How to Fix the Helicopter EMS Accident Rate

Helicopter Emergency Medical Services(HEMS) is an industry at risk. Due to a rash of fatal accidents, the industry is sicker than the patients being flown. The air med business is dying because, instead of saving lives, it’s killing people, namely helicopter crews, and often their patients.

The problem didn’t happen overnight; the solution won’t come quickly, either.
From the beginning, air medical helicopters have experienced a high accident rate. The risk can never be eliminated, but it can be mitigated and reduced to the point where an air med accident is rare. The following treatise tells how that can be done. If all the initiatives listed here were put in place tomorrow, the HEMS accident rate would drop to near zero. Here’s the road map of how that can happen.

” First recommendation: for those programs requesting it, an immediate safety stand-down for FAA or another outside party review on all aspects of the HEMS operation.

One of the difficulties with the accident rate in air medical is simple semantics. What is an accident, and how are the statistics compiled? Here’s the bottom line: the stated expectation must be a zero accident rate.

A Special FAR is needed, a new regulation aimed specifically at air medical operations similar to the regs in place for helicopter tour operators. For years the FAA has been unwilling or unable to simply shut down an operator or individual program site for safety or regulatory violations. There should be the institution of an anonymous tip line to the FAA, a whistle-blower feature for passengers, crew, or other employees of the various operators to use, something similar to the NASA safety reporting form. The potential for abuse is always present with such a system; but the potential for increased transparency is, as well, and the issue is critical.

” Pilots must be better vetted and trained.

There are too many programs and too many helicopter operators such that the pilot staffing pool is too thin. With lower experience levels, and more programs flying more aircraft more hours, a growing accident rate is almost inevitable. A direct link can be made between the start of hostilities in Iraq and the latest rise in the rate of air medical accidents. Many veteran pilots with a military affiliation are flying overseas, leaving programs at home understaffed, or with less experienced pilots in cockpits or both.

Given the fact that most air medical accidents are weather-related, this makes sense. Military pilots are better able to maintain control in IIMC. The skills military pilots acquire, both in flight and with access to simulators, also confer a level of confidence unavailable to non-military pilots.

Another reason air med requires more professionalism and oversight is, that programs are 24/7 operations, with a high percentage of flying at night. Pilot error is the single most common factor in air medical accidents, and current crew rest rules are inadequate to address that. Shutting down a program after dark is not an option*, as these are emergency response vehicles, and must be staffed accordingly.

” Instrument Flight capability for recovery only in all air medical helicopters.

If used correctly, IFR capability is a powerful risk reducer in HEMS operations. What operators commonly substitute for IFR capability is company policy which demands that pilots avoid instrument weather at all cost. But the denial of upgraded capability is inexcusable in a company which offers aviation assets to the public. The FAA should demand IFR capability for air medical helicopters as part of the new SFAR. This would serve two purposes: it would give pilots needed options; it would increase the standard of companies competing for air med business, drive marginal operators away.

Let me be clear about this: I propose IFR capability for recovery only, not for launch. IFR equipment, coupled with ongoing instrument training, will go a long way toward eliminating air med accidents.

Most fatal accidents have happened en-route to a patient pickup, or after a pilot has aborted the flight, and turned toward home base. This says that air med crews are accepting missions in weather that’s marginal at best, an attempt to take off and check conditions over a commonly flown route. Just so, the more emphasis placed on weather avoidance, and dismissal of IFR capability instead of weather minimums and dogmatic measures, have made air medical less safe.

Pilots must find the delicate balance between program needs and their professional standing. Air med pilots are just charter pilots with a single client. But the trappings of the air med program, the flight suits, logos, and close interaction with medical staff is constant enforcement of the team concept at a client hospital. There’s nothing wrong with team spirit. But the elite nature of air med flight crews can dilute a pilot’s command authority in situations where patient need appears to override aviation considerations. Weather factors can be minimized. Nuisance maintenance issues ignored. Crew rest times can be arbitrarily extended to pursue a patient mission at crew change time. At most programs, pilots are shielded from patient information, to avoid undue pressure on them to accept or reject a flight. This is a good protocol. But the simple truth is, that pilot exposure patient medical condition is unavoidable at the onset of the mission, or at any time during the flight. What’s needed is a more professional, more objective pilot in the first place.

Give site managers the authority they need to enforce safe practices. Site managers have little authority to enforce pilot codes or punish unprofessional behaviour. Most accidents begin in the hiring phase, lying in wait for the right conditions. Posting a pilot to a contract site is expensive. But when a client hospital demands a pilot’s removal or a site manager learns of safety infractions, that manager must be able to take action.

Air medical flying has always had a reputation for having an emergency, rapid-response atmosphere. This sheen of excitement is what attracts certain people to it, the so-called adrenaline junkies. From my 20 years in a HEMS cockpit, I can attest to the high-profile nature of the work. There’s nothing more exciting than having the helicopter clatter out of the sky, arrive on the scene, and land to save the day. The feeling is intoxicating, even if it is illusory. It’s easy to lose sight of the aviation aspect of it.

The bottom line is, that pilots at air med programs are locked and loaded to fly, and not every pilot is cut out for it. Accepting a mission is the default mode. But instead of being paid to fly, pilots must understand that they’re being paid for the judgement to not fly at times. FAR part 105, the so-called ‘pilot-in-command’ rule, not only protects pilots and the decisions they make, but it eliminates the potential hazard of a diluted decision, a decision made by a committee. Especially with the rapid growth of the HEMS industry, hour requirements and necessary experience levels have dropped. The pilot pool has shrunk beyond the competence level required.

” Multi-engine aircraft in air medical operations.

All air medical programs should field multi-engine helicopters. If that proves too much for the budget, the hospital should abandon the air medical program, or seek a consortium arrangement.

