Medevac Helicopters—Helping People But Killing Crews

There's a dirty little secret in the helicopter emergency medical services (EMS) industry: management pressure to fly in bad conditions is raking in profits while killing crews. Medicare reimbursement rules and lax regulation that fueled the industry’s growth over the last two decades also provide an incentive to fly substandard helicopters in poor weather conditions. Pat Shaub, an author, speaker and former EMS helicopter pilot who provides Decision Making and IFR Refresher training programs for EMS companies, emailed me earlier this year about these issues. Now everyone can learn about the deadly problem in a series of investigative reports published this past weekend by the Washington Post.

The series turns a bright spotlight on...

an industry, widely viewed as flying angels, in which pilots and crews suffer an on the job fatality rate second only to commercial fishing! I regularly see EMS helicopters go in and out of Bear Valley, CA where my family and I like to ski and I’ve often thought about how one day one of them may give me a ride. But after reading the articles, I don’t think I’d accept a ride in an EMS helicopter unless I had a life threatening injury. Even then, I’d hitchhike before I’d fly in one at night or in inclement weather.

I compiled this industry timeline from the Washington Post articles: 

• The first EMS helicopter went into service in Denver in 1972. 

• The Airline Deregulation Act of 1978 prohibits states from restricting EMS operations. 

• From 45 helicopters in 1980, the industry grew to more than 850 helicopters in 2008. 

• In 2002, Medicare introduced a new fee schedule, increasing payments for EMS flights and giving a 50% premium for rural flights. However payments are the same for single-engine VFR and twin-engine IFR-certified helicopters. 

• Medicare payments for EMS flights in 2008 were $220 million, 20 times more than just a decade earlier. 

• A record 23 EMS crew members were killed in 2008.

Show Me the Money

Pat Shaub once started up a helicopter EMS service and understands the economics driving the industry. In his email to me he wrote: “Being a ‘for profit’ operation, the less spent in operating means more profit. That's why most HEMS operators are single engine, VFR. They'll fight it tooth and nail if they have to spend more money to run their operation."

But Shaub chose to use more expensive twin-engine helicopters in his business. ”Good thing. We lost an engine over trees, at night, with a patient. Worst case and it happened. We would have had a fatal, no doubt in my mind. Anyway, money is the driving force in HEMS."

The Washington Post series also talked about industry marketing practices and competitive pressures that lead pilots to take flights other crews have turned down. 

• EMS firms compete ferociously with each other for business by offering NASCAR tickets and riverboat cruises to local fire, emergency medical service and hospital workers, who often control which helicopter team is requested for a patient. Some helicopter crews pass out T-shirts and bottle coolers at accident scenes. 

• “Helicopter shopping,” in which hospitals or EMS dispatchers call EMS companies until they find one willing to take the flight, is prevalent. Often dispatchers don't tell pilots that other operators have rejected the same flight or aborted because of weather.

Safety Compromised

According to Shaub’s email, “Nothing has halted the EMS helicopter accident rate. Nothing will stop the bleeding until they are required to have real IFR equipment (not just an attitude gyro ‘just in case’), fly IFR and stay current. Helicopter pilots just don't fly IFR. They don't have enough gas to do it.

"American EMS pilots in particular fly VFR everywhere. Most have instrument ratings, but they are not even remotely ready for going IMC. I was told by my boss that if I went inadvertent IMC I'd be fired. Then I was given a job in which I could probably have logged half my night time as actual."

The Washington Post series highlights similar safety issues: 

• More than half of fatal crashes occur at night, but only one-third of medical helicopter pilots are equipped with night-vision goggles. 

• The fatal death rate for EMS crews is 113 deaths per 100,000 employees, making it deadlier than logging, mining, or police work. 

• Poor communications, competitive pressures to accept risky missions, pilot fatigue and a lack of equipment to help pilots flying in dark, unfamiliar settings, identified as problems by the NTSB in 1988, continue to affect the industry today. 

• In 2006, the NTSB issued their second industry study and called on the FAA to require use of night vision goggles and terrain awareness systems. The FAA has not made their use mandatory. 

• In the past, the FAA has been reluctant to impose new rules, relying instead upon safety seminars, recommendations and voluntary compliance. However in April, the FAA announced they were preparing to propose new rules the NTSB recommended 4 years ago, but noted that the rules could take several years to draft.

Change Needed

Although the poor EMS safety record has been recognized for more than a decade, the problem continues. Organizations like the Helicopter Association International have developed voluntary recommendations through their Air Medical and Safety committees. And periodically, after spikes in EMS accidents, the FAA holds industry seminars and issues new safety recommendations. But until new regulations are promulgated, little is likely to change. And the impetus for change may not occur until the accident rate gets so bad that the public forces Congress and the FAA to take action. Sadly, dozens of EMS crew members and patients will die needlessly between now and then.

