Rising Helicopter Crash Deaths Spur Debate Over Proper Use of Air Transport
Article Outline
On a foggy night in September 2008, 2 young women crashed their car in rural Prince George's County, Maryland, outside Washington, DC. The call for help went to the nation's oldest air ambulance service, considered one of the best, run by Maryland's state police. A helicopter was sent to the scene and picked up the teenagers and an EMS worker.
On its way to a hospital, the pilot sought help in landing, but crashed in a heavily wooded park before he could get assistance. Four people died, including one of the car crash patients. The other, the sole survivor, suffered much more serious injuries in the helicopter crash than she'd had from the car accident.
It's bad enough when an air ambulance goes down, taking the lives of patients and emergency responders alike. But a crash really stings when it is unclear whether the airlift was necessary to begin with–some questioned whether the teenagers' moderate injuries warranted a helicopter transport, though the Maryland EMS agency said it met protocol.
The Maryland crash was one of 9 EMS accidents in 2008 that took the lives of 35 people. The rash of fatalities has prompted a new round of scrutiny of air medical services, focusing both on the safety of the aircraft and whether they are used too often and for patients who could just as effectively be transported by ground.
The National Transportation Safety Board (NTSB), unhappy with the progress made on safety issues by the Federal Aviation Administration, placed air medical transport on its top Most Wanted List of safety improvements in October 2008. The NTSB held 4 days of hearings on the issue in February to learn more about helicopter EMS operations so it can better evaluate the factors that lead to accidents.
Why Do Helicopters Crash?
The number of EMS helicopter accidents was on the decline for many years, but began to rise again a few years ago–going from 1.7 per 100,000 flight hours in 1997 to 4.8 in 2004.
A study of 182 helicopter EMS crashes over 22 years by researchers at Johns Hopkins University found that fatalities were most commonly associated with post-crash fire and with accidents that occur in darkness or bad weather. The researchers, led by Susan P. Baker, MPH, suggested the number of crashes could be reduced with “improved crashworthiness and measures to reduce flights in hazardous conditions.”1
The NTSB's prodding of the Federal Aviation Administration (FAA) in October 2008 was a follow-up to recommendations made in January 2006. These included adding terrain awareness warning systems to helicopters, requiring stringent safety rules even if helicopters are carrying only emergency medical personnel, requiring a formal flight risk evaluation before an EMS flight, and requiring EMS flights to use formalized dispatch procedures including up-to-date weather information and assistance in flight risk-assessment decisions.
Board members said in 2008 that they wanted the FAA to make faster progress on the recommendations given the continuing toll in helicopter crashes; the FAA responded that it was working on all 4 issues.
“This goes back and forth periodically, and we update (the board),” says FAA spokeswoman Alison Duquette. “We feel we are responding to the essence of what the board is requesting. We're pretty much going down the road they are seeking.”
Dawn Mancuso, executive director of the Association of Air Medical Services, which represents about 90% of EMS helicopter services, says the industry is making good progress working with the FAA on the safety recommendations the NTSB sought in 2006. “We have continued to work with the FAA to implement those recommendations with the understanding that any federal regulatory process is time-consuming,” says Mancuso. “Three of 4 of the recommendations have been implemented or will be implemented any day now.”
Automated terrain avoidance systems have been difficult to implement, she said, because they were designed for high-flying aircraft, not helicopters that maneuver at lower altitudes close to buildings and trees. The industry has been working to modify those systems to work for helicopters.
Mancuso said another innovation, night vision goggles, are not required but are quite useful and have been obtained by about 40% of the nation's air medical services fleet.
Medical Management
Beyond issues of safety are those of the proper use – and possible overuse – of helicopter transport, and how it should be regulated. State EMS regulators say they've been hampered in their ability to set rules for helicopter EMS because of the FAA's authority to oversee aircraft. In some regions of the country, critics say, helicopter services compete for business, ending in unnecessary costs and risks to both patients and emergency personnel.
Bryan Bledsoe, DO, an emergency physician from Midlothian, TX, and a clinical professor of emergency medicine at the University of Nevada School of Medicine in Las Vegas, is probably the nation's loudest and most persistent critic of the expansion of helicopter EMS. “I'm not anti helicopter EMS,” Dr. Bledsoe says. “It's just way out of control and way overused.”
He points to research questioning whether many patients transported by helicopter actually benefited from the time saved. “A significant amount of financial resources are going into a transport modality that actually benefits few patients,” Dr. Bledsoe argues in an article in the journal Emergency Medical Services.2
Furthermore, he contends, too many helicopters are sited in urban areas when they are really needed in rural places, but state officials have no authority to allocate helicopter resources where they are more needed. The number of EMS helicopters has expanded dramatically over the years–from 39 in 1980 to 753 in 2005.
Representatives of the Association of Air Medical Services counter that the industry has grown only as fast as the need for its services. “It's demand-driven,” says the association's Mancuso. “If those resources aren't called for they won't be there.”
Meanwhile, state EMS regulators are pushing for greater latitude to bring air medical services within the EMS umbrella. Some states are interested in a certificate of need process to keep helicopter services from expanding too fast. Some would like to see a more unified dispatch process so that it's easier to choose whether ground or air would be the best method of transport from the scene of an incident or between hospitals.