Having two engines, and the doubling of other onboard systems simply brings the aviation asset up to par with the medical equipment it carries. Medical staff routinely have backups for everything; their aircraft should have nothing less.

Multi-engine aircraft also obviate additional mechanic staffing. Two mechanics are more efficient, better rested, doubly trained, and have more latitude toward performing required tasks to keep the equipment operating.

Another less obvious benefit to fielding twin-engine aircraft is the potential for pilot training. Depending on the aircraft, an extra seat is available in the cockpit on every flight. That empty seat ought to be used for an observer, a rookie pilot, or a new hire to ride along, to see first hand how the operation works.

Another advantage of this change is, that the copilot could be someone in training. If done properly, this position could be a revenue source for innovative operators willing to help a pilot build up his or her logbook, and willing to pay for the opportunity, to the benefit of the operator’s bottom line.

” CVR/FDR/TAWS/GPS moving map installation in air med helicopter cockpits.

The FAA should mandate cockpit voice recorders, and/or flight data recorders in every HEMS cockpit. This would add transparency to every air med mission. These boxes would have two additional benefits: they would assist in an accident investigation, a use for which they were designed; and they would facilitate maintenance work by recording and archiving system operating parameters. TAWS is nothing more than ground avoidance technology, another layer of protection. GPS should be a requirement in all HEMS cockpits.

” De-emphasize rapid response/takeoff time.

In spite of programs’ PR efforts, and patient impact evidence to the contrary, a rapid response only puts the aircraft and crew at risk, makes a negligible difference in patient outcome, and should be de-emphasized. Launch time of ten minutes is not unreasonable. No other part 135 operation would advertise a five minute takeoff time, nor would the FAA grant operations specifications for such a thing. In actual practice, the HEMS mission is, by and large, a transport system to provide a stable, monitored environment for patients between hospitals.

” Higher program weather minimums, and mandatory down-status.

Weather is a factor in 50% of HEMS accidents. Program and FAA-mandated weather minimums are typically stringent, but at most programs, they still border on marginal VFR. The environment in which air medical aircraft operate is typically where weather information is least available and/or reliable–below three thousand feet, far from weather reporting outlets, and often below radar coverage.

” Hospital administration must be more involved.

The administration of air med programs must become more intimately involved in the day to day operations. Launch decisions should be reviewed; mandatory short takeoff times should be abandoned; borderline pilots or those who consistently make poor decisions should be held accountable; safety committees should be established, with authority to make major decisions, including the configuration of the aircraft.

Medical directors should apprise physician staff of safety issues concerning air medical, including the need for better triage to eliminate non-emergent air transports. A culture of support must be effected for no-go decisions. The tendency for medical staff receiving a transport request is to use the helicopter if any indication exists that it’s needed. The underlying assumption is, that the patient needs to be flown, or a doctor would not have called.

But patients are often flown only for mundane logistical reasons. Various EMS services are available on a limited basis. Taking a ground rig away leaves the county uncovered for long periods. The helicopter is often used as a substitute in these cases. Thus, the air medical asset closest to the patient is often used when there’s no indication the patient needs to be flown.

I was a pilot in command of an air medical helicopter for twenty years. I understand the pressures and contingencies, regulations, environment and politics that air med pilots are exposed to every day. From my first air medical flight in July 1983 to my last in October 2003 I saw one of every kind of patient mission there is, except one. I never witnessed a birth on board the helicopter. That simple fact, that in 3,200 patient missions I never once witnessed a birth is instructive. It means triage for women about to deliver was done with utmost care. Both attending and receiving physicians knew not to call the helicopter.

The point is, that adequate triage, better consultation, or both, especially with today’s technical ability for doctors to share information, is a key in the air medical safety puzzle because it means fewer flights, thus more attention to truly urgent flights.

With four pilots per contract, and where program hours are low anyway, the operator may (rightly) be concerned about less flying proficiency. In this case, the sponsoring hospital should contract for more training hours, match their assets with another hospital in a consortium arrangement, or cede the air medical transport service altogether, thus saving needed health care dollars.

Do fewer flights mean lowered service to potential clients? No, it means better service to clients who need the service more. While flying a routine, stable hospital transfer patient, the helicopter is out of service to respond to trauma or another emergent patient.

“The bottom line must be secondary to safe practices and hard aviation realities.

Typically, a hospital-based helicopter system is set up on a mixed staff basis, with pilots and mechanics employed by the aviation vendor, and the hospital staff employed in the house. Sponsoring hospitals can budget for aircraft services; they have the option of renewing a contract with a vendor–or not; they don’t assume the burden of aircraft maintenance, or staff training, and they avoid out of service time by having a backup aircraft within guidelines established in the contract. Leasing the asset also provides a hospital with the opportunity to more easily upgrade to additional program functionality, such as IFR, NVG, multi-engine, or other changes.

But contracts offer only so much, and therein lies one of the more entrenched problems, with air medical safety, often hanging in the balance: innovation is stifled, and safety initiatives shuttled between client and vendor, with little or no, or extremely slow resolution. There’s no direct connection between funding and safety, of course. But there needs to be more attention paid to backup systems for HEMS operations. No surgeon would operate when the hospital’s standby generator is out of service. No flight nurse would take off with no backup batteries for a heart monitor, or extra oxygen bottles. No hospital would place its million-dollar MRI machinery uncovered in the parking lot, exposed to the elements.

But hospitals use single-engine helicopters, with VFR only cockpits, no NVG or GPS or TAWS capability, one electrical system, one hydraulic system, and one pilot on the overwhelming number of air med missions. The aircraft is typically parked on a pad outside, exposed to wind, rain, icing, heat, and all manner of corrosive elements, when hangarage could be acquired for little cost, keeping the helicopter dry, clean, ice and snow-free, reducing maintenance issues and more quickly prepared for flight.

