NY Times Article
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.