Fatal Crashes Provoke Debate on Safety of Sky Ambulances

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http://www.nytimes.com/2005/02/28/national...print&position=

Fatal Crashes Provoke Debate on Safety of Sky Ambulances

By BARRY MEIER

On a mild afternoon last week, emergency workers raced up to Jana Austin's

rural Arkansas home to ask if a medical helicopter could land on her

property to transport a victim of a car crash to a nearby hospital. Ms.

Austin, a nursing student, said she readily agreed, and along with her

4-year-old daughter, she watched spellbound as the chopper landed.

But soon after it took off, the helicopter began to spin, slowly at first,

then faster, until it twirled out of control into a nearby pasture. The

patient died, and the three crew members were seriously hurt.

The accident, whose cause is under investigation, was hardly isolated. In

January, a medical helicopter plunged into the Potomac River in Washington,

killing the pilot and a paramedic. In less than two months this year, four

people have died in four accidents. Last year was a particularly deadly one

for flight crews and patients, with 18 people killed in 11 accidents, the

highest number of deaths in a year in more than a decade, according to

federal regulators and an industry group.

The spike is putting a spotlight on a little-regulated and fast-growing

sector of health care: the medical helicopter industry. There are an

estimated 700 medical helicopters operating nationally, about twice the

number flying a decade ago.

Medical helicopters were once nearly all affiliated with hospitals. But more

generous federal reimbursements and changes in payment methods have

attracted more operators, including publicly traded corporations and smaller

concerns that in some cases set up outposts and market their services to

rural emergency units and even homeowners.

Emergency medical helicopters do save lives, by speeding some patients to

hospitals far faster than a ground ambulance could and by reaching remote

areas. But the industry's rapid, competitive growth may also be exacting a

toll. Federal regulators and some doctors worry that the pool of skilled

helicopter pilots has become drained and that some of those flying are

making poor decisions. In addition, some companies are flying older

helicopters that lack the instruments needed to help pilots navigate safely.

Of the 27 fatal medical helicopter accidents that occurred between 1998 and

2004, 21 were at night and often in bad weather, according to federal

statistics.

"You need to raise the bar and say this is where the bar is," said Dr. Scott

Zietlow, the medical director for the helicopter program at the Mayo Clinic.

"If you can't get over it, you can't fly."

Last month, the Federal Aviation Administration, after a meeting with

helicopter operators, proposed steps to improve flight safety. They included

helping pilots assess risks and providing them with up-to-date electronic

equipment.

Separately, the National Transportation Safety Board has been examining

medical helicopter safety and plans to issue recommendations to the Federal

Aviation Administration, a safety board official said.

Initial reviews by the aviation agency and the safety board indicate that

pilot error was to blame in many of the recent accidents. A report in 1988

by the board, which came after a string of accidents in the preceding years,

found that medical helicopters were crashing at a rate three times higher

than that of other helicopters. At that time, the safety board made a number

of recommendations adopted by the aviation agency, including better pilot

training, particularly for flying in bad weather.

Executives of medical helicopter companies and trade groups said they were

greatly concerned by the rising accident numbers but added that the figures

might simply reflect the fact that more helicopters were flying, rather than

an increase in the accident rate.

The executives said they could not be sure a trend existed because the

industry had been operating without a system to track its total flight

hours, a standard measure for assessing air deaths.

Under pressure from regulators, company officials say they hope to have such

a database in place by late spring, and several asserted that they were not

pressuring pilots to take on dangerous missions.

"We are seeing the number of accidents creeping up, and we need to be able

to understand what the factors are," said Tom Judge, executive director of

Lifeflight of Maine, owned by two health care systems there.

The growing concerns about medical helicopter safety are unfolding alongside

a long-running debate over whether many such flights are medically

necessary. The cost of a medical airlift typically ranges from $5,000 to

$8,000, five times or more than that of a traditional ambulance. Private

health plans and some public ones, like Medicare, cover air services, at

least in part.

There are about 350,000 medical helicopter flights annually, with about 30

percent involving calls to accidents or other emergencies, according to the

Association of Air Medical Services, a trade group in Alexandria, Va. Most

other flights involve the transfer of patients between hospitals.

As recently as a decade ago, medical helicopters were generally operated

directly by hospitals and emergency service units or run under arrangements

with aviation companies, including publicly traded ones like the Air Methods

Corporation and Petroleum Helicopters Inc., which provided the helicopters

and pilots.

But industry officials said the business began to change in the late 1990's

when the federal government required hospitals to charge separately for

ambulance services, including airborne ones, rather than bundling such costs

in bills paid by all patients. In addition, Medicare, in adopting a national

fee schedule, increased reimbursement rates for air ambulance flights in

some regions.

As a result, many hospitals decided to abandon their helicopter operations,

and for-profit companies saw an opportunity.

Mr. Judge, the Maine official, said studies showed that 20 percent of

patients transported by air might have died from injuries or illnesses had

they not been flown.

But Dr. Bryan E. Bledsoe, a former emergency room doctor who lives in

Midlothian, Tex., a suburb of Dallas, said 14 medical helicopters operated

within a 75-mile radius of his home.

