Reconsidering Air Ambulance Usage
“Medical helicopters and their flight crews are of tremendous importance to the nation, especially rural Americans,” says one expert.
MARBLE FALLS, Texas — The helicopter pad behind the firehouse in this town of 5,000 people is hardly thought about on weekends when fireworks, boat races and music festivals overwhelm the streets and nearby Colorado River.
“Medical helicopters and their flight crews are of tremendous importance to the nation, especially rural Americans,” says one expert.
AP file
But make no mistake about it: The air ambulance in Marble Falls has long been considered an important part of life — and the saving of it. When the town’s population swells to 25,000 on Saturday nights as visitors flock toward the mesquite barbecue or the famous pie at the Blue Bonnet Cafe, a pilot, flight nurse and a paramedic stand by the helicopter, just in case.
Now, as the booming air ambulance industry deals with a spate of deadly crashes, Marble Falls and hundreds of other communities across the USA are wondering whether air ambulances are always the best medicine.
“Just because they are sitting there doesn’t necessarily always make them the best resource,” says Loren Stagner, assistant operations manager for Marble Falls Area emergency medical services (EMS). “Their initial concept was phenomenal, but the execution has failed.”
Most still agree that Marble Falls needs an air ambulance service. There are times, in rare emergencies, when patients need to get to a hospital by air. In cases where time contributes to loss of life or limb, the hour-long drive to Austin is too much time to waste. The chopper can make the trip in 20 minutes.
But the challenge now faced by Marble Falls’ emergency medical services — and others across the nation — is determining how to use helicopters in a way that reduces the risk to patients.
A USA TODAY investigation found that federal air safety regulators have failed to keep pace with the rapidly growing industry. As a result, patients and crew members have died in crashes that could have been prevented.
More patients have died in helicopter ambulance crashes in the past five years than in the 10 previous years combined. Over the past five years, helicopter ambulance crashes have killed 60 people, including seven patients and two mothers of sick infants.
The nation has never relied more on air ambulance helicopters. As rural emergency rooms close and specialty care becomes more centralized in big cities, moving patients in from rural areas fast has become more important in emergency medicine.
Helicopters are the only rapid way that 28% of the nation’s population can get to a top trauma center within 60 minutes, according to a study published in the June issue of the Journal of the American Medical Association.
“Medical helicopters and their flight crews are of tremendous importance to the nation, especially rural Americans,” says the study’s lead author, Charles Branas, an assistant professor of epidemiology at the University of Pennsylvania School of Medicine.
So while emergency medical services officials don’t want to limit access to helicopters, they are concerned about the crashes and they want to protect their patients.
Applying safety standards is particularly important, industry officials say, because no two air ambulance operations are exactly alike.
Two distinct approaches for providing the service have emerged. The long-standing approach is to base a helicopter at a specialty hospital — a trauma, cardiac or burn center — and send hospital specialists to patients to bring them back to the hospital. These operations tend to use expensive helicopters with top-notch navigational instruments and safety gear, as well as highly experienced pilots.
Because these helicopters are more expensive to own and operate, and because the pilots and medical personnel are paid well, these operations typically lose money on each flight. They stay afloat through financial support from the hospital, which makes money by maintaining a steady flow of incoming patients.
The more recent approach, which continues to grow across the nation, is to base a helicopter in a rural area so that it is closer to the prospective patients. Because these operators stand alone in a community with little or no financial support, each helicopter must earn a profit to stay in the area.
These operators use helicopters that are less expensive to own and operate and lack the more sophisticated safety features of the typical hospital-based helicopter, such as calibrated navigational instruments that help pilots fly in poor visibility. Both their pilots and their medical crews tend to be less experienced than those at a traditional hospital-based operation.
“We’ve grown so fast in this industry that we’ve outpaced our ability to have that level of personnel on a consistent basis,” says Christine Zalar, a former flight nurse and an industry consultant with Fitch & Associates. “We’ve also placed aircraft in areas where those kinds of people don’t exist. You are working in an area that makes great sense because patients need to be moved but your talent pool in that area is a little more stretched.”
Today there are hybrids of both types of operations — with hospitals deploying helicopters in rural areas and freestanding aviation companies operating helicopters at hospitals.
But for the most part, the differences are still significant, says Bob Bass, Maryland’s EMS medical director, who is part of a nationwide effort by the air ambulance industry, health regulators and emergency physicians to help state officials craft air ambulance rules.
“The larger carriers are trying to run a quality program and pay their pilots and pay their mechanics and run safely, and they are feeling they are being undercut by these other programs doing it on the cheap,” he says.
Reducing the Number of Flights
Meanwhile, across the EMS field, there is a sense of urgency as emergency workers try to apply more logic to airlifts.
Marble Falls has never had any concern about its helicopter crew’s safety, but the accidents across the nation have paramedics here scrutinizing the performance of the many helicopters in the area and finding ways to reduce the number of times patients have to be loaded onto helicopters.
Waving off a chopper in a small town like Marble Falls means making a tough and complicated decision — fast.
