Time for our annual rant on safety issues related to medical helicopter/air ambulance transports. Since 2008 we’ve been doing columns pertinent to the rash of crashes of medical helicopter and air ambulance vehicles that we’ve seen in recent years with consequent loss of life of patients, staff and crew (see the full list of our prior columns at the end of today’s column).
Since our last column on helicopter/air ambulance accidents, there have been multiple subsequent accidents. The most recent one, leading to today’s column, occurred in California on December 10, 2015 (CBS/AP 2015). Four people, including a patient, a nurse, a paramedic, and the pilot died in that crash. That crash occurred during a planned 50-mile night flight in rainy, foggy conditions. Initial reports did not provide the medical reason the patient was being transported. A quick search on Google Maps estimates ground transport time between the two sites to be 49 minutes (though rainy, foggy conditions would be expected to likely increase that time as well). Without knowing the medical reason for transport or the equipment/staffing needs for the transport, we’re not in a position to comment on the most appropriate mode of transport in this case.
Actually, another one just occurred after we began work on this column. A medical helicopter crashed in Arizona, killing the pilot and a nurse and injuring a paramedic (Schwartz 2015). No patients were on board when the crash occurred. The helicopter was apparently returning to its base. Details are not known at this time.
A fatal crash in Oklahoma in March 2015 occurred in the setting of lower than expected cloud ceilings during a night flight (NTSB 2015a). A fatal crash of a twin-engined medical evacuation plane in New Mexico in August 2014 occurred after the plane was erroneously fueled with Jet A fuel instead of the required fuel (NTSB 2014a). An engine caught fire, leading to the crash, and four people including a patient, a nurse, a paramedic, and the pilot died in that crash. The patient had been staying in Las Cruces and receiving radiation therapy after having surgery for a brain tumor in a Phoenix hospital. He was being transported back to the Phoenix hospital after recent deterioration (Llorca 2014).
In March 2015 a helicopter attempting to land on a rooftop helipad at St. Louis University Hospital hit the edge of a hospital building and crashed in an adjacent parking lot, killing the pilot who was the only one aboard at the time (NTSB 2015b). The pilot had dropped off his crew and a patient previously, returned to his air base to refuel, and was now returning to the hospital to again pick up his crew. This was a night flight, with winds gusting to 25 knots, and the helicopter experienced loss of directional control.
In October 2014 a medical helicopter crashed in Wichita Falls, TX during a night flight in light winds (NTSB 2014b). The patient being transported died and 3 crew members were seriously injured. The pilot had aborted a first attempt at landing on the helipad, then went into a violent spin during the second attempt.
There are many factors that make accidents involving medical helicopters (and some other medical aviation) more likely to occur. Many medical flights occur at night or in inclement weather. The landing areas are also often not nice ample open spaces like airport runways, but are often rather tight spaces with wires and other obstacles nearby. The emergent nature of the medical mission often keeps the team from canceling the flight or diverting to safer routes. Most helicopter programs say that any crew member has the ability to call off the flight at any time but we wonder how often that really happens. The time pressures may be great. If you are trying to get a true level I trauma patient to a level I trauma center within the “golden hour”, or a rural stroke patient to a stroke center within the 3-hour therapeutic “window”, or an MI patient to a site for thrombolytic therapy or primary angioplasty site within their respective “windows”, time is of the essence. The same applies when transporting organs for transplantation.
Medical helicopters also are often flying without the benefit of air traffic controllers and sometimes without flight dispatchers. They most often fly by “sight” rules and have to visually look out for other aircraft and other obstacles. The NTSB report had pointed out that most medical helicopters do not make optimal use of night vision imaging systems or night vision goggles. Many medical helicopters also still do not utilize terrain awareness and warning systems, another safety feature recommended by the NTSB.