But state and local regulators are limited by the federal Air Deregulation Act of 1978, which limited regulation of air services to the FAA. Steve Blessing, director of Delaware's state EMS and president of the National Association of State EMS Officials, says the act didn't anticipate the huge growth in air medical services and the need to clarify aircraft regulation versus medical regulation. “It's our feeling we need to go back and look at that act and get clearer definitions of what is medical in nature and what would fall under our purview,” Blessing said. His organization will be seeking help from the new Congress with the issue, though its members have not yet come to consensus on what the language should look like.
Robert Bass, MD, executive director of the Maryland Institute for Emergency Medical Services Systems, says the federal law gets in the way of state officials who want to do things such as require 24-hour coverage by helicopter services or limit their numbers based on need. “The whole issue of location, affiliation and integration with other components of the EMS system, all of those issues are very important,” says Dr. Bass. “We need to be able to do that without a constant challenge or threat of challenge.”
Mancuso, on the other hand, sees little need for more regulation, arguing that state EMS officials already have plenty of latitude to organize dispatch arrangements and establish medical guidelines for using air transport.
Dr. Bledsoe complains that helicopters are overused, and thereby pose an unnecessary risk to both patients and responders, because most services rely on trauma guidelines developed by the American College of Surgeons. The 4-part guidelines, he argues, are too broad, including patients by the method of their injuries—a high-speed motor vehicle accident, for instance—rather than on the actual symptoms.
Others agree that the guidelines are broad, but that's no accident. They are designed to over-triage by a certain percent to avoid undertreating a patient whose injuries aren't so obvious.
“From the perspective of the ACS you don't want to miss serious trauma cases,” says Alex Isakov, MD, MPH, founding medical director of Emory Flight, Emory Healthcare's helicopter service. “You want to have more cases to make it more sensitive than specific.”
While Dr. Isakov would welcome efforts to adjust the trauma criteria specifically for helicopter transport, he questions whether it's the kind of issue that can be handled nationally, given the many variables involved. “This doesn't easily lend itself to something off the shelf,” Dr. Isakov says.
Part of the trouble, says Maryland's Bass, is that the ACS guidelines address only who should go to a trauma center, not how they should get there. “You have to ask if the time saved is likely to be of clinical benefit, and that's a difficult judgment with cases of potential internal injury that is not yet producing symptoms,” says Bass. “You're out there in a noisy, chaotic, dangerous environment and have to decide very quickly do they have to go to trauma and do they benefit by going by air. It's a tough decision that has to be made very quickly.”
Bass would like to see federal officials, potentially at the Centers for Disease Control and Prevention or the National Highway Traffic Safety Administration, work on national guidelines for EMS helicopter use. Dr. Bledsoe, by contrast, believes national medical societies such as the American College of Emergency Physicians or National Association of EMS Physicians should take a stab at it.
But John Morris, MD, a trauma surgeon and director of trauma, burn and LifeFlight at Vanderbilt Medical Center in Nashville, TN, argues that even though there are a number of patients who end up walking away from the emergency department after an air transport, tightening up the trauma guidelines isn't possible without causing more harm than good. “There isn't anybody who is sophisticated clinically enough to any degree of reliability to determine the people who will need trauma care,” Dr. Morris argues. “You can't do that in the dark at the scene of an accident in the rain. I would be very worried to try and get those guidelines any tighter because we'll lose more lives than we save.”
Beyond scene responses for trauma, Dr. Bledsoe also takes aim at the other half of the helicopter use conundrum–interfacility transfers. “You're saying the emergency department is busy and you're sick enough to be in the hospital, so we're going to put you in a helicopter. So instead of $800 for an ambulance it's going to be $8,000 and you're going to assume the risk of transport,” Dr. Bledsoe complains. “I don't see how ethically we do it.”
Given the costs, Dr. Bledsoe thinks insurance companies will ultimately step in to reduce the number of helicopter transports in those markets where they are used too much. Calls to 2 large national insurers–Aetna and United Healthcare–revealed no imminent changes to their payment practices, however.
Dr. Isakov, however, was more understanding of the physicians who call for interfacility transfers, particularly those at rural hospitals who lack the resources to care for a critically ill patient. He notes that the federal EMTALA statute “squarely rests the responsibility for choosing the right mode (of transportation) on the physician….Most communities don't have any kind of robust capacity to do critical care ground transport but air transport is available. You have the patients' interests in mind.”
He acknowledges, though, that critics don't have these cases in mind when they point to unnecessary air transport. “Clearly there's no utility for it in downtown Atlanta and no one should be taking patients with shoulder pain to a helicopter,” Dr. Isakov says. “But beyond that it's hard.”
Local control of helicopter dispatch, overseen by physicians, is one way to ensure appropriate use of the services, argues Dan Hankins, MD, medical director for the Mayo Clinic's air ambulance service. “You have to have intense and strict medical oversight,” he says. His service has a 2% discharge rate from the hospital after transport, compared with some helicopter companies that see 20% or more of their patients walking out of the ED soon after air transport.
A bigger problem, he argues, are the people who don't have access to trauma care because of their rural location, and the difficulty of maintaining air medical services in those places. “There are vast areas of the country that can't get to a trauma center in an hour. The state has a public safety obligation to make sure people get appropriate EMS.”
References
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PII: S0196-0644(09)00031-6
doi:10.1016/j.annemergmed.2009.01.007
