Patient Safety Tip of the Week


February 3, 2009

NTSB Medical Helicopter Crash Reports: Missing the Big Picture





A couple columns back we mentioned that the NTSB has released its preliminary report on several of the medical helicopter crashes. We have been waiting for that since we did a couple columns previously regarding the “epidemic” of EMS helicopter crashes in the recent past (see our July 8, 2008 Patient Safety Tip of the Week “Medical Helicopter Crashes” and our October 2008 What’s New in the Patient Safety World column “More Medical Helicopter Crashes”). In all there were 7 EMS helicopter crashes, in which 28 people died in 2008.


On January 15, 2009 the NTSB released its public dockets regarding investigations into nine helicopter EMS accidents. The NTSB reports cite the litany of proximate causes we see in many aircraft accidents – flying in the dark or poor visibility, poor weather conditions, flying without night vision or terrain awareness and warning systems, lack of GPS guidance, “pilot” error, “air traffic controller” error, etc. But they don’t delve deeply into the root causes and we can find almost no reference to the question that should be asked first in any such accident “Was the helicopter transport necessary in the first place?”.


Ironically, on the very day we started preparing this column, I chanced upon a medical helicopter evacuation scene. I couldn’t help but wonder if helicopter was the most appropriate vehicle. Judging by the state of the cars involved in the crash, it was pretty clear that the injuries suffered by someone were likely severe enough to merit transport to a Level I Trauma Center. By car from that spot is exactly 29 minutes in morning traffic (I know because I did that exact drive daily for over 12 years, where I was medical director of the hospital). It was a sunny day and the roads were dry, though it was a bit windy. It was not rush hour. Rather it was just shortly before 1PM. It would probably take the helicopter about 10 minutes to fly to the Trauma Center. I wondered how long it had taken the helicopter to arrive. The helicopter base site is about 30 miles from the accident site. The accident site was actually less than half a mile from another hospital so an ambulance was probably available within minutes of the accident. I don’t know if the victim had required extrication that might have added to any time elapsed. And I don’t know whether any specific medical expertise was required during that transport to the Trauma Center. The helicopter team is staffed by very well-trained EMT’s and I personally know each of the very well-qualified medical directors who are available round-the-clock to provide medical guidance for the helicopter team. Yet I couldn’t help but wonder whether the total time elapsed to get the patient to the trauma center was faster by helicopter than he would have if he had been taken there by ambulance (keeping in mind that considerations other than speed may have also been important).


So you can see some of the thinking that should go on in planning and implementing a medical rescue and transport to a trauma center. The first responders on the scene need to rapidly determine a number of factors and contact the emergency medical hub. Questions like the following need to be addressed:


  1. What type of facility does the victim/patient need to be transported to? (The guidelines for field triage of trauma victims have just been updated and are fairly clear in providing guidance about what facility the victim should be taken to.)
  2. How far is the crash site/response site from the destination hospital?
  3. How far is the helicopter from the crash site/response site?
  4. How long will it take for the helicopter to get to the crash site/response site?
  5. How long will it take for the ambulance to get to the crash site/response site?
  6. Will there be any delays at the crash site (eg. for extricating the victims)?
  7. What is the weather like? (important for both flying and driving)
  8. What is the ground traffic like? (Is it rush hour? Are there bottlenecks? Is there any road construction on the likely route to the Trauma Center?). Note that today the plethora of webcams and GPS devices can help rapidly answer the question as to whether there are likely to be any traffic delays en route.
  9. Are there likely to be special medical needs that a medical helicopter team can provide that cannot be provided by the ambulance EMT staff?


The above questions are really subquestions to the main question “What’s the fastest way to get the patient/victim the medical interventions he needs?”.


After the Maryland helicopter crash in September 2008, the Baltimore Sun did its own investigation of 26 fatal medevac crashes since 2003. They found a substantial number of the patients being transported probably could have been transported by other means. They did point out that Maryland implemented changes after the 2008 crash to limit the number of flights not medically necessary.


This, of course, is not the first time that the lack of medical necessity for helicopter transport has been raised. In our July 8, 2008 Patient Safety Tip of the Week “Medical Helicopter Crashes” we noted the studies done by Bledsoe and others that raised the issue of potential overutilization of air medevac services. Our prior column also discussed some of the time pressures and financial pressures that may play roles as contributory factors in medical helicopter crashes.


A position paper on medical helicopter crashes prepared for the NTSB meeting by a consortium of air medical services providers does address numerous safety issues and makes recommendations. However, it is written primarily from the same perspective that the NTSB had and does not address the medical need issue. At times, it seems to be more of a self-promotional document than one addressing overall safety. Nevertheless, it is worth reading and contains a good description of the evolution of medical helicopter services in the US and the various models in different communities.


Hopefully, several of you reading this column are saying to yourselves “Why wait for a crash to do a root cause analysis?”. You are correct. There should be an independent review of every medical helicopter transport to assess whether it was medically necessary and whether alternative transport might have been more appropriate. We suspect that solutions to reduce the numbers of fatal medical helicopter crashes are more likely to come from community-wide reviews that encompass the bigger picture rather than from the more narrow focus taken by the NTSB to date.






Update:  See also our Patient Safety Tip of the Week for September 1, 2009 “The Real Root Causes of Medical Helicopter Crashes”.







Safety board probes EMS helicopter crashes.


Houston Chronicle ( Jan. 15, 2009, 3:45AM



NTSB Advisory. January 13, 2009




Sassser SM, Hunt, RC, Sullivent EE, et al. Guidelines for Field Triage of Injured Patients Recommendations of the National Expert Panel on Field Triage. MMWR 2009; 58(RR01): 1-35 January 23, 2009



Unnecessary flight risks? Review of 26 fatal medevac crashes shows many didn't involve life-or-death missions. By Robert Little. Baltimore Sun. October 23, 2008,0,5946638.story



Air Medical Service Safety Position Paper. AAMS, HAI and AMOA. National Transportation Safety Board. January 13, 2009.









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