And you can add drones to the list of hazards as a drone in Pennsylvania almost collided with a medical helicopter (Choate 2014). There was no patient on board at the time. As the cost of personal drones has come down the number of drones being flown has increased significantly. A recent report counted at least 241 reports of close encounters between drones and manned aircraft that meet the Federal Aviation Administration's definition of a near-collision, including 38 that involved helicopters. (Lowy 2015). Helicopter blades are considered especially vulnerable if collisions were to occur. In New Hampshire a program was recently introduced requiring anyone operating a drone within 5 miles of Manchester-Boston Regional Airport to contact air traffic control before flying the drone (Brewer 2015). And the FAA just put forward a new rule requiring drone owners to register their drones by February 19, 2016 (Morgan 2015).
Surviving a medical helicopter crash may also be difficult for a number of reasons. Helmets, shown to help save lives and prevent head injuries in military helicopter crashes, are often not worn by all medical helicopter occupants. The same applies to shoulder harnesses. And there is some evidence that serious or fatal injuries are more likely to occur to those who are not in the front seats, that is those back in the cabin may be at more risk. And the lack of aviation flight risk evaluation programs by many helicopter EMS programs was also cited by the NTSB. They also noted that helicopter EMS accidents were more likely to occur when a patient is not on board (when rules and regulations are less stringent).
But the NTSB and FAA have been shortsighted and operated in a silo mentality in their analyses and approaches to the problem and the state and local regulatory agencies and even the medical community have done the same. Our September 1, 2009 Patient Safety Tip of the Week “The Real Root Causes of Medical Helicopter Crashes” pointed out that the only regulatory agency with any oversight of the medical helicopter industry is the FAA (Federal Aviation Administration) and, even then, it only has oversight of the aviation component. That column delved into some of the financial and other less altruistic incentives driving the industry.
Our issue #1 with the approaches taken by the NTSB and FAA to all these crashes has been that they have never asked the question “Was this method of transport necessary in the first place?”. They have focused only on the issues related to flights that they would address in their investigations of any aircraft crash or other transportation accident. Proposed solutions to these crashes have always focused on proximate causes and recommendations have come out in favor of mandating night vision goggles, terrain warning systems, better weather information, changes in pilot training, etc. Even the NTSB’s most recent communication addressing the need to do more to prevent the increasing frequency of helicopter accidents (NTSB 2014) fails to even mention the issue of necessity of the medical helicopter flights. It focuses on inspection and maintenance, crew fatigue, and the need for flight risk evaluation programs and formalized dispatch and flight-following procedures. Not a word about assessment of the medical necessity of air transport.
When we do a root cause analysis (RCA) of an event related to a medical or surgical procedure, one of the first questions we always ask is “Was the procedure indicated in the first place?”. When we approach the issues of CAUTI’s and CLABSI’s we ask the question “Was the catheter really necessary in the first place?”. No one is asking similar questions when reviewing medical transport crashes.
Ironically, on the very day we started preparing one of our 2009 columns, we chanced upon a medical helicopter evacuation scene. We couldn’t help but wonder if helicopter was the most appropriate means of transport. Judging by the state of the cars involved in the crash, it was pretty clear that the injuries suffered by someone were likely severe enough to merit transport to a Level I Trauma Center. By car from that spot is exactly 29 minutes in morning traffic (we know because we did that exact drive daily for over 12 years, where I was the medical director of the trauma hospital). It was a sunny day and the roads were dry, though it was a bit windy. It was not rush hour. Rather it was just shortly before 1PM. It would probably take the helicopter about 10 minutes to fly to the Trauma Center. We wondered how long it had taken the helicopter to arrive. The helicopter base site is about 30 miles from the accident site. The accident site was actually less than half a mile from another hospital so an ambulance was probably available within minutes of the accident. We don’t know if the victim had required extrication that might have added to any time elapsed. And we don’t know whether any specific medical expertise was required during that transport to the Trauma Center. The helicopter team is staffed by very well-trained EMT’s and we personally knew each of the very well-qualified medical directors who are available round-the-clock to provide medical guidance for the helicopter team. Yet we couldn’t help but wonder whether the total time elapsed to get the patient to the trauma center was faster by helicopter than it would have been had he/she been taken there by ambulance (keeping in mind that considerations other than speed may have also been important, such as staffing and equipment).
