally for it. He got a phone call a few days later, thought it would be a complaint, but the woman had torn the placenta and an emergency delivery was performed. Apparently right time and right facility had been critical to a good outcome. Since his experience, I've bumped it up a notch for anyone with a viable fetus.

A real screw up with a bird..... We left the door open to the pumper at the landing zone on a hot, dry summer day and the rotor wash filled up the cab with sand. And I mean filled it up.