After the helicopter set up its base in town, anytime an ambulance responded to find a victim near death, the medics called for the chopper. Many patients benefited, but others were flown just because things looked bad, and the paramedics lacked the training and experience to make more precise decisions.
“A lot of our newer paramedics, especially, they really weren’t sure,” Stagner says. “And it was just easier to err on the side of the patient and fly them.”
For example, he says, the medics were “flying everything that resembled a stroke” to Austin. But some of those patients did not meet the criteria for stroke center care, “so we were kind of wasting the resources.”
By teaching the medics to be more precise, the city raised the quality of care to match, and sometimes exceed, the care delivered by the local flight crew.
Marble Falls crews flew 189 patients the first 12 months after the local chopper base opened. In the past nine months, they flew 78.
In nearby Austin, the governor’s trauma advisory council — doctors, paramedics, hospital administrators and air ambulance employees — is working to lasso an air ambulance industry that has grown fast and largely unregulated. In just a few years, the number of air ambulance transports in Texas has nearly tripled, from 4,144 in 2002 to 11,694 last year.
Texas health officials are drafting rules that would require, as some other states have, that all air ambulances in the state meet the same safety benchmarks. But there is some confusion about whether the state or the Federal Aviation Administration should play the leading role in industry safety oversight. Some air ambulance companies have resisted similar attempts in other states to impose the standards, which cover everything from mechanics’ tools to managers’ role in aviation safety. Some of those who opposed the state oversight cited the Airline Deregulation Act, which in the 1980s gave the federal government authority over aviation companies.
“The Federal Aviation Administration has said they don’t regulate medicine,” Bass says. “But there is a big gray zone about what is medical and what is aviation. The safety issues raise some additional concerns about what should be the state role.”
Accreditation Has Its Benefits
State emergency medical directors are working to identify the boundaries of federal aviation rules and medical oversight. Meanwhile, says Tom Judge, president of the Association of Air Medical Services, “this really speaks to the need for national accreditation and national standards so the public has some idea what it is that they are purchasing.”
If the rules are implemented in Texas, as they have been in Utah, the state would require all of the 54 helicopter ambulances that operate in the state to be accredited by the non-profit Commission on Accreditation of Medical Transport Systems (CAMTS).
New Mexico is also working to require accreditation. Other states, including West Virginia and Oklahoma, have written state rules based on the detailed standards that must be met for CAMTS accreditation.
Such accreditation — which involves in-depth inspections by a team of industry experts to analyze a health care team’s principles, practices and culture — is widely viewed as a vital patient safety tool. “We believe in an outside review of quality,” Judge says. “We don’t believe it is enough to just say ‘we’re great,’ but to have somebody come in and test it.”
A scientific study is now underway to try to determine accreditation’s impact on air ambulance safety. Proving a link between accreditation and improved safety may be difficult, Judge says, but the accreditation process itself has benefits.
“To me, the bigger part of accreditation is that when the accreditation people leave, you could see a palpable change in the program,” he says. “That is where the real benefit for safety and quality of care comes in.”
Training Helped Him Survive
Flight nurse Jonathan Godfrey is not waiting for studies to determine whether accreditation saves lives. He is traveling to air ambulance bases telling flight crews that it does.
Godfrey, 36, survived the crash of an air ambulance into the Potomac River Jan. 10 in part, he says, because his air ambulance company, LifeNet, part of Denver-based Air Methods Corp., was focused on safety as it sought CAMTS accreditation at the Stafford County, Va., base.
Federal air safety investigators have not determined what caused the crash, which occurred as the helicopter flew over a bridge near Ronald Reagan Washington National Airport. Investigators are trying to figure out whether wake turbulence from a jet landing at the airport might have contributed to the crash.
Godfrey, paramedic Nicole Kielar, 29, and pilot Joseph E. Schaefer III, 56, had just dropped a patient off at Washington Hospital Center and were returning to their base. Kielar and Schaefer died in the crash.
Whatever the cause, Godfrey attributes his survival to the detailed training he got from a company officer with years of military experience. Godfrey was required to demonstrate his safety skills before being allowed to fly, as required by accreditation.
It paid off, he says, when he found himself strapped to his seat beneath the 39-degree river with a broken back, chest and arm.
“I did not do the normal reaction, which is to gasp when you hit cold water,” he says. “I kept the sense of mind not to inhale.”
He tried to unbuckle his seatbelt but his right arm didn’t work. “I didn’t know the bone was sticking out of my flight suit,” he says.
“I freaked out a couple of more seconds and then decided to do what my training had told me and that was to get my bearings of where I was and where everything else was,” he says. “I reached with my left hand, twisted the belt and came up to the surface.”
Godfrey says when he saw news reports about earlier helicopter crashes, he considered each a fluke. Now he sees a pattern.
“I don’t think complacency had anything to do with our crash, but the industry as a whole had become complacent,” he says.
Now, he says, “I think the attention to detail has gone up and the complacency has been suppressed a little bit. I think that little bit makes enough of a difference. It keeps us out of trouble.”
SOURCE: Robert Davis USA Today
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