Accountability is a very good thing. But due to the glacial pace of change in any institution, and given today’s focus on reducing health care costs, any innovation, regardless of how appealing or relevant to minimizing risk in the air medical environment, is inevitably caught up in the control/justification/budget triangle, with numerous layers of bureaucracy. In the meantime, needed innovations and safety measures are shelved, or passed between client and vendor, with neither accepting financial responsibility. Until safety prevails in the air medical field, contracts should be renegotiated year to year, with an escape clause for both parties. This would allow clients to better budget for innovations, and for operators to escape onerous contracts, better serve customer demands, and be more attentive to the bottom line in a field already littered with bankrupt operators.

One beneficial byproduct of yearly contracting would be to drive out marginal operators, by recognizing that only larger, more flexible companies can bid on and expect to win hospital contracts, which require a rapid turnaround of assets. Another advantage to one-year contracts is, that this would force standardization of equipment. Presently, even two aircraft sited at the same hospital often have different medical installations, radio packages, lighting, warning systems and cockpit instrumentation. This may not be a problem for a contract site using the same pilots all the time, (or it may be a major problem), but the lack of standardization precludes another solution to the air medical accident puzzle.

Pilots at a particular program operate with little or no oversight from company headquarters. In such an arrangement, pilots often share only among themselves the various problems, maintenance gripes, and operational glitches. There exists no mechanism for collective focus and sharing of safety information company-wide, except for contact through annual check flights, or a company newsletter of some kind. This is yet another reason client hospitals should employ larger companies, as they have more latitude to hire and employ check pilots and relief pilot staff to float between programs. Doing so would disseminate good data and safety practices across the company.

Larger companies are also better able to use another innovation that would enhance safe operations: the transfer, or shared pilot concept. Transference between contract sites would add to the transparency and oversight of programs, and increase the level of professionalism. This is yet another reason hospitals should field multi-engine aircraft. The unoccupied cockpit seat could be used to orient a relief or transfer pilot, like a company check pilot station, or again, to train a new hire pilot, a functionality unavailable to single-engine operations.

In addition to the transparency and increased knowledge base, visiting pilots would offer the medical staff an objective forum to discuss deficiencies in the program or challenges with sited pilot staff. It would also have the desirable effect of decreasing whatever level of protective opacity that may exist in the ‘team-oriented’ environment.

Yet another solution to safe operations is to decrease the level of team cohesion that may promote protective amnesia about unsafe or marginal individuals, either aviation or medical staff. Client hospitals may even consider altering the makeup of flight staff, replacing the traditional flight nurse team with floating medical staff to go along with visiting pilot staff. This would place more emphasis on the ‘air’, and less on the ‘medical’ part of the equation, increasing the level of safety. Patients and nurses don’t crash; pilots and helicopters do.

One solution to this dilemma has already been listed, a solution that is open heresy to the air medical community. There are simply too many air medical helicopters, operating at too many hospitals, by too many vendors. If patient outcomes, mortality and morbidity were being positively affected, all to the good. But, after thirty years of operating air medical helicopters, there’s no objective evidence either of those is happening. Meantime, more air medical crews are dying in accidents. There’s plenty of anecdotal information, and hundreds of patients will testify to the good these aircraft and crews have done, as will I. But the simple, stark reality is, that air medical aviation is sicker than the patients it’s attempting to reach. Measures must be taken to change the situation.

” Reduce operating areas at night, or use two pilots/ IFR/NVG and TAWS.

One of the boldest solutions to the air medical accident rate will also be the most controversial. Given the nature of air medical, particularly in light of its image Vs reality, hospitals interested in reducing risks, and raising the standard of safety should consider reducing their response radius after a certain time, midnight being the likely cut-off, to a distance of twenty-five miles from the home facility. This restriction would benefit safety in several ways: it would automatically reduce fatigue levels in air med crews; it would be an automatic triage function, putting requesting hospitals and physicians on notice that a patient needing air transport must be flown before midnight, or wait till morning. A reduced operations area would cut the risk of weather-related accidents, putting helicopters closer to the home hospital, thus obviating the aircraft’s use for only emergent patients. Shrinking the response area would also preclude much of the risk associated with weather changes en-route, or due to long wait times at outer hospitals and/or loiter points. Another benefit, particularly at programs with two or more aircraft, is the increased availability for maintenance. It would also save sponsor hospitals money since the revenue hours flown would likely be less. Plus, the possibility exists that fewer pilots would be needed with a reduced coverage area after midnight.

An alternative to this proposal is the use of IFR cockpits, NVG equipped crews (including medical staff), and adoption of proposed Terrain Awareness & Warning System in all air medical helicopter cockpits per Section 508 of S. 1300*, a bill in the U.S. Senate aimed at rectifying the accident rate in HEMS operations**.

Every program’s statistics are different, and air medical is, after all, an emergency rescue service. But limiting the rescue service would not be the intent; the intent is increased oversight through better triage of transport requests. At most programs, so-called on-scene missions comprise the lowest percentage of response flights. The larger number is stable, non-emergent patient missions. It’s been debated for years whether or not the use of helicopters impacts patient mortality and/or morbidity. That debate will continue. But until the safety issue is adequately addressed, it will override all others. And until the safe flight of air medical helicopters becomes a given, advisability of using them for patient transport must be watched more carefully.

The HEMS accident rate will only be reduced when the three legs of the stool are in place: pilots; aircraft & equipment; and hospital/operator oversight. Until the changes listed herein are accepted practice in air medical flying, accidents will continue to plague this critical industry. I hope that all involved can step away from the habits of the past, and focus on the changes needed to make HEMS the safe, efficient patient transport system it can be.