As above, all the solutions proposed by NTSB and the FAA ignore some of the most important root causes and failed to ask an important question “Was an air medical evacuation really necessary here or could ground ambulance have been adequate?”. Even the few root cause analyses (RCA’s) we have seen following actual medical helicopter crashes have failed to ask that fundamental question “Was the helicopter transport indicated in the first place?”.
We’ve several times noted a 2006 study done by Dr. Bryan Bledsoe and his colleagues that was a meta-analysis of helicopter transport of trauma patients (Bledsoe 2006). Using several widely-used injury severity or trauma scores, they showed that almost 2/3 trauma patients brought by helicopter to a trauma center had minor or non-life-threatening injuries and that 25% were discharged from the hospital within 24 hours. Some helicopter services apparently have rates as high as 20% of transported patients being discharged from emergency rooms shortly after arrival (Greene 2009). Even in Maryland, where the trauma system is a model and the medical helicopter system a public one, the post-crash hearings revealed that almost half of patients transported by helicopter to trauma centers were released within 24 hours (Dechter 2008).
In our March 2012 What's New in the Patient Safety World column “Helicopter Transport and Stroke” we noted that many patients with acute ischemic stroke or with acute MI are having thrombolytic therapy delayed pending helicopter transport to tertiary centers and finally reach those destinations beyond the therapeutic “windows” for successful intervention. Most hospitals on the “sending” end never even get feedback on either transport times or whether their patients got the desired therapies within the prescribed timeframes. For example, if a remote hospital is transporting a patient to a tertiary center for percutaneous coronary angioplasty for an MI and the statistics suggest that such patients seldom arrive within the standard window for PTCA, the remote hospital should consider giving thrombolytic therapy before sending the patient. The real question you should always be asking is “What’s the fastest way to get the patient/victim the medical interventions he needs?” and then assessing the risk:benefit ratio of air vs. ground transport.
Of course, it would also be nice to have a better understanding of how often crashes occur with ground ambulance transports. Such data are surprisingly hard to come by and are likely to be underreported (Ballan 2011). But it certainly seems there are a disproportionate number of medical helicopter/air ambulance accidents, given the relative frequencies of the two types of transport.
In view of the lack of effective oversight of the medical helicopter/air ambulance industry and the several potential conflicts of interest among key stakeholders (see our September 1, 2009 Patient Safety Tip of the Week “The Real Root Causes of Medical Helicopter Crashes”), the onus for reform falls either to (1) the public to put pressure on their state governments to develop oversight or (2) the hospital community to ensure appropriate use of such services. Good luck with the former! Unless a celebrity dies in such a crash it is unlikely that state legislatures will do anything.
So the task really falls to hospitals. Even if your organization does not own its own medical helicopter, there are things you can do to help ensure the safety of your staff and patients:
<![if !supportLists]>· <![endif]>Look at the data. Get good data from the helicopter company about transport times and any issues that arose. Make sure you get the data you need from the receiving hospital on key measures like time to angioplasty.
<![if !supportLists]>· <![endif]>After each transport, assess whether the benefit of the helicopter trip outweighed the risks and assess whether alternative (ground) transport would have been appropriate.
<![if !supportLists]>· <![endif]>If you are a receiving hospital make sure you periodically get together with your referral hospitals (and EMS organizations) to review the medical necessity of cases, transport times, and outcomes.
<![if !supportLists]>· <![endif]>Make sure the company that runs the helicopter has a culture of safety. If it uses standardized dispatch protocols, has night vision imaging equipment and terrain awareness and warning systems, does flight risk assessments, is meticulous in maintenance, has fatigue mitigation programs, has (and enforces use of) helmets and shoulder harnesses, and has good training programs for its pilots and any of your staff that may fly – that’s the sort of partner you are looking for.
