—Jim Hall, past chairman of the National Transportation Safety Board, in the Rockford Register Star, Dec. 24, 2012.
The incident was tragic, the plot all too familiar: On the evening of Dec. 10, a medical helicopter flew south from Rockford Memorial Hospital to pick up an adult patient at Mendota (Ill.) Community Hospital, a door-to-door ground distance of 62.9 miles via Interstate 39. The solo pilot, 65-year-old Andy Oleson, had four decades of experience flying choppers. He was four work shifts shy of retirement.
During the outbound flight, Oleson radioed that he had "encountered weather" — it may have been sleet — and would be turning back. Shortly after that final transmission the helicopter, a twin-engine MBB/Kawasaki model favored for military transport, police and air ambulance uses, nose-dived into a farm field. Oleson died, as did veteran flight nurses Karen Hollis, 48, and Jim Dillow, 40.
Rockford Memorial declines to discuss the patient's medical condition, other than to say that he or she eventually was transported by ground ambulance and was hospitalized for nine days, including several in Rockford Memorial's critical care unit, before being discharged.
EMS air service plainly is vital for patients with time-sensitive emergencies — heart attacks, strokes and severe trauma. But consider: Has rising medical need driven the increase in air ambulance traffic? Or has greater availability of helicopters and flight crews tempted hospitals to redefine routine transfers as necessary flights? Paradoxically, the survivors of some patients killed in crashes have sued providers, contending that those flights weren't medically necessary.
This much is certain: After each of these crashes, safety experts ask whether overuse or lax rules or, instead, medically justifiable risk explains why ostensibly lifesaving flights take so many lives.
Medical helicopters transport some 400,000 patients annually, a number that has risen in recent years despite a death toll that, over the last decade, has alarmed federal safety officials. The Tribune's Jon Hilkevitch reported after the Dec. 10 plummet that more than 100 people — some of them patients — have died in EMS helicopter crashes since 2003. He cited a study by Dr. Ira Blumen of the University of Chicago Hospitals that, using death rates, identified the job of helicopter emergency medical crew member as the highest-risk occupation — more dangerous than deep-sea fisherman, logger or nine other hazardous categories. (Over the past five years, crashes of fixed-wing medical planes killed an additional 25 people.)
TV dramas have conditioned all of us to view EMS flights as missions of mercy, and many times they are: Often in difficult terrain, and often at night, pilots evacuate trauma victims, transport patients who need special care, and ferry life-giving organs to transplant teams.
But as air ambulance services expanded, transports also became big business. Last July, the industry publication Modern Healthcare cited a June presentation by one of the nation's biggest air ambulance operators as stating that the company's net revenue per transport in the first quarter of 2012 was more than $10,000. That was after Medicare/Medicaid discounts and bad-debt expenses.
High equipment and operating costs arguably justify high fees. What are the offsetting benefits? Modern Healthcare cited a large study of adult trauma patients with a minimum level of injury severity: Patients transported by helicopter to Level I trauma centers had a 16 percent greater chance of survival than those transported by ground; the survival advantage was 15 percent for those choppered to Level II trauma centers.
One of the study authors, a Johns Hopkins researcher, cited a factor other than the speed of flight: Air medical crews generally have better-qualified personnel — often at least one registered nurse with critical care expertise, and sometimes a doctor — than do ground ambulances staffed by emergency medical technicians and paramedics.
As the Jim Hall op-ed quoted atop this editorial suggests, the NTSB for years has pushed the Federal Aviation Administration to demand safety improvements, including standardization of what today are inconsistencies in pilot training, communications and navigation gear.
On Oct. 7, 2010, U.S. Transportation Secretary Ray LaHood, a former Illinois congressman, unveiled what he called "a significant proposal" — extensive new rules that, the FAA noted, would require helicopter operators "to use enhanced procedures for flying in challenging weather, at night, and when landing in remote locations." The agency's public comment period closed in January 2011. But 27 months after LaHood's news release, the FAA tells us the final rules still are under "executive review."
We don't know whether the proposed rules might have prevented the Dec. 10 crash. Nor do we know enough to question the decision to launch that flight. Hall argues that "similar accidents could be prevented by requiring all EMS helicopters to have two active pilots at night. ... The underlying principle that should govern EMS helicopter operations is simple: when a patient is evacuated by helicopter, there should not be additional risk of injury or death because of shortcomings in the safety culture associated with these operations."
Aviation is steeped in acronyms: Previous FAA recommendations to make EMS flights safer include AMRM (for Air Medical Resource Management) guidelines, HEMS (Helicopter Emergency Medical Services) rules, and promotion of TAWS (terrain awareness warning systems).
Still, though, medical helicopters fall from the sky and kill innocents: Wednesday night, three crew members died in another EMS crash, and resulting fireball, west of Mason City, Iowa. If the sheer volume of federal regulations could prevent these tragedies, they already would occur less often than they do.
The likelier fix is basic, and humble, reform in how medical personnel decide to request flights, and whether aviators comply. If we could write one mandate, it would evoke the redundant, precautionary questions that surgical teams repeatedly answer, out loud, before performing operations: "What is this patient's name and date of birth? What is this procedure? Which side of the body? Does anyone here disagree or have anything to add? ..."
From the moment anyone at any hospital considers requesting an EMS flight, everyone involved should discuss, out loud, a new phrase built on a new acronym: "Will we, each of us, OWN this flight?" — short for Only When Necessary.