Accidents are not inevitable; they happen when factors conspire against a program and pilots who are relaxed and complacent regarding safe practices. Helicopter air medical is unforgiving of neglect and incompetence; operators, pilots and their colleagues, and sponsor hospitals must be aggressive in identifying and addressing any safety issues immediately, without regard to personnel, political, financial or administrative matters. There’s too much at stake to maintain a cavalier attitude, or assume that an accident can’t happen. Helicopters are flown safely all the time. But it doesn’t happen by accident.

In summary, my recommendations for raising the safety level of air medical helicopters are the following:
*Senate Rule S.1300 is listed.

– For those programs requesting it, an immediate safety stand-down for FAA or other outside party review and report on all aspects of the operation.
– Pilots must be better vetted and trained to emphasize weather incursion recovery.
– Instrument flight capability for recovery only in all air medical helicopters.
– Higher pilot hours in the aircraft being flown, to include a minimum of 2,000 hours to be hired, 20 hours in type, 10 hours at night, and 50 hours of actual or simulated weather time.
– Multi-engine aircraft in all HEMS operations.
– CVR/FDR/TAWS installation in air med helicopter cockpits + modular installations.
– De-emphasize rapid response/takeoff time.
– Higher program weather minimums, and mandatory down-status.
– Hospital administration must be more involved.
– The contract bottom line must be secondary to safe practices and hard aviation realities. Yearly contracts to expedite innovation time for safety proposals.
– Reduce operating areas at night, or use two pilots.
– The requirement for availability to all medical crews of a no-flight or abandon-mission protocol without fear of repercussion.
– Site manager a hospital employee with authority to hire and fire, with pilot status a plus.
– FAA SFAR for air medical helicopter operations codifying weather minimums, IFR equipment, NVG, TAWS, dual pilot capability, and op specs required for expanded area operations after dark or below specific weather values.
– All air medical flights conducted under part 135 regardless of patient presence.

Equipment Requirements:

Multi-engine aircraft

IFR for recovery only

NVG capability

TAWS

Wire cutters

CVR/FDR

GPS moving map

Weather access in the cockpit in real-time

*Legislation, S. 1300, has been introduced in the U.S. Senate to authorize appropriations for the Federal Aviation Administration (FAA) for fiscal years 2008 through 2011 to improve safety and capacity and to modernize the air traffic control system. In addition to the issues previously discussed concerning user fees and surcharges and an increase in the fuel tax, S. 1300 also would mandate significant changes for helicopter emergency medical service operators.

Section 508 of S. 1300 would mandate compliance with Part 135 regulations whenever medical crew are on board, without regard to whether there are patients on board the helicopter. Within 60 days of the date of enactment of S. 1300, the FAA would be required to initiate rulemakings to create standardized checklists of risk evaluation factors and require helicopter EMS operators to use the checklist to determine whether a mission should be accepted. Additionally, the FAA would be required to complete a rulemaking to create standardized flight dispatch procedures for helicopter EMS operators and require operators to use those procedures for flights.

Any helicopter used for EMS operations that are ordered, purchased, or otherwise obtained after the date S. 1300 was enacted would also be required to have onboard an operational terrain awareness and warning system (TAWS) that meets the technical specifications of section 135.154 of the Federal Aviation Regulations (14 C.F.R. 135.154).

To improve the data available to National Transportation Safety Board (NTSB) investigators at crash sites, the FAA would also be required to complete a feasibility study of requiring flight data and cockpit voice recorders on new and existing helicopters used to EMS operations. After the feasibility study, the FAA would be required within two years of S. 1300’s enactment to complete a rulemaking requiring flight data and cockpit voice recorders on board such helicopters.

All Helicopter Association International (HAI) operators conducting EMS operations are strongly encouraged to review the provisions contained in *Section 508 of S. 1300. HAI is interested in hearing from you concerning any concerns you might have over the requirements contained in this legislation. Please contact David York or Ann Carroll via email at david.york@rotor.com or ann.carroll@rotor.com.

HAI continues to analyze legislation in the U.S. House of Representatives and the U.S. Senate concerning FAA reauthorization and general aviation user fees, surcharges, and other safety provisions. More information will be provided on the HAI Web site as developments occur in Washington.

**Section 508 of S. 1300

S.1300
Aviation Investment and Modernization Act of 2007 (Introduced in Senate)

SEC. 508. INCREASING SAFETY FOR HELICOPTER EMERGENCY MEDICAL SERVICE OPERATORS.
(a) Compliance With 14 CFR Part 135 Regulations- No later than 18 months after the date of enactment of this Act, all helicopter emergency medical service operators shall comply with the regulations in part 135 of title 14, Code of Federal Regulations whenever there is a medical crew on board, without regard to whether there are patients on board the helicopter.
(b) IMPLEMENTATION OF FLIGHT RISK EVALUATION PROGRAM- Within 60 days after the date of enactment of this Act, the Federal Aviation Administration shall initiate, and complete within 18 months, a rulemaking–
(1) to create a standardized checklist of risk evaluation factors based on its Notice 8000.301, issued in August 2005; and
(2) to require helicopter emergency medical service operators to use the checklist to determine whether a mission should be accepted.
(c) COMPREHENSIVE CONSISTENT FLIGHT DISPATCH PROCEDURES- Within 60 days after the date of enactment of this Act, the Federal Aviation Administration shall initiate, and complete within 18 months, a rulemaking–
(1) to create standardized flight dispatch procedures for helicopter emergency medical service operators based on the regulations in part 121 of title 14, Code of Federal Regulations; and
(2) require such operators to use those procedures for flights.
(d) IMPROVING SITUATIONAL AWARENESS- Any helicopter used for helicopter emergency medical service operations that are ordered, purchased, or otherwise obtained after the date of enactment of this Act shall have onboard an operational terrain awareness and warning system that meets the technical specifications of section 135.154 of the Federal Aviation Regulations (14 C.F.R. 135.154).
(e) Improving the Data Available to NTSB Investigators at Crash Sites-
(1) STUDY- Within 1 year after the date of enactment of this Act, the Federal Aviation Administration shall complete a feasibility study of requiring flight data and cockpit voice recorders on new and existing helicopters used for emergency medical service operations. The study shall address, at a minimum, issues related to survivability, weight, and financial considerations of such a requirement.
RULEMAKING- Within 2 years after the date of enactment of this Act, the Federal Aviation Administration shall complete a rulemaking to require flight data and cockpit voice recorders on board such helicopters.

