What’s New in the Patient Safety World

November 2010


FAA Safety Guidelines for Medical Helicopters Short-Sighted



In our July 8, 2008 Patient Safety Tip of the Week “Medical Helicopter Crashes” and our October 2008 What’s New in the Patient Safety World “More Medical Helicopter Crashes” we discussed the “epidemic” of crashes of helicopters and other medical rescue aircraft in the recent past. In 2008, there were 28 deaths of patients and crew members in crashes involving medical emergency flights. Such crashes continue to be problematic. After a lull in 2009, this year there have been 16 deaths so far and the Federal Aviation Administration (FAA) has just released its proposals for improve medical helicopter safety (Flaherty 2010). The FAA plan would require terrain warning systems, operation control centers for larger companies, pre-flight risk analysis particularly for weather, and stricter flight rules whenever crew are on board (current regulations only apply when patients are on board). The FAA does not require some of the recommendations made last year by the NTSB such as use of night-vision goggles or an autopilot to help relieve the workload on pilots during difficult flights (note that the NTSB makes recommendations when it investigates crashes but it is the FAA that is responsible for implementation of rules and regulations).


We have been very critical that the regulatory agencies involved in oversight of the air medical industry have focused too much on proximate causes and ignored root causes (see our Patient Safety Tips of the Week for February 3, 2009 “NTSB Medical Helicopter Crash Reports: Missing the Big Picture” and September 1, 2009 “The Real Root Causes of Medical Helicopter Crashes”). 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.


All these solutions ignore some of the most important root causes. How did we solve the problem of too many catheter-induced urinary tract infections (CAUTI’s)? We asked “Why are we using so many Foley catheters? Are they all necessary?”. And, of course, we found out that many Foley catheters were not necessary and we successfully reduced CAUTI’s by avoiding unnecessary Foley catheters. We need to apply the same reasoning to medical air rescue crashes and ask “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?”.


The problem is that the only regulation for the medical evacuation industry is by the FAA (Federal Aviation Administration). There is no regulation at the state or regional level. And the FAA’s expertise is aviation, not healthcare. There is virtually no system in place by which an air transport has to be justified nor any system to review air transports for necessity and appropriateness.


We previously noted a 2006 study done by Dr. Bryan Bledsoe and his colleagues that was a meta-analysis of helicopter transport of trauma patients. 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).


Financial considerations (either cutting costs or pursuing profit) often appear as root causes. The same applies to the air medical rescue industry (and we do mean industry). Our September 1, 2009 Patient Safety Tip of the Week “The Real Root Causes of Medical Helicopter Crashes” discussed the other real root causes of the problem brought out in an excellent series in the Washington Post by Flaherty & Johnson. The most important root cause is money and what has turned into a highly profitable venture. And many consider pushback from the medical rescue industry to be playing a role in the current FAA proposal (Levin 2010).


In our Patient Safety Tip of the Week for February 3, 2009 “NTSB Medical Helicopter Crash Reports: Missing the Big Picture” we recommended some of the thinking that should go on in planning and implementing a medical rescue and transport to a trauma center. The first responders on the scene need to rapidly determine a number of factors and contact the emergency medical hub. Questions like the following need to be addressed:


  1. What type of facility does the victim/patient need to be transported to? (The guidelines for field triage of trauma victims have just been updated and are fairly clear in providing guidance about what facility the victim should be taken to.)
  2. How far is the crash site/response site from the destination hospital?
  3. How far is the helicopter from the crash site/response site?
  4. How long will it take for the helicopter to get to the crash site/response site?
  5. How long will it take for the ambulance to get to the crash site/response site?
  6. Will there be any delays at the crash site (eg. for extricating the victims)?
  7. What is the weather like? (important for both flying and driving)
  8. What is the ground traffic like? (Is it rush hour? Are there bottlenecks? Is there any road construction on the likely route to the Trauma Center?). Note that today the plethora of webcams and GPS devices can help rapidly answer the question as to whether there are likely to be any traffic delays en route.
  9. Are there likely to be special medical needs that a medical helicopter team can provide that cannot be provided by the ambulance EMT staff?


The above questions are really subquestions to the main question “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.


The trauma center or hospital on the receiving end should be completing the loop and completing some sort of Quality Improvement tool that links the process to outcomes. But can we really expect the receiving hospital or trauma center to jeopardize the business it receives from the air transports? And, of course, there would be pushback from the medical air transport industry itself. There probably should be a more neutral party that does the evaluations. Most states and regions have perinatal task forces that assess the care provided at local hospitals and that provided at the tertiary referral centers. Why can’t there be a similar arrangement for oversight for air transport cases?






Flaherty MP, Johnson J. FAA proposes safety guidelines for emergency medical copters. Washington Post. October 8, 2010


Levin A. Rules on medical copters to tighten. USA Today 10/8/2010




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):1257-65 http://www.jtrauma.com/pt/re/jtrauma/abstract.00005373-200606000-00015.htm;jsessionid=LzvDYgJNbkdJpBhDDCFtr3VBPJJ6WwQ1bvdXstQHvMNQ7Lk0Mygl!447927974!181195628!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=1&nav=search



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




Levin A. Medevac industry opposing upgrades wanted by NTSB. USA Today 8/19/2010















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