July 8, 2008
Medical Helicopter Crashes
We had intended to discuss a root cause analysis of a fireworks accident for the 4th of July. However, in our attempts to find a good RCA on fireworks, we kept coming across references related to the crash of 2 medical helicopters in Arizona that resulted in 7 deaths. Interestingly, I had just made the comment to my wife last month that “they’ve got to do something about these medical helicopter crashes – they’re happening every other week”. One had occurred in Arizona just a few days earlier and another in Texas in June. In May there had been crashes in Wisconsin and on a hospital rooftop in Michigan. Well it is not quite every other week but there has been a rash of such crashes in 2008 – nine in all, resulting in 17 people dying. Those dying have included patients, nurses, doctors, technicians and pilots. Medical helicopter crashes had been frequent in the early 1980’s but then tapered off until the last decade, during which the frequency increased to a peak of 18 deaths in 2004. That trend prompted the NTSB to do a special investigation in 2006 and issue a number of recommendations to the FAA for implementation. Not all those recommendations have yet been mandated by the FAA. And the trend in fatal crashes is disturbing.
The Air Medical Physician Assosiation (AMPA) did a safety report in 2002. It reviewed medical helicopter accident rates historically and looked at death and fatality rates, putting them in perspective compared to other industries. The death rate for helicopter medical personnel was 192 per 100,000 workers compared to a rate of 3.8 per 100,000 workers for all industries in general. That paper is an excellent source of information on factors contributing to medical helicopter accidents and things that can be done to avoid them or survive them.
Of interest is that we could not find a single comprehensive RCA on a medical helicopter crash, i.e. one that looked at all potential causative or contributory factors from stem to stern. Most RCA’s just focused on the aviation aspects of the crash and few look at the factors on the medical side.
There are many factors that make accidents involving medical helicopters (and some other medical aviation) more likely to occur. Many medical flights occur at night or in inclement weather. The landing areas are also not nice ample open spaces like airport runways, but are often rather tight spaces with wires and other obstacles nearby. The emergent nature of the medical mission keeps the team from canceling the flight or diverting to safer routes. The time pressures may be great. If you are trying to get a true level I trauma patient to a level I trauma center within the “golden hour”, or a rural stroke patient to a stroke center within the 3-hour therapeutic “window”, or an MI patient to a site for thrombolytic therapy or primary angioplasty site within their respective “windows”, time is of the essence.
Medical helicopters also are often flying without the benefit of air traffic controllers or flight dispatchers. They most often fly by “sight” rules and have to visually look out for other aircraft and other obstacles. The NTSB report had pointed out that most medical helicopters do not make optimal use of night vision imaging systems or night vision goggles. One comment made after a recent crash was that it is difficult to obtain the night vision imaging equipment since it is being sent over to the wars in Iraq and Afghanistan. Most medical helicopters also do not utilize terrain awareness and warning systems, another safety feature recommended by the NTSB.
Surviving a medical helicopter crash may also be difficult for a number of reasons. Helmets, shown to help save lives and prevent head injuries in military helicopter crashes, are often not worn by all medical helicopter occupants. The same applies to shoulder harnesses. And there is some evidence that serious or fatal injuries are more likely to occur to those who are not in the front seats, that is those back in the cabin may be at more risk. And the lack of aviation flight risk evaluation programs by many helicopter EMS programs was also cited by the NTSB. They also noted that helicopter EMS accidents were more likely to occur when a patient is not on board (when rules and regulations are less stringent).
When we do an RCA in a hospital or other medical facility, one of the first questions we ask is “did the patient have an appropriate indication for the procedure done?”. That question seems to be asked far too infrequently when doing an RCA on a medical helicopter crash. Dr. Bryan Bledsoe, quoted in a NY Times and USA Today articles, noted that only a small subset of patients actually need emergency air transportation. In 2006. Bledsoe and his colleagues did a meta-analysis of helicopter transport of trauma patients. Using several widely-used injury severity or trauma scores, they showed that almost 2/3 trauma patients brought by helicopter to a trauma center had minor or nonlife-threatening injuries and that 25% were discharged from the hospital within 24 hours. They point out that numerous studies have begun to question the benefit of helicopter vs. ground transport for trauma patients. Particularly for trauma patients with less than 45 minutes of ground transport time, there does not appear to be a significant benefit for helicopter transport.
So the question should always be asked: “Does the benefit of helicopter transport outweight the potential risks in this patient?”. Remember, it’s not just your patients – it’s your friends and colleagues who may be going on one of those ill-fated helicopter trips.
One does need to consider the risks of alternative transport as well. Certainly there are ambulance crashes. But they are not nearly as frequent as helicopter crashes.
Even if your organization does not own its own medical helicopter, there are things you can do to help ensure the safety of your staff and patients. First and foremost, make sure the benefit of the helicopter trip is likely to outweigh the risks. Second, make sure the company that runs the helicopter has a culture of safety. If it uses standardized dispatch protocols, has night vision imaging equipment and terrain awareness and warning systems, does risk assessments, is meticulous in maintenance, has (and enforces use of) helmets and shoulder harnesses, and has good training programs for its pilots and any of your staff that may fly – that’s the sort of partner you are looking for. You should be participating in simulation exercises and other crew resource management drills with them. Also, the medical helicopter transport is another great process to consider for one of your FMEA (Failure Mode and Effects Analysis) activities. And beware of the old adage that new safety technology may simply push the envelope – there is a tendency to take more risks when the system is perceived to be safer. So a healthy dose of skepticism and vigilance is always a good thing.
And if you are not actually riding in the helicopter yourself, be sure you and all your staff know what to do when a helicopter lands at or near your facility (see Marshall 2007) to ensure safe transfer of the patient to your facility, while protecting you and your staff from injury.
Update: See our February 3, 2009 Patient Safety Tip of the Week “NTSB Medical Helicopter Crash Reports: Missing the Big Picture” and our November 2010 What’s New in the Patient Safety World column “FAA Safety Guidelines for Medical Helicopters Short-Sighted”
National Transportation Safety Board. Special Investigation Report: Emergency Medical Services (EMS) Operations NTSB Report Number: SIR-06-01, adopted on 1/25/2006 [Summary | PDF Document] NTIS Report Number: PB2006-917001
Air Medical Physician Assosiation. AMPA Safety Report: November 2002
Bledsoe BE. Wesley AK. Eckstein M. Dunn TM. O'Keefe MF. Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis. [Review] [81 refs] Journal of Trauma-Injury Infection & Critical Care. 60(6):1257-65; discussion 1265-6, 2006 Jun. http://www.jtrauma.com/pt/re/jtrauma/abstract.00005373-200606000-00015.htm;jsessionid=LzvDYgJNbkdJpBhDDCFtr3VBPJJ6WwQ1bvdXstQHvMNQ7Lk0Mygl!447927974!181195628!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=1&nav=search
Marshall WJ. Get ready: a patient's arriving by helicopter. Prepare the equipment and yourself to ensure a safe transfer into the hospital. Nursing 2007; 37(11):46-9, 2007 Nov
Update: See also our Patient Safety Tips of the Week for February 3, 2009 “NTSB Medical Helicopter Crash Reports: Missing the Big Picture” and September 1, 2009 “The Real Root Causes of Medical Helicopter Crashes” and our October 2008 What’s New in the Patient Safety World column “More Medical Helicopter Crashes”.