Byron Edgington is a former Helicopter Air Medical pilot with 35 years, 12,500 hours in the cockpit, and with over 3,200 patient flights. His career in commercial aviation included corporate, air medical, offshore, forest fire and tour flying. Byron Edgington is the author of several books, including his memoir The Sky Behind Me, available soon on Amazon.com. This article is a condensed version taken from chapter 7 of the memoir.

Dreams, Books, E-Books, Writing and Other Random Thoughts From My Publisher’s Life

The start of random thoughts: I recently spent three days as a faculty member at the Midwest Writing Center in the Quad Cities and lots and lots of ideas floated through my mouth for both want to be writers and established authors. The field of being a writer is truly vast and inspirational. Someone could be out of work and yet, the thrill of writing, of sharing their story causes their face to light up. Someone could be overburdened with rejection slips from submitting their writing to publishers, yet, what do I say to them, “Be glad you got the rejection letter, truly, speed ahead, look for the letter that says ‘yes.'” Much as reading a tarot card deck, each symbol is at once positive and negative. As is the quest to be a published author.

More random still: Most everyone I meet, most everyone I have not met wants to write a book buku mimpi 2d. A retired financial executive wants to write their life story. A medical doctor wants to write a novel and on and on. When E-book publishers talk about something other than an E-book they refer to these other things as “real” books. When a paperback is opened it’s easy to read, it’s portable and it always turns on. When a book has been treated with the respect it has a lower outside margin fit for the fingers to hold the page. When an A and a T are joined together with a ligature, this is tradition steeped in practicality, not a mark meant to rub off the page. When a natural, sixty-pound paper is read off of the eyes want to say thank you.

Randomness has gone random: A new author wants to know the average book contract terms. I want to say, write your book first. Does a beginning author ask who will edit my work? Will they alter what I have to say? I want to plead, “I insist that you coax the most imagination out of yourself as you can. Be a writer, enjoy the process.” A struggling author asks if maybe they shouldn’t switch genres entirely, I want to beseech them to find the “flow” of creativity. To turn your fiction into 51 per cent fiction and 49 per cent nonfiction. And vice versa. I want to say, come to a spot in your story and then pause, consider and think through all the options, SURPRISE yourself and your reader.

Ask me my final advice and I’ll say, enjoy the process of the writing first and foremost. Then enjoy the editing process. Then enjoy the marketing process. But first, enjoy the writing or nothing else will matter.

Increase Facebook Likes – How To Do It

How does the like button work?

We all click the like button on Facebook dozens of times without knowing what happens in the background. Clicking this like button on Facebook creates a connection in the graph between the individual who clicks it and the content itself. An ‘open graph like action’ is published when this button is clicked and this, in turn, drives the distribution and promotion of the content. The story or content that is created can be enriched and enhanced by using meta tags. If you plan on using the like button on a website, you will need to use meta tags to make sure that the published content or news feed looks great and attractive on your timeline, thus attracting more people and getting more likes. This will enable the best possible distribution of content on Facebook.

Only great content is bound to get more likes, having said that just typing in some great content may not get you the publicity that you may be aiming for.

Here are a few tips that are sure to help you get more Facebook likes “توثيق حسابات انستقرام, promote a story or even your small-sized business via Facebook. So what are you waiting for, read on!

4 steps to get you one step closer to fame

Create exclusive content and also like-gate it- Apart from putting together some exclusive content, also like gate your news feed or story. The alike gate is a custom tab, that allows only those who have liked your link to view the entire content. So a good idea would be to put in a trailer and lead the reader into clicking like, to get to read the entire feed. Something to the tunes of click like to get unlock download is sure to pique the interest of the reader and have him like your link to get to the actual content. A salon that is trying to promote their services, could put in a message such as like us to get a discount on our many services or like us to get a sneak preview of the many latest offers. This is sure to not just get likes but also promote the business in itself.

Promote your like-gate offer- Once the like-gate offer is thought of and created, promote it by customizing your tab image accordingly and make it visible so that visitors who click on your page do not miss it. You could use Facebook ads to achieve this.

Add the like box to your website/blog- If you own a business, you are bound to have a basic website. Feature your Facebook page on your website. This will enable prospective clients to have a peek into your Facebook page.

Update your FB page regularly-Keep the Facebook page updated and ensure all latest happenings are updated. You could use a social media calendar to plan out regular updates on your page.

Involve your fans- Do not simply put promotional content. Also ask questions, raise discussions, and have small contests that will keep your fans engaged in conversation.

Know your audience’s needs and respond to them- Ask questions that will prompt your audience to share their suggestions and their requirements. This will enable you to understand the market needs and upgrade or tweak your services to suit their requirements, which in turn will increase your brand value. Responding to your fans, helps you buy their trust in your and the services you provide. A prompt reply to their queries though may seem time-consuming at times, will ensure that you have a good rapport with your clients, which will help increase your revenues steadily.