"The problem is that there is not that much of a need," said Dr. Bledsoe, a

critic of the air-ambulance industry.

Another significant area of industry growth involves companies that are not

connected to hospitals but instead set up helicopter bases in rural areas

and then market their services to local hospitals, emergency officials and,

at times, homeowners.

For example, Air Evac Lifeteam, which started 20 years ago with a single

base in West Plains, Mo., now has 43 sites in 10 central states. For $50 a

household, homeowners receive a company membership guaranteeing that Air

Evac Lifeteam will not seek additional payment from them beyond what an

insurer will pay. Over 150,000 households are signed up, Air Evac executives

said.

The splintering in the way the industry operates has led to a hodgepodge of

standards. For example, the Mayo Clinic, which gets its craft and crews from

an aviation company, requires pilots to have 5,000 hours of experience and

uses only twin-engine helicopters. Air Evac requires pilots to have 1,500

hours of flight time before hiring them and uses older single-engine craft.

"There is a wide variation in self-imposed standards," said Mr. Judge, who

is also president of the industry's trade group.

The Arkansas accident a week ago involved an Air Evac Lifeteam helicopter

that had just been refurbished after spending 20 years ferrying workers and

supplies to oil rigs. Colin Collins, the company's president, says that it

uses only Bell model 206 helicopters like the one that crashed in Arkansas

because they have an excellent safety record and are relatively simple to

maintain.

Local emergency officials said that the Arkansas car-crash victim, Robert

Arneson, 71 of Harlingen, Tex., had a gash on his forehead but was stable

and alert when brought by ambulance to a field for helicopter transfer.

It was about 20 air miles, or a seven-minute flight, from the crash site, a

trip that would have taken about 45 minutes by ground. But because emergency

workers had to locate a landing area and get Ms. Austin's permission to let

the helicopter land on her property, nearly an hour elapsed, officials said,

after the first emergency call and before the helicopter took off.

Mr. Collins said he expected the National Transportation Safety Board to

release its preliminary findings as early as tomorrow.

In recent months, Air Evac Lifeteam has had two fatal crashes. Other

companies have also had troubles. In January, Air Methods, the industry's

biggest operator, had two fatal crashes within one week, including the one

in Washington. Both operators said those incidents involved their first

deaths in many years.

Even company executives acknowledge that the industry's rapid growth may be

outpacing the pool of experienced pilots.

Mr. Collins said most of his pilots a decade ago were Vietnam veterans, but

the majority have retired, and fliers coming out of the military now are not

interested in helicopters.

While company executives said pilots were not being pushed to fly, industry

critics and federal regulators are concerned about whether pilots are making

the right judgments or have the right information and equipment to base them

on.

Last summer, emergency officials in South Carolina summoned a helicopter to

transport a woman found seriously injured beside a highway. But the first

helicopter, which was based in Columbia, S.C., about 50 miles southeast of

the accident, aborted its mission four minutes after takeoff with the pilot

citing fog and deteriorating weather conditions.

The next two helicopter crews contacted also refused to fly, citing the

weather. Officials called a fourth helicopter, in Spartanburg, S.C., which

agreed to fly, arriving about an hour after the accident. The helicopter,

which was owned by the Med-Trans Corporation, picked up the victim and

crashed shortly after takeoff in a nearby national forest. All four people

aboard were killed.

The South Carolina crash remains under investigation by the National Safety

Transportation Board, and Jeffrey B. Guzzetti, its deputy director for

flight safety operations, said the agency was reviewing the pilot's decision

to fly.

Reid Vogel, a spokesman for MedTrans, based in Bismarck, N.D., said the

company could not comment on the accident because of the federal

investigation. But Mr. Vogel said the company's flight team had thoroughly

checked the weather that day.

In last month's notice, the Federal Aviation Administration, citing the

industry's rapid growth and an "unacceptable" number of accidents, suggested

that operators increase the use of technical aids like radar altimeters,

night-vision goggles and terrain awareness warning systems, among other

things.

In addition, it recommended that companies emphasize a "safety culture" and

also improve systems that will give pilots better information about changing

weather conditions while they are in flight.

"In essence, this is a first step in looking at ways to improve operations

and reduce the number of accidents in helicopter emergency services," said

James Ballough, director of flight standards service at the Federal Aviation

Administration.

Stephanie Saul contributed reporting for this article.

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Wow - talk about scary. Brings back a memory of a call I did that involved Stat-Flgiht. The call was for a diving injury at Croton Pt. Park. I don't remember the details of the injuries, but we landed stat flight in the big grass field just west of the beach. After loading the patient into the bird,it took off. As it was less than 150 ft up tin the air, a plastic shop-rite bag that was on the ground got sucked right into the engine. All of a sudden the engine dramaticly changed its pitch, and slowed down. At the same time, about 10-15 firefighters/emts all dove behind their cars with the fear that the Bird was going down. Fortunaly, it didn't, but just one more potential incident that could have been added to that list if the conditions were right. (or wrong)

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Thankfully the 117s have two engines so even if one goes down you at least have a backup.