February 28, 2005 Crashes Start Debate on Safety of Sky Ambulances [size=-1]By BARRY MEIER [/size] n a mild afternoon last week, emergency workers raced up to Jana Austin's rural Arkansas home to ask if a medical helicopter could land on her property to transport a victim of a car crash to a nearby hospital. Ms. Austin, a nursing student, said she readily agreed. But moments after the helicopter took off, she and her 4-year-old daughter stood stunned, watching as the helicopter began to spin, slowly at first, then faster, until it twirled out of control into a nearby pasture. The patient died, and the three crew members were seriously hurt. The accident, whose cause is under investigation, was hardly isolated. In January, a medical helicopter plunged into the Potomac River in Washington, killing the pilot and a paramedic. In less than two months this year, four people have died in four accidents. Last year was a particularly deadly one for flight crews and patients, with 18 people killed in 11 accidents, the highest number of deaths in a year in more than a decade, according to federal regulators and an industry group. The spike is putting a spotlight on a little-regulated and fast-growing sector of health care: the medical helicopter industry. There are an estimated 700 medical helicopters operating nationally, about twice the number flying a decade ago. Medical helicopters were once nearly all affiliated with hospitals. But more generous federal reimbursements and changes in payment methods have attracted more operators, including publicly traded corporations and smaller concerns that in some cases set up outposts and market their services to rural emergency units and even homeowners. Emergency medical helicopters do save lives, by speeding some patients to hospitals far faster than a ground ambulance could and by reaching remote areas. But the industry's rapid, competitive growth may also be exacting a toll. Federal regulators and some doctors worry that the pool of skilled helicopter pilots has become drained and that some of those flying are making poor decisions. In addition, some companies are flying older helicopters that lack the instruments needed to help pilots navigate safely. Of the 27 fatal medical helicopter accidents that occurred between 1998 and 2004, 21 were at night and often in bad weather, according to federal statistics. "You need to raise the bar and say this is where the bar is," said Dr. Scott Zietlow, the medical director for the helicopter program at the Mayo Clinic. "If you can't get over it, you can't fly." Last month, the Federal Aviation Administration, after a meeting with helicopter operators, proposed steps to improve flight safety. They included helping pilots assess risks and providing them with up-to-date electronic equipment. Separately, the National Transportation Safety Board has been examining medical helicopter safety and plans to issue recommendations to the Federal Aviation Administration, a safety board official said. Initial reviews by the aviation agency and the safety board indicate that pilot error was to blame in many of the recent accidents. A report in 1988 by the board, which came after a string of accidents in the preceding years, found that medical helicopters were crashing at a rate three times higher than that of other helicopters. At that time, the safety board made a number of recommendations adopted by the aviation agency, including better pilot training, particularly for flying in bad weather. Executives of medical helicopter companies and trade groups said they were greatly concerned by the rising accident numbers but added that the figures might simply reflect the fact that more helicopters were flying, rather than an increase in the accident rate. The executives said they could not be sure a trend existed because the industry had been operating without a system to track its total flight hours, a standard measure for assessing air deaths. Under pressure from regulators, company officials say they hope to have such a database in place by late spring, and several asserted that they were not pressuring pilots to take on dangerous missions. "We are seeing the number of accidents creeping up, and we need to be able to understand what the factors are," said Tom Judge, executive director of Lifeflight of Maine, owned by two health care systems there. The growing concerns about medical helicopter safety are unfolding alongside a long-running debate over whether many such flights are medically necessary. The cost of a medical airlift typically ranges from $5,000 to $8,000, five or more times that of a traditional ambulance. Private health plans and some public ones, like Medicare, cover air services, at least in part. There are about 350,000 medical helicopter flights annually, with about 30 percent involving calls to accidents or other emergencies, according to the Association of Air Medical Services, a trade group in Alexandria, Va. Most other flights involve the transfer of patients between hospitals. As recently as a decade ago, medical helicopters were generally operated directly by hospitals and emergency service units or run under arrangements with aviation companies, including publicly traded ones like the Air Methods Corporation and Petroleum Helicopters Inc., which provided the helicopters and pilots. But industry officials said the business began to change in the late 1990's when the federal government required hospitals to charge separately for ambulance services, including airborne ones, rather than bundling such costs in bills paid by all patients. In addition, Medicare, in adopting a national fee schedule, increased reimbursement rates for