Flying in the face of danger

Editor's Note:The death toll from the Flagstaff, Ariz., crash reached seven with the death of registered nurse James Taylor, 36, who died July 4. This story has been updated to reflect that.

Despite the alarming number of U.S. air ambulance crashes in the first half of 2008—which have claimed 17 lives—several healthcare providers say the benefits of air medical services still outweigh the risks involved.

National Transportation Safety Board officials continue to investigate the accidents, including the most recent one on June 29, when two helicopters approaching 263-bed Flagstaff (Ariz.) Medical Center collided in midair and led to the deaths of seven people. Given the pending investigations, no one knows yet what caused the most recent crashes, although a few experts have cited human error. Meanwhile, as emergency physicians, flight directors, paramedics and hospital administrators await the NTSB’s findings, they are far from discontinuing a service that was developed from advances made during the Vietnam War and that they consider a vital component of the nation’s healthcare system today.

Proof of this can be found in the Flagstaff tragedy. In that crash, one of the helicopters was operated by privately held Classic Helicopters, Woods Cross, Utah, while the other was with Guardian Air Transport, a division of Flagstaff Medical Center. Flagstaff contracts with Englewood, Colo.-based Air Methods Corp. for all aviation services for Guardian, including the Federal Aviation Administration license, pilots and maintenance. Shares of Air Methods—which traded as high as $59.50 per share in November 2007—hit a 52-week low of $23.70 on July 2 before closing at $24.47 per share on July 3. After voluntarily suspending flights after the accident, Guardian Air resumed healthcare missions two days later, showing Flagstaff’s support for air medical services in spite of its recent loss and renewed risk.

And in Grand Rapids, Mich., the Spectrum Health system issued a written statement about the value of air medical services a month after an Aero Med helicopter crashed at the system’s Butterworth campus helipad. Aero Med Spectrum Health is a full-time, physician-staffed medical transport program that serves West Michigan. No one died in the May 29 accident.

“Spectrum Health views air medical transportation as a service to the community,” the statement said. “Spectrum Health is proud of Aero Med and how it works with emergency responders throughout the region to improve the quality and timeliness of care.”

Experts said the air medical services sector in the U.S. began at 263-bed St. Anthony Central Hospital in Denver, which says it launched the nation’s first emergency medical transport system 36 years ago. Since then, air medical transport has evolved into an industry that flies about 500,000 helicopter emergency medical service missions and between 100,000 and 150,000 airplane medical flights each year, according to the Association of Air Medical Services. In a February 2007 report, the Government Accountability Office said that there were 89 air ambulance accidents between 1998 and 2005 (resulting in 75 fatalities and 31 serious injuries), which represents nearly 40% of the total air ambulance accidents since 1972.

But the absence of some data prevents the GAO from calculating if the rate of accidents has risen. “During the eight-year period we examined (1998 through 2005), 89 air ambulance accidents occurred, but a lack of data about the number of flights or hours flown prohibits us from calculating whether the rate of accidents has increased, decreased or remained the same over this period,” the report said.

The report also showed that the number of accidents tripled to 18 in 2003 from six in 1998, and then declined to 12 and 11 in 2004 and 2005, respectively. Since the start of this year, there have been 10 air ambulance accidents (See chart), and all 16 fatalities have occurred in helicopter emergency medical service, or HEMS, crashes, the NTSB reports.

“The spate of accidents is likely something of an aberration, but it has to be viewed in the context of increasing exposure to risk of helicopter EMS providers and pilots as the number of HEMS increases,” said Mark Greenwood, an Aero Med flight physician who also has a law degree. “I think this exposure to risk is the result of the for-profit, nonhospital-operated aircraft.”

The GAO report said available data from 2003 to 2005 showed the number of helicopters involved in air ambulance operations increased by 38% to 753 from 545, while the number of locations from which they operated grew by 30%. And while the report said data are not available on the number of stand-alone and hospital-based operators, researchers found most of the growth in operations since 2003 has been in airports and stand-alone helipads, rather than hospital-based operations.

“Industry sources indicate that this growth has produced more competition in certain areas and potentially led to such unsafe practices as ‘helicopter shopping’—a continued search for air ambulance service by emergency medical service dispatchers until an operator agrees to accept a flight,” the report said.

In April 2002, just before that period of growth, the Balanced Budget Act of 1997’s mandate to implement a national ambulance fee schedule became effective. As of January 2006, the total payment amount for air ambulance providers and suppliers is based on 100% of the national fee schedule. Payment includes a nationally uniform base rate for fixed wing (airplanes) and a nationally uniform base rate for rotary wing (helicopters); a geographic adjustment factor for each ambulance fee schedule locality; a nationally uniform mileage rate for each type of air service; and a rural adjustment to the base rate and mileage for services furnished for a rural point-of-pickup, according to the CMS.

“Like any payment system, there are those who like it and some who don’t,” said Dawn Mancuso, executive director at the Association of Air Medical Services, or AAMS, which represents about 90% of the medical air transport capacity in the U.S. “Some hospital-based systems probably felt if their expenses were higher, they lost revenues. Some of our members felt like reimbursement was—if not adequate—at least predictable.”

