Sky Anxiety

     Over the last 12 months, the fatal EMS helicopter crashes have come in rapid succession. First were Whittier, AK, and Cherokee, AL, last December, respectively killing four and three. Then South Padre Island, TX, in February and La Crosse, WI, in May, three each. Huntsville, TX, in June, four more. Two collided in Flagstaff, AZ, that same month, claiming seven, then another fell in Burney, IN, in August, taking another three. Finally, as this story neared completion in late September, a Maryland State Police medevac crashed in suburban Washington, DC, killing four.

     That's eight accidents and, pilots and patients and crew, a total of 31 dead in the last year. It could have been worse—another half-dozen events saw everyone emerge alive.

     It's easy, if natural, to ask what equipment or practices might help reduce the spiraling yardsticks of air-medical crashes and fatalities. It's harder to look at the proliferating use of helicopter EMS (HEMS) resources and try to decipher the optimum balance of benefit, risk and safety, and the most likely path to achieving it.

     But as all the metrics climb—aircraft, missions, flight hours, crashes and deaths—it becomes increasingly worth doing.

     "At this year's National EMS Memorial in Roanoke, half the people inducted were air medical people," notes Texas emergency physician Bryan Bledsoe, DO, FACEP, perhaps the most prominent critic of the accelerating use of HEMS resources (not all were killed in 2007). "The flight paramedics and flight nurses, they're the victims in this. And those are smart, dedicated people who just want to help people."

     Certainly, EMS can ill-afford to lose those.

     As recently as 2002, researchers with the University of Chicago Aeromedical Network calculated the number of medical helicopters in the U.S. at around 400. Today, that's doubled.

     Some reasons for that growth are clear. The population's greying. Rural hospitals and EDs have closed. Top trauma resources and specialty care are consolidated. The importance of timely interventions in situations like stroke and cardiac arrest is ever more widely reflected in protocols and practice. Even in urban areas, traffic congestion and overstretched ground resources may sometimes make flight a faster option. Concomitantly, total EMS flight hours have risen steadily in the U.S., from fewer than 200,000 in 1998 to more than 400,000 in 2006.

     In terms of relative safety, at least until this year, things have been improving. Reviewing a decade's worth of accidents from 1992–2001, UCAN found an average of 3.8 accidents per 100,000 hours flown. Through June, the rate for 2008 was…3.8 accidents per 100,000 hours flown. However, that rate represents a major increase from 2007, and a reversal of four straight years of decline.

     So what's happening this year?

     "What's causing the accidents is probably very simply poor decision-making and a lack of situational awareness while flying at night in marginal weather conditions and people hitting something they didn't see," says Ed MacDonald, lead pilot for PHI Air Medical in Santa Fe, NM, and chair of the National EMS Pilots Association's Safety Committee. "The question we always ask is, why were they out there? Why did they keep going? Why did they keep pushing?"

     The obvious answer is that there was a patient in need. But the longer answer also involves things like indications and procedures for air-medical use, financial realities, restrictions on oversight and the overall design of communities' emergency response networks.

     "Right now, we don't have a thoughtfully designed system," says Tom Judge, executive director of LifeFlight of Maine and past president of the Association of Air Medical Services (AAMS). "It's not unlike many other things in medicine. It's not well-integrated into EMS. There needs to be more medical oversight and oversight of use, and making sure people are making the right decisions about risk, benefit and cost. It's a lot of money—it's 10 times the cost to be put in a helicopter as in a ground ambulance. So we really want to make sure that when we do that, there's a benefit attached to that cost and that risk. Right now that's not well done."