Mubashir Shafi is a professional Internet Relationship Marketer who teaches others to build a business online. He is very active on Facebook these days you can learn a lot from him. He mostly writes about ways to increase Facebook fans.

How to Use Sports Arbitrage Betting

When the internet became the online force that it is today it opened up many opportunities to ordinary folks like me and you that we never had before. As well as giving us the ability to buy products cheaper connect with others all over the world other instantly it also gave us instant access to whatever information we need it also allowed us, for the first time, to learn things that only small elite groups knew and profit from them. Sports arbitrage betting is one such profit opportunity.

For decades this 100% legal and guaranteed winning systems were kept “under wraps” by professional gamblers who knew how to wok the system to make large piles of cash (millions in some cases).

Using arbitrage betting systems these professional gamblers knew when they placed their bets exactly how much money they were guaranteed to win. There was no luck involved. There was no gambling taking place. There was just a guaranteed payout – every time!

The practice of arbitrage betting mm88, or arbitrage trading as it is often called, is utilizing opportunities to guarantee a profit by taking advantage of price differentials between two or more bookmakers or online betting sites.

Before the internet and sports arbitrage software it usually took two professional bettors to be in two different bookmakers so they could place their bets in tandem before the odds changed. Now it can be done in moments, by the same bettor, using the power of the internet and basic home computing equipment!

So how does it work?

Bookmakers and online betting sites work with their odds in a way that will always ensure they make a profit. This means that the odds given by one betting site may differ slightly, or greatly, from the odds given by another betting site.

As I have already mentioned when a bookmaker calculates the odds of a sporting event he will make sure he always makes a profit and will, therefore, adjust his odds as bets come in. As more people bet on one side of a sporting event so the odds for them winning will be brought down to ensure the bookmaker stays in profit.

However, a different bookmaker may be experiencing the exact opposite happening and this he will adjust his odds to ensure that he is in profit.

This means that these two bookmakers have dramatically different odds from one and other – sometimes the exact opposite.

An example of this would be when one bookmaker has Team-A at 11/10 while a second bookmaker has Team-B at 11/10 because each bookmaker must attract the type of bet that will help them balance their books and ensure a profit.

By placing a bet on each side to win with the respective bookmakers who are offering 11/10 odds you ensure a profit for yourself.

Arbitrage usually has a rather small return on investment between 3% and 5%. However, it is a guaranteed return and thus a stake can be quickly built up so that you have sufficient betting funds to earn large sums of money. For example a $100 on each sports side would cost you $200 and only guarantee $210 return (a profit of $10) but because this is guaranteed you can very quickly turn that $210 into thousands!

How Do Invisible Braces Compare To Traditional Braces?

If you’ve heard of invisible braces then you may well have come across Invisalign, one of the leading manufacturers of invisible braces. But what are the benefits of invisible braces, either from Invisalign or anyone else? The word invisible is a pretty good indication of what one of the chief advantages is from Invisalign braces, but it isn’t the only advantage, and it’s well worth being completely clear about how invisible braces or clear braces differ from traditional braces, and what you can expect from the process.

Having braces fitted at any age can often be the result of a great deal of thinking, worrying and wondering, and it certainly isn’t an easy decision for anyone to make. Advantage of Traditional Braces are often worn for a couple of years or more, and if this is during a period where someone is taking their first steps towards adulthood, it can be extremely awkward because of how traditional braces look. There are no hiding traditional braces, because every time you open your mouth to talk, to eat or to smile, people are going to notice the metalwork more than anything else.

So one of the clear advantages that come from wearing invisible braces from a company such as Invisalign is that people will not notice that you are wearing braces unless they deliberately look at your teeth. Therefore for many people, the deciding factor on whether to wear invisible braces or traditional braces is the fact that people are unlikely to notice that they are wearing braces at all.

But what of the other benefits and differences which clear braces have to offer? One of the other key factors to consider is the fact that invisible braces are worn for a much shorter period. With traditional braces, you can expect to have to wear them for at least two years or more. However, with invisible braces from Invisalign, you need only have them in for a matter of months.

So as well as being virtually invisible, modern clear braces can also get the job done in a fraction of the time. How is this achieved? The answer is very simple, because effectively with traditional braces you are given one pair of braces to wear for the duration of the experience. But with clear braces, you only wear the first set you are given for about two weeks.

Throughout the entire period, you are wearing clear braces, you will usually be required to revisit your dentist every two weeks, at which point you will be given a replacement set of Invisalign braces. Each subsequent set of invisible braces will be very slightly different from the previous set, helping to increase the pressure on teeth to move.

Imagine if you were to stand in one place in a room pushing against a cardboard box. If the box is very close to you then you will be able to push it easily, to begin with, but as the distance increases between you and the box your ability to push it lessens.

This is roughly what takes place with traditional braces. But because clear braces are replaced at regular intervals it is a little bit more like taking a step forward each time a new set of braces is provided, decreasing the distance between you and the imaginary box, providing you with the ability to apply consistent pressure in a consistent direction.

Although the benefits of wearing invisible braces from companies such as Invisalign are clear to see, or rather invisible, there are still other advantages and benefits, which I will cover in my next article.

Love Spells Introduction

Contrary to popular belief, love spells are not just for those of the Wiccan faith. There are Wiccan love spells, but you don’t have to be Wiccan to perform a love spell. Even better is that there are countless free love spells listed on the Internet. The hard part is knowing which ones to consider using and which ones to discard. Before choosing and casting love spells, it helps to learn more about the spell casting process so you can locate or even create love spells that work.