Comments

[John Halbrook]

Max,

Aero-medical safety is a huge problem. The NTSB has repeatedly made recommendations for several years now. As the rash of accidents as increased leaders in the EMS industry have begun to speak out about the need to implement stricter safety programs. I'm glad that aviation experts such as yourself have begun to comment on these issues.

Here are a few of my observations on the issue.

http://www.halbrookassociates.com/halbrook_associatescom/2008/10/is-air-ambulanc.html

[Ken Lane]

I have an instrument student who is an aviation attorney. One of the sore spots he speaks of is helicopter EMS operations. He has been involved in more than a few and wouldn't mind if that source of business dried up. That means, no more helo EMS incidents. I don't see that happening any time soon as long as the rules are so relaxed. I know of one close to home here in Texas. That was a quite a blow. At least it wasn't a crew I talked to all the time where I flew out of.

[Luca Bencini-Tibo]

I'm all for safety - no question here and I do have sympathy for the lost crews, patients and their families. I'm very active in the FAA Safety program as a rep.

But a couple of "things" are missing in this discussion:

1. Profit motive - since these are not government operations nor charities, profit needs to be a motive for the operators to stay in business. What is the solution: increase the amount reimbursed and then mandate that all operators use twin engine IFR certified helicopters with IFR certified pilots? Or would it be better to have counties / municipalities take this over with their limited budgets?

2. A cost / risk analysis is needed, we need to see how many patients were saved through EMS helicopter flights (rather than ground bound ambulances) and the patients (and crews) lost in EMS operations. Clearly these ops are of higher risk - car accidents are more prevalent at night and in bad weather and that is when they need to fly. Similar issue with USCG helicopters - they tend to fly in worse weather - the mission demands it. This is what's missing from everything I have read about - only the number of accidents and lost crews / patients without regard to the positive outcomes.

The question boils down to: what level of risk can we live with given a budget level? To say: "zero accidents" is a lofty goal with no context.

Now it could be when this cost / risk analysis is actually done, that "good old" ground based ambulance service comes out ahead. In that case, EMS helicopters would then be outlawed.

[Matt Johnson]

Nice article and enough good stuff can't be said about Pat Shaub - a true-to-heart aviation professional.

For more insight on the Air Medical industry check out my article "Improving the Air Medical Industry - A matter of Life or Death"

http://www.eagleeyesolutionsllc.com/downloads/Air%20Med%20Safety.pdf

[Bick Eubanks]

Max, the same is true for many professional flight positions. In check/freight flying the Chief Pilot (CP) or Director of Operations (DO) will often pressure pilots to fly in weather that they are not comfortable flying in. When I was working as a "freight dog", I would tell new pilots to make it clear that they were the pilot in command and ,by law, the go or no go decision was theirs to make. The C P or D O may threaten them with their jobs but that is usually a hollow threat. I know it has happened to me. Funny though I was flying with the same company after aborting a flight due to weather. It has to be really dangerous weather though. Two hundred feet and a half mile visibility are not considered dangerous for a properly trained and current instrument pilot and management knows that.

With rescue helicopters, I suspect that the pilots pressure themselves since they know that a life may depend on them being able to complete the flight.

[Josh Thompson]

Max, interesting post and as a MEDEVAC pilot I thought I'd give my two cents. You say in your post, "I’ve often thought about how one day one of them may give me a ride. But after reading the articles, I don’t think I’d accept a ride in an EMS helicopter unless I had a life threatening injury." Well if it's not a life, limb, or eyesight injury that requires care within the "golden hour" then you shouldn't be getting on a helicopter at all. Unfortunately in our business the higher risk levels are ignored by those requesting the services because of convenience. Many times the helicopter that is truly needed at the scene of one accident is already tied up flying a patient that didn't really need the ride in the first place. Unfortunately, we're in the business of respond first and ask questions later. Perhaps a better tack for the industry to take is establishing guidelines for when helicopter use is appropriate. That would at least ensure that when EMS crews risk their lives they are doing so for a worthy cause...

[Steve Allcorn]

As a former flight medic I can tell you that more often then not the patients condition does not warrent the level of care on the helicopter. My former company flies really nice equipment (A Star B3)with goggles etc..The pilots are all high time with mountain experience. That all means nothing when the ship is balled up and everyone dies while they are lifting a 90 year old with a bowel obstruction to a hospital when a ground ambulance is sitting right there. I stopped flying after a close call one moon less night after a brown out on approach almost cost us.