Patient Safety Tip of the Week
December 29, 2015
More Medical Helicopter Hazards
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:
·
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.
·
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 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.
·
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.
·
You should be participating in simulation
exercises and other crew resource management drills with them.
·
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.
·
Do a FMEA (Failure Mode and Effects Analysis) on
your medical helicopter transport.
·
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”
References:
CBS/AP. 4 dead after medical helicopter crashes in heavy
rain, fog. CBS News 2015; December 11, 2015
http://www.cbsnews.com/news/4-dead-after-medical-helicopter-crashes-in-heavy-rain-fog/
Schwartz D. Two killed, one critically hurt in medical
helicopter crash in Arizona
Reuters 2015; December 16, 2015
http://www.reuters.com/article/us-arizona-helicopter-idUSKBN0TZ2HH20151216
NTSB (National Transportation Safety Board). NTSB
Identification: CEN15FA171. March 12, 2015
http://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20150313X72113&key=1
NTSB (National Transportation Safety Board). NTSB
Identification: CEN14FA462. August 27, 2014
http://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20140827X25654&key=1
Llorca JC. 4 killed in New Mexico
crash of medical flight. Associated Press 2015;
August 28, 2014
http://news.yahoo.com/4-killed-mexico-crash-medical-flight-141944120.html
NTSB (National Transportation Safety Board). NTSB
Identification: CEN15FA164. March 6, 2015
http://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20150308X10201&key=1
NTSB (National Transportation Safety Board). NTSB
Identification: CEN15FA003. October 4, 2014
http://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20141004X60516&key=1
Choate K. Close Call: Drone Nearly Collides With Medical
Helicopter. PAhomepage.com 2014; November 21, 2014
http://www.pahomepage.com/news/close-call-drone-nearly-collides-with-medical-helicopter
Lowy J/Associated Press. Report cites 241 near collisions
between pilots, drones. WFMJ 2015
http://www.wfmj.com/story/30724687/report-cites-241-near-collisions-between-pilots-drones
Brewer R. WMUR. Manchester airport introduces new drone
guidelines. WMUR News 2015; December 10, 2015
http://www.wmur.com/news/manchester-airport-introduces-new-drone-guidelines/36892412
Morgan D. New U.S. FAA rule requires drone owners to
register by Feb 19
Reuters 2015; December 14, 2015
http://news.yahoo.com/faa-drone-registry-rule-feb-19-deadline-current-145439603.html
NTSB (National Transportation Safety Board). NTSB Most
Wanted List 2014. Address Unique Characteristics of Helicopter Operations. 2014
http://www.ntsb.gov/safety/mwl/Documents/2014/01_MWL_HeliOps.pdf
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)
http://www.annemergmed.com/article/S0196-0644%2809%2900031-6/pdf
Dechter G, Jones B. Md. medevac
crash raises question about trauma procedures. The Baltimore Sun. October 1,
2008
http://www.volunteerfd.org/sogs/articles/430962
Ballan E. Ambulance Crash Roundup. EMS World. February 9,
2011
http://www.emsworld.com/article/10225399/ambulance-crashes
Maryland Institute for Emergency Medical Services Systems.
The Maryland Medical Protocols for Emergency Medical Services Providers. Effective
July 1, 2014
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