air ambulance flights in some regions. As a result, many hospitals decided to abandon their helicopter operations, and for-profit companies saw an opportunity. Mr. Judge, the Lifeflight of Maine official, said some studies suggested that 20 percent of patients transported by air might have died from injuries or illnesses had they not been flown. But Dr. Bryan E. Bledsoe, a former emergency room doctor who lives in Midlothian, Tex., a suburb of Dallas, said 14 medical helicopters operated within a 75-mile radius of his home. "The problem is that there is not that much of a need," said Dr. Bledsoe, a critic of the air-ambulance industry. Another significant area of industry growth involves companies that are not connected to hospitals but instead set up helicopter bases in rural areas and then market their services to local hospitals, emergency officials and, at times, homeowners. For example, Air Evac Lifeteam, which started 20 years ago with a single base in West Plains, Mo., now has 43 sites in 10 central states. For $50 a household, homeowners receive a company membership guaranteeing that Air Evac Lifeteam will not seek additional payment from them beyond what an insurer will pay. Over 150,000 households are signed up, Air Evac executives said. The splintering in the way the industry operates has led to a hodgepodge of standards. For example, the Mayo Clinic, which gets its craft and crews from an aviation company, requires pilots to have 5,000 hours of experience and uses only twin-engine helicopters. Air Evac requires pilots to have 1,500 hours of flight time before hiring them and uses older single-engine craft. "There is a wide variation in self-imposed standards," said Mr. Judge, who is also president of the industry's trade group. The Arkansas accident a week ago involved an Air Evac Lifeteam helicopter that had just been refurbished after spending 20 years ferrying workers and supplies to oil rigs. Colin Collins, the company's president, says that it uses only Bell model 206 helicopters like the one that crashed in Arkansas because they have an excellent safety record and are relatively simple to maintain. Local emergency officials said that the Arkansas car-crash victim, Robert Arneson, 71 of Harlingen, Tex., had a gash on his forehead but was stable and alert when taken by ambulance to a field for helicopter transfer. It was about 20 air miles, or a seven-minute flight, from the crash site, a trip that would have taken about 45 minutes by ground. But because emergency workers had to locate a landing site, nearly an hour elapsed, officials said, after the first emergency call and before the helicopter took off. Mr. Collins said he expected the National Transportation Safety Board to release its preliminary findings as early as tomorrow. In the last 12 months, Air Evac Lifeteam has had two fatal crashes. Other companies have also had troubles. In January, Air Methods, the industry's biggest operator, had two fatal crashes, including the one in Washington. Both operators said those incidents involved their first deaths in many years. Even company executives acknowledge that the industry's rapid growth may be outpacing the pool of experienced pilots. Mr. Collins said most of his pilots a decade ago were Vietnam veterans, but the majority have retired, and fliers coming out of the military now are not interested in helicopters. While company executives said pilots were not being pushed to fly, industry critics and federal regulators are concerned about whether pilots are making the right judgments or have the right information and equipment to base them on. Last summer, emergency officials in South Carolina summoned a helicopter to transport a woman found seriously injured beside a highway. But the first helicopter, which was based in Columbia, S.C., about 50 miles southeast of the accident, aborted its mission four minutes after takeoff with the pilot citing fog and deteriorating weather conditions. The next two helicopter crews contacted also refused to fly, citing the weather. Officials called a fourth helicopter, in Spartanburg, S.C., which agreed to fly, arriving about an hour after the accident. The helicopter, which was owned by the Med-Trans Corporation, picked up the victim and crashed shortly after takeoff in a nearby national forest. All four people aboard were killed. The South Carolina crash remains under investigation by the National Transportation Safety Board, and Jeffrey B. Guzzetti, its deputy director for flight safety operations, said the agency was reviewing the pilot's decision to fly. Reid Vogel, a spokesman for MedTrans, based in Bismarck, N.D., said the company could not comment on the accident because of the federal investigation. But Mr. Vogel said the company's flight team had thoroughly checked the weather that day. In last month's notice, the Federal Aviation Administration, citing the industry's rapid growth and an "unacceptable" number of accidents, suggested that operators increase the use of technical aids like radar altimeters, night-vision goggles and terrain awareness warning systems, among other things. In addition, it recommended that companies emphasize a "safety culture" and also improve systems that will give pilots better information about changing weather conditions while they are in flight. Company officials said they were working with regulators to find solutions. "I think there is a lot of concern within the industry in terms of what it would require in terms of retrofitting helicopters," said Dr. Zietlow of the Mayo Clinic. "The anxiety is that this can't happen with the medical industry overnight." Stephanie Saul contributed reporting for this article.