Everything in the Universe is energy. This includes thoughts, words, actions and more. Gemstones, flowers, trees, herbs, candles, colours and even planets carry their special energy. When you put your intention together with the particular energy in the spell items you are using, they work together and help manifest the spell you are casting. While there are plenty of free easy spells in witchcraft books and online, you should make sure the instructions and components of each spell make sense to you. To learn, study what are called the correspondences. For example, Friday is a good day to cast a love spell because it corresponds with Venus, the planet of love. And when casting love spells, a new, waxing or full moon is beneficial to bring love into your life.

You can create a love potions spell, which involves the blending of essential oils along with other aspects. When blending essential oils, use a carrier oil like jojoba or olive and keep your potion in an amber dropper bottle. You can use a love potion as a personal fragrance or to dab on correspondence to the one you adore. Oils that are ideal for a love potions spell include rose, vanilla, sandalwood, jasmine and cinnamon. When creating the potion, proclaim your intention for the oil and charge it in your left hand by holding it and affirming the intention to bring in love. To send love, charge it in your right hand. Left is for sending, right is for receiving and this is the case if you are setting up a spell altar with items.

The best spells online are the ones that make sense. Do they contain a powerful intention? Are they comprised of the right ingredients that correspond to love? After some searching, you can tell a poorly written spell to a good one. You can even modify free online spells that you come across to put a personal touch on them. Because so many people use online love spells, it may be fortuitous to put your spin on the spell, whether it is adding something or changing something. Of course, the individual energy you bring to the spell is unique to only you.

While it is not advisable to try and force someone to love you by using love spells, you can ask that your true love comes to you. Or, that you are receptive to love and naturally attract the right love for you. There are spells for all kinds of romantic desires.

LASIK Eye Surgery – Nurse’s Guide – What You Should Know About LASIK And Laser Eye Surgery

LASIK surgery is a laser vision correction procedure approved for the treatment of nearsightedness, farsightedness, astigmatism, and in some cases, presbyopia correction. Before making your decision, learn about the LASIK procedure, its benefits, and its risks, and discuss any questions you have with your doctor. It can treat both myopia and hyperopia with or without astigmatism.

Questions to ask yourself: Am I a good candidate for LASIK? What are the advantages? And what are the disadvantages? Can I correct my vision problem some other way? Am I aware of complications that may arise following surgery?

LASIK represents the combination of two separate procedures: 1) making a corneal flap, and 2) sculpting the cornea under the flap with a laser. LASIK can treat both myopia and hyperopia with or without astigmatism. Patients have been treated from over 87 countries.

Though the excimer laser had been used for many years before, the development of LASIK is generally credited to Ioannis Pallikaris from Greece around 1991. Before 1999, all LASIK was performed off-label, meaning the FDA did not approve its use. This next-generation LASIK addresses underlying vision problems that previously were undetectable and untreatable.

In the United States alone, Laser surgery is performed on over a million patients every year, and it is currently the most popular refractive surgery available. If you are interested in laser vision correction, consider what surgery can do for you. Choosing the right LASIK surgeon is a critical part of any eye surgery cataratta padova. Your surgeon should be available to answer your surgery questions before the procedure.

The surgery is worthwhile for anyone unhappy wearing glasses or contact lenses. The surgery is best suited for healthy patients who are at least 18 years of age. The surgery may now also be an option for presbyopia correction; the surgery can correct one eye for distance vision and the other eye for close vision in a procedure known as Monovision.

At the vision correction centres, surgery begins after the patient is made comfortable with numbing anaesthetic eye drops. The surgery itself is virtually painless, and results can be seen immediately. Those who found out about LASIK eye surgery open their once blurry eyes and are instantly able to see the alarm clock and the beautiful morning – no glasses and no contacts.

It’s important to be aware that the surgery is not a guarantee of perfect vision, and some patients may require additional surgery to further enhance their vision. And there may be complications.

We don’t know the long-term effects of the surgery. However, the vast majority of patients who have undergone laser eye surgery are happy with the results. In addition to general ophthalmology care and regular eye exams, eye surgeons usually offer their patients the latest vision correction procedures, including LASIK, Custom LASIK, PRK, Intacs for Keratoconus, and Cataract Surgery.

If your vision insurance or health insurance policy or plan doesn’t cover the cost of laser eye surgery or the cost of LASIK eye surgery or vision correction or any other eye procedure you need you might consider travelling to another country to get the low-cost laser eye surgery you need.

LASIK eye surgery or Laser-assisted in-situ keratomileusis, has changed the way millions of Americans have viewed the world for several years now. Before making your decision, learn all you can about the procedure, its benefits, and its risks, and the cost of laser eye surgery. Discuss any questions you have with your eye doctor or laser vision surgeon.

Free Sports Betting Tips For Betting on NBA Games

There’s no doubt about it: When it comes to sports betting, betting on NBA games is one of the most popular choices there are. The NBA attracts hundreds upon hundreds of sports bettors during its regular season – and the numbers double up as the playoff games take place. If you love watching the NBA games at home or live, then you’d love betting on สล็อตออนไลน์ your chosen team and taking home part of the victory – in big, buffalo bucks. These days, with the popularity of betting on NBA games continuously on the rise, you can find several articles that offer free sports betting tips, but you need to practice discernment in following the right tips.

Free sports betting tips ufabet can be overwhelming. You are sure to find different opinions on how to go about in betting on NBA games. What you need to do is to exercise caution and filter the information you receive through practical wisdom. You don’t have to follow every single tip that comes your way. If you already have a betting strategy, stick with it for a while and see how it goes. Don’t be fickle-minded and weak – sports betting is certainly not for the faint of heart.