Thomas Judge, a paramedic who serves as executive director of LifeFlight of Maine, said prior to 2002, reimbursement was “all over the map.” Today LifeFlight receives reimbursement that is equivalent to about 63% of its cost vs. 34% before the ambulance fee schedule was established. LifeFlight has a base associated with 188-bed Central Maine Medical Center in Lewiston and another with 338-bed Eastern Maine Medical Center in Bangor.

Both Mancuso and Judge acknowledged the significant growth of air medical services in recent years. The AAMS offers three main reasons for the increase: a shift in demographics, closure of emergency departments and hospitals, and changes in delivery—and availability of—rural healthcare. The shifting demographics relate primarily to the medical needs of an aging population, and can be seen in the growing rates of trauma and time-dependent diseases such as heart attack, stroke and nontrauma surgical emergencies. With regard to the number of emergency departments, the American Hospital Association reports there were 3,867 hospitals with emergency departments in 2002, down 14.6% compared with 4,530 hospitals with emergency departments in 1992.

“One of the things we have to realize is that air medicine is a growing component in the healthcare system in the country,” Mancuso said. “With the advent of closure of emergency rooms, with the number of changes in rules regarding coverage of medical specialties and availability of those specialties, with rural areas and critical-access hospitals, and the centers of excellence and need to be regionalized, the need for patient transport is a growing field,” she said.

Judge, who has served as president of the AAMS, said the segment’s growth has created a need for greater medical oversight. “It really is the discipline of focus that is the hardest part,” Judge said. “If you think about performing critical-care emergency medicine, at 180 mph, in the middle of the night, in the middle of nowhere, it’s a complex arena. But if we don’t have these services, thousands of people a year will die.”

Last year, the GAO recommended in its report that the FAA identify the data necessary to better understand the air ambulance industry and develop an approach for gathering and using this data. It also said the administration should collect information to evaluate the effectiveness of voluntary FAA guidance. On June 30, a day after the Flagstaff crash, the FAA issued a news release listing 17 FAA-led initiatives that focus on the leading causes of helicopter emergency medical-service accidents. “The FAA inspects HEMS operators, but is prompting changes beyond inspection and surveillance,” the release said. However, except for the last item on the list—about a May 2008 FAA advisory on best practices for HEMS operators in establishing operational control centers—each action was taken between 2004 and 2006, before the February 2007 GAO report was issued.

LifeFlight in Maine has designed its air medical transport system as a “physician-prescriptive event,” so that a helicopter transferring a patient is analogous to a physician writing a prescription, according to Norm Dinerman, the organization’s medical director who served as chief of emergency medicine at Eastern Maine Medical Center from 1988 to 2006. One way to gauge if a system is effective is by examining the rate at which patients are discharged from a hospital within 24 hours of being transferred. As Aero Med’s Greenwood explained, a rate of 10% or less of patients discharged within 24 hours indicates a “pretty good job of providing enough benefit to those patients to justify the risk to the patient and the air medical crew of transport by helicopter.” In the case of LifeFlight’s patients—those who are transferred from a scene of an accident or from a hospital—6% are discharged within 24 hours of arrival, according to Dinerman.

“It’s easy to see the helicopter for all its beauty and technological innovation and miss the most important concept: quality and what’s going on in the rear and the medical transport team,” Dinerman said. “It’s not the minutes you save; it’s how you invest those minutes that count.”

In Tyler, Texas, East Texas Medical Center Regional Healthcare System considers air medical services as an integral component of its care. “Our job in healthcare is to provide care to our patients as quickly as possible,” said Art Chance, vice president of operations. “We see helicopter service as a vital part of that. It’s important that we get a patient—especially a trauma patient—in the hands of a healthcare specialist as quickly as possible.”

The system purchased its first aircraft in 1985. Today, its air medical services system, called Air 1, owns four aircraft, including one that is a backup so East Texas is never without three helicopters. Since the program started, Air 1 has transported about 21,000 patients. The system currently averages about 120 transports a month, and a flight crew consists of a pilot, flight nurse and paramedic. According to Chance, about 32% of transport patients are Medicare patients, and East Texas loses about $40,000 per month in revenue to operate Air 1.

“We can always improve and we learn from events that transpire,” Chance said. “One of the things we do here that has been extremely beneficial: any one of those three individuals can call off a flight if they feel something isn’t right,” he said of the crew members, adding that the system has not had an accident since the program began 23 years ago.

According to Chance, the 14-hospital system could not serve the patients of East Texas as effectively without the Air 1 program, which comes back to the beginning of the discussion and the critical question for hospitals: Do the benefits of air medical services offset the associated risks?

“It’s about providing a higher level of care and transporting patients more quickly and reducing out-of-hospital time,” said Aero Med’s Greenwood. “And sometimes those are beneficial to the patient; sometimes not. It’s our job as an industry to determine when those times are.”

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