<![if !supportLists]>· <![endif]>You should be participating in simulation exercises and other crew resource management drills with them.
<![if !supportLists]>· <![endif]>Be familiar with any guidelines for emergency transport of patients that may be available in your state or region. If there are none, be familiar with guidelines from well-established emergency systems like the Maryland Medical Protocols for Emergency Medical Services Providers.
<![if !supportLists]>· <![endif]>Do a FMEA (Failure Mode and Effects Analysis) on your medical helicopter transport.
<![if !supportLists]>· <![endif]>Get feedback from your patients who you sent via helicopter/air ambulance. Were they satisfied with the service? Did they feel it was preferable to ground transport? Did they get stuck with big out-of-pocket expenses they did not anticipate?
Medical helicopter/air ambulance transport can be lifesaving in innumerable cases. Yes, compared to the total number of transports, crashes of such aircraft are relatively few. But any time we might unnecessarily put lives at risk we need to be circumspect. We pay lots of attention to other medical “never events” (eg. wrong-site surgery, surgical fires, etc.) that are equally rare. Even if you don’t end up preventing a crash, doing the above exercises may alert you to problems in the referral-receiving relationships between hospitals that are leading to suboptimal care for your patients.
Our prior columns dealing with medical helicopter issues:
July 8, 2008 “Medical Helicopter Crashes”
October 2008 “More Medical Helicopter Crashes”
February 3, 2009 “NTSB Medical Helicopter Crash Reports: Missing the Big Picture”
September 1, 2009 “The Real Root Causes of Medical Helicopter Crashes”
November 2010 “FAA Safety Guidelines for Medical Helicopters Short-Sighted”
March 2012 “Helicopter Transport and Stroke”
April 16, 2013 “Distracted While Texting”
August 20, 2013 “Lessons from Canadian Analysis of Medical Air Transport Cases”
CBS/AP. 4 dead after medical helicopter crashes in heavy rain, fog. CBS News 2015; December 11, 2015
Schwartz D. Two killed, one critically hurt in medical helicopter crash in Arizona
Reuters 2015; December 16, 2015
NTSB (National Transportation Safety Board). NTSB Identification: CEN15FA171. March 12, 2015
NTSB (National Transportation Safety Board). NTSB Identification: CEN14FA462. August 27, 2014
Llorca JC. 4 killed in New Mexico crash of medical flight. Associated Press 2015;
August 28, 2014
NTSB (National Transportation Safety Board). NTSB Identification: CEN15FA164. March 6, 2015
NTSB (National Transportation Safety Board). NTSB Identification: CEN15FA003. October 4, 2014
Choate K. Close Call: Drone Nearly Collides With Medical Helicopter. PAhomepage.com 2014; November 21, 2014
Lowy J/Associated Press. Report cites 241 near collisions between pilots, drones. WFMJ 2015
Brewer R. WMUR. Manchester airport introduces new drone guidelines. WMUR News 2015; December 10, 2015
Morgan D. New U.S. FAA rule requires drone owners to register by Feb 19
Reuters 2015; December 14, 2015
NTSB (National Transportation Safety Board). NTSB Most Wanted List 2014. Address Unique Characteristics of Helicopter Operations. 2014
Bledsoe BE. Wesley AK. Eckstein M. Dunn TM. O'Keefe MF. Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis. Journal of Trauma-Injury Infection & Critical Care 2006; 60(6): 1257-1265
Greene J. Rising Helicopter Crash Deaths Spur Debate Over Proper Use of Air Transport. Annals of Emergency Medicine 2009; 53: A15-A17 (March 2009)
Dechter G, Jones B. Md. medevac crash raises question about trauma procedures. The Baltimore Sun. October 1, 2008
Ballan E. Ambulance Crash Roundup. EMS World. February 9, 2011
Maryland Institute for Emergency Medical Services Systems. The Maryland Medical Protocols for Emergency Medical Services Providers. Effective July 1, 2014
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