While free sports betting tips เว็บแทงบอล can vary greatly, one thing that betting kings or experts agree on is the significance of a tried and tested money management strategy. Sure, money is not the only reason why people engage in sports betting UFABET สมัคร – there’s also the thrill of the ride and the pleasure of watching a good game. But the profit you can yield is one great reason to bet on NBA games, so it’s important to pay attention to how you can make your money grow and how you can avoid or at least cut down on betting losses.

Thus, one of the most common free sports betting tips สมัครUFABET is to avoid raising the bets to come peak season. In the NBA, the peak season is the playoffs, the series that determines the two teams that will play in the finals. Since this is not just one game but one whole series, going all the way with all you have is not a very wise move. You could end up losing more money because the games are spread out in weeks. Don’t give in to temptation. Stick with the money management strategy you’ve used since the beginning of the NBA season and see it through the entire playoffs.

During this time, the odds become loosely favoured upon the teams with the most popular players, which is not a good way to gauge a win. Instead of relying on the predictions made by oddsmakers, it is best to dig up on the history of the key players in your chosen team. If their records say they can take the pressure, a claim evidenced by quality performances and stunning wins, then you’d have a better chance of raking in the money with such players, odds aside. Going with the statistics instead of succumbing to glamorized guesswork is one of the most recommended free sports betting tips around.

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How To Append More Worth To Your Residence and Enhance Its Selling Potential

Loft conversions Hamstead is the process for renovation of living space. Whether you are thinking about a new home (Kitchen, bathroom, office place) an en suite or a total re-decoration. If you select the right project, you can add worth to your home. This can be a good future investment and will increase your properties selling potential, should you desire to sell your home in the future.

Add 10-15% with a loft conversion

If you live in a city where the place is limited, an attic conversion is a fine way to create the most of what you have. As long as the renovation gives good standing room upstairs, it can be added to the property’s room. This would be helpful as a home office or bedroom and should lead to more attention in the house.

Add 5-7% with a new kitchen

A kitchen is very significant for the scalability, but it rarely adds more worth than it costs. Yet if a kitchen is an in reality poor state, buyers tend to need a discount to enforce across the whole house.

Up to 5% with a new bathroom

The possibility of improving a bathroom can put off some buyers. We all know the negative influence that a coloured site has. A new, neutral coloured bathroom that needs no work can be a precious asset, depending on the property’s place.

Up to 4% with an en-suite bathroom

An en-suite can put in more worth in a bigger property, where a high-quality bathroom count is important. The recent tendency has seen many proprietors opt to add a fitted to the master bedroom; a walk-in wardrobe or deep storeroom space is the ideal starting point to creating an en-suite.

Add between 3 and 10% with a conservatory

A conservatory adds important space and light, mainly desirable in built-up areas. It is a relatively simple and gainful way of rising space within a property. Make sure you decide a design that complements the method of your home and it doesn’t take over the garden. Positioning is also significant. For example, a south-facing conservatory requirements ventilation and shade, while good heating is necessary for a north-facing room.

Add 5% with a complete cosmetic redecoration

In a good market, a great cosmetic makeover could put in up to 20% onto a sale price. Buyers like to have a modern kitchen and out-of-date paint colours will be harder to sell.

Add between 5 and 15% with a garden room

A garden room is a genuine draw in the nation with its picturesque views. It’s also probable to add value to your home by adding an outdoor studio space part of the house, which expenses less than an extension and gives a retreat away for domestic life.

Add between 15-20% with an extension

Additional space may be a great outlay, but it will add important worth in the long run. Although an additional room that eats considerably into a tiny garden will not attain optimal value.

Add up to 2% with an outdoor swimming pool

The thought of a swimming pool may sound like a vision, yet in realism, they add little to homes as their successive costs can be expensive.

London Loft Conversion Company is the popularity & admired way for home renovations.

Small Cup Bra – What’s the Best Bra For Small Cup Size Breasts?

One of the common questions that are asked in the bra world is what the best bra is for women who have either; A, Double-A, Triple-A or B cup sized breasts, to enlarge the look of their cleavage. If this is a burning question for you, do not worry you are not alone, this is one of the most common searched questions on the internet concerning bras. Many women are seeking to enhance the look of their cleavage and a simple bra can make all the difference.

There are numerous different types and designs of bras on the market currently, so it can be hard to decide which, are the right ones for you. According to studies the best bra available at the moment to help increase the size of your cleavage is the Padded Push-Up Bra.

The padded push-up bra is specifically designed to add volume to the cleavage, by use of cotton pads inserted into each cup, thus increasing the size of your breasts. Secondly, the padded push-up bra lifts the breasts upwards and in together further emphasising the look of increased sized cleavage. Normal Cotton-padded inserts can add up to one cup size to your breasts, so, for example, you can go from a B cup to a C cup instantly.

There is a further development of the padded push-up bra in recent years, the water bra, also known as the gel bra and the silicone bra. This is, in essence, the same bra, but the only thing that has changed is the cotton-padded inserts have been replaced with liquid-filled inserts (the liquids are water, gel or silicone, hence their name). These bras offer further enhancements on the padded push up bra, they offer more volume, in some bras they come with interchangeable inserts allowing the wearer to dictate how much of an increase they desire and since the inserts are liquid-filled, they allow natural movement to be carried across the breasts, resulting in a very real and natural-looking cleavage.

The amazing things about the bras are that they have no side effects, as long as you are correctly fitted, the results are instantaneous. And by choosing a bra with interchangeable inserts, you can control how you wish to look on a day by day basis, no other options for enhancement offer you as much.

For further information on all bras and which is the best bra for small breasts, please take time to visit Best 4 Breast.

R.foley is a consultant with over ten years of experience. He has set up https://www.ucigallery.com to help and offer advice on all matters relating to Breast Enhancement.