Hearing Probes Helicopter Medevac Safety

In 2008, helicopter emergency medical services experienced 13 crashes, resulting in 29 deaths. Leaders in emergency medical transport want to learn why the crashes occurred and how to prevent future ones.

To that end, officials with the National Transportation Safety Board (NTSB) held a 4-day fact-finding hearing in February in Washington, DC. A wide range of witnesses, including physicians, helicopter operators, and government regulators, offered testimony to help the board better understand the scope of the problem and evaluate the factors leading to crashes. The NTSB will now decide whether to offer recommendations in hopes of minimizing such crashes.

“What we are trying to accomplish is to learn more to offer knowledgeable recommendations to those making policy to assure these flights are as safe as possible,” said Robert Dodd, chief of safety studies and statistical analysis with the NTSB and a technical officer at the hearing. The hearing focused on 3 elements: what government is or is not doing to oversee and regulate the industry, how helicopter operators can better improve flight safety, and how the medical community's approach to air transport of patients affects safety.

While 2008 had the highest number of fatalities ever recorded for medical helicopter crashes, the total should be kept in perspective. Ira Blumen, MD, medical director and program director of the University of Chicago Aeromedical Network, said that from 1972 to 2008, there were 264 medical air transport crashes, with 98 of these resulting in a total of 264 fatalities. Of the 264 crashes, 256 involved dedicated medical helicopters and 8 occurred with dual-purpose helicopters, such as those operated by city, county, or state agencies that may perform medical missions but also have primary missions supporting agencies such as the police or fire department (http://ntsb.gov/events/Hearing-HEMS/NTSB-2009-8a-Blumen-revised-final-version.pdf).

However, the number of crashes has increased in large part because the use of medical helicopter transport has increased. While fewer than 50 medical helicopters were in operation in 1980, today more than 830 are providing patient transport, Blumen said. In 1980, the total number of patients transported by helicopter was less than 25 000; by 2007 that number had increased to more than 275 000 patient transports by helicopter. Blumen's figures were extrapolated from data gathered through surveys of the major helicopter operations representing more than 80% of total flights.

Putting the data together, Blumen estimated that the fatal crash rate has declined from almost 10 deaths per 100 000 flight hours in 1980 to slightly less than 2 deaths per 100 000 flight hours in 2008. Still, the 2008 crash data reversed a 3-year trend of declines in the rate of fatal crashes. “I’d like to think that last year was an unusual year and not the beginning of a new trend,” Blumen said.

One possible barrier to improved safety is the lack of coordinated government oversight. Currently, regulation of all aeromedical transport is under the authority of the Federal Aviation Administration (FAA). Arguably, the states could regulate the medical aspects of helicopter transport of patients, but they are preempted from doing so by the federal government’s 1978 Airline Deregulation Act, Dodd said. “[Suppose] you are a state medical director trying to have oversight of quality medical care,” Dodd said. “You can do it with ambulance services, but the air companies say the FAA is the only one that can regulate how they operate their helicopters, and judges have agreed.”

Steven Andrews, MD, an emergency physician at North Memorial Hospital in Robbinsdale, Minn, and chair of the medical transport section of the American College of Emergency Physicians (ACEP), said any change in this federal preemption over state regulations will have to come from Congress. No such bill has been introduced but the legislative mindset might be changing, Andrews said. “When there are more crashes, that's when legislators start paying attention,” he explained.

In the meantime, FAA oversight of aeromedical transport has been called into question. In 2006, the NTSB published a report that examined 55 airplane and helicopter medical transport crashes and determined that 29 could have been prevented if corrective actions recommended in the report had been in operation. The NTSB offered 4 safety recommendations to the FAA: ensure that all flights with medical personnel on board adhere to charter aircraft regulations; develop and implement flight risk–evaluation programs; require formalized dispatch and flight-following procedures, including up-to-date weather information; and install terrain awareness and warning systems on aircraft (http://www.ntsb.gov/Dockets/Aviation/DCA09SH001/409984.pdf).

But the FAA declined to mandate such recommendations and only offered them as voluntary measures to medical air transport companies. The NTSB was not pleased and put the recommendations on its “most wanted” list of transportation safety improvements in October 2008. The list focuses attention on improvements intended to have the greatest impact on transportation safety.

Another aspect to improving the safety of these medical emergency flights is upgrading equipment and properly training staff to use it. For example, some observers recommend equipping helicopters with terrain-awareness technology and supplying pilots with night-vision goggles.

Data on whether such actions are effective are limited, and air operators are reluctant to invest up to $150 000 per helicopter for such equipment and training. However, these steps appear to make sense because, according to Blumen’s estimates, almost half of all crashes occurred at night between 1998 and 2008. Blumen also estimated that for 77% of all crashes, human error was the probable cause. These crashes were mostly due to collisions with objects or were weather-related.

But technology is not sufficient in and of itself. Rigorous protocols for determining terrain risk and weather risk also could minimize safety dangers associated with patient transfers by helicopter. Susan Baker, ScD, MPH, a professor at the Bloomberg School of Public Health at Johns Hopkins School of Medicine in Baltimore, called for dedicated preflight risk evaluation. “We do not have a system where there's a safety-oriented person deciding whether a flight should or should not be made,” Baker said.

Physicians also play a role in the safety of medical helicopter transport by controlling, in large part, its use, said Alexander Isakov, MD, MPH, an associate professor in the department of emergency medicine at Emory University School of Medicine in Atlanta. “We’d like this tool to be used appropriately,” said Isakov, who also is director of Emory's section of prehospital and disaster medicine. “It makes these fatalities more tragic when in retrospect you say, ‘Gee, that patient didn't need to be helicoptered.’”

Over the years, the ACEP, along with the National Association of Emergency Medical Services Physicians, has issued guidelines for air medical dispatch, most recently in 2002. Andrews said a lack of new research data has slowed the revision process for these guidelines (for example, there is limited literature directly addressing beneficial outcomes associated with air transport), but noted that the organizations have begun working on an updated document that will draw upon similar guidelines issued by the Association of Air Medical Services and the American Academy of Pediatrics.

Although using helicopter transport of patients only for medically appropriate reasons should reduce the number of unnecessary missions, non–patient-related issues have emerged that promise to increase the number of flights. Isakov said the consolidation of major trauma centers leaves certain populations isolated from such facilities, and ambulance coverage may be minimal in rural areas. Transferring a patient to a hospital some distance away by ambulance could leave these areas without services, perhaps for hours.

Physicians also have the responsibility to avoid “helicopter shopping.” This occurs when one air medical company declines to transport a patient because of dangerous weather or terrain and medical personnel call other companies until they find one that accepts. “One of the most dangerous trends in emergency care is helicopter shopping,” Blumen said. “If someone says it is unsafe to fly, it should be a red flag.” Blumen added that there is a growing trend among helicopter operators to alert competitors when they turn down a particular mission, to encourage the other services to consider the environmental risks if they receive a request from the same physician.

Dodd said he hoped the NTSB hearings and conversations between interested parties will lead to improved safety, but he is not convinced they will. “Twenty years ago we did a study on air medical safety and identified many problems that remain to this day,” Dodd said. “If we identified them 20 years ago, why do they still exist today?”