Accident numbers raise questions about safety, necessity of airlifts
02/02/02
Diane Solov and Roger Mezger
Plain Dealer Reporters
The calendar had barely rolled over to Friday, Jan. 18, when the MedEvac helicopter crew scrambled into action.
Doctors requested a helicopter transport for an elderly man at LakeWest Hospital with gastrointestinal bleeding. MedEvac 8, stationed atop University Hospitals' Lerner Tower, was the fastest way to the Cleveland Clinic.
Minutes after accepting the assignment, MedEvac 8 was on the radio, reporting "three souls" on board, then liftoff. The crash came moments later.
Nearly two hours would pass before the patient arrived at the Cleveland Clinic. He came by ground, not air, and was discharged from the Clinic three days later.
The familiar sound of rotor blades slicing through air as a helicopter swoops to the scene of an accident has become synonymous with lives saved. But most flights that medical choppers make these days are hospital-to-hospital transfers, like the one that ended in tragedy last month.
Just after liftoff, a gust of wind pushed the helicopter toward a wall. The pilot tried to compensate, but the helicopter glanced off the side of the building, clipped the edge of the building and plunged 12 stories, killing pilot Bill Spence, 51, and nurse Kelly Conti, 38, and seriously injuring Joe Paoletta, a paramedic. The falling chopper just missed six floors filled with patients.
An investigation continues into the cause.
In critical care, speed matters. The military learned it in Korea and perfected it in Vietnam, where wounded soldiers evacuated by choppers were more likely to survive. Hospitals began using helicopters in the early 1970s.
But medical helicopters also take lives at a rate that some find alarming. Since 1998, they have been involved in at least 57 accidents and incidents that have killed 43 people and injured 33, according to an analysis of National Transportation Safety Board and Federal Aviation Administration data.
Some say the accident rate, the worst since the mid-1980s, simply reflects the fact that there are more helicopters flying more hours. Medical helicopters actually have a better safety record than choppers in general, they say.
As the number of local flights heads skyward, critics contend that medical helicopters are overused, sometimes picking up patients whose conditions do not warrant air transport or flying at night or in bad weather, when conditions are riskier.
They say that competition, marketing and the need to cover costs are powerful reasons explaining why medical helicopters are such frequent flyers. And they say no hard scientific data supports the notion that delivering a patient by air - at about $5,000, roughly four times the cost of a ground critical-care ambulance - is likely to improve a patient's outcome.
"We're taking the most expensive transport modality and we're starting to want to use it for anything," said Dr. Bryan Bledsoe, an associate professor of emergency medicine at the University of North Texas Health Sciences Center in Fort Worth. "It's time to reassess the whole thing. We've got to stop killing our nurses and medics."
No one has suggested the chopper shouldn't have been dispatched the night of the crash. Whether a medical helicopter or a ground ambulance is the right choice for a sick patient can be a tough call.
For hospital-to-hospital transfers, doctors have to consider the seriousness of a patient's condition and how quickly treatment is needed. Emergency resources also are considered. A ground transfer that could keep a critical-care ambulance out of service too long may be bumped to the skies.
At accident scenes, medics tell time by the so-called "golden hour" - the critical period during which a patient with a traumatic injury must get treatment. Miss the window and you miss the chance to pull a critical patient from the brink of death.
Calling for a helicopter when ground transport might do is not uncommon. "It is intended to protect the patient and must be accepted as a part of air medical service," according to the Association of Air Medical Services.
Around the country, it happens 10 to 15 percent of the time, according to Dr. William Fallon, medical director of MetroHealth's Life Flight.
In hindsight, he said, "it's a lot easier to see if someone should have been flown."
A matter of minutes
Today more than 300 companies provide helicopter service to hospitals nationwide. In Northeast Ohio, three companies keep five medical choppers at the ready. All three figured into how events unfolded the night of the crash.
Doctors caring for the LakeWest patient called MedFlight of Ohio at 12:15 a.m., seeking transport from Willoughby to the Clinic. Columbus-based Med Flight stations a helicopter at Lodi in Medina County, a 23-minute flight to the patient.
Looking for a faster alternative, the MedFlight dispatcher called Metro's Life Flight, which keeps a chopper in Highland Heights, a six-minute flight from LakeWest. That helicopter was not available, Life Flight advised, but the chopper based at MetroHealth Medical Center could get there in 15 minutes.
At 12:16, the MedFlight dispatcher checked with MedEvac, which said it could reach the patient in 11 minutes from UH and took the job. MedEvac 8 crashed on takeoff at 12:24.
MedEvac called MedFlight back at 12:48, asking it to make other arrangements because there had been "an incident," said MedFlight dispatch supervisor Jerry Bandy. MedEvac offered no details.
MedFlight then placed its second call of the night to Life Flight, which agreed to make the run. But Life Flight soon called back with news of the crash. Life Flight thought its choppers might be needed to transport injured UH patients and asked MedFlight to handle the LakeWest job itself.
By this time, however, Med Flight's pilot in Lodi, a friend of the MedEvac pilot killed in the crash, was too distraught to fly.
So at 1:10 a.m., MedFlight contacted LifeStar, an ambulance service that has an advanced level of care similar to the chopper's.
Ten minutes later, LifeStar rolled from its base at St. Vincent Charity Hospital in downtown Cleveland. It delivered the patient to the Clinic at 2:15 a.m. - exactly two hours after the initial call to MedFlight.
By ground or by air
Because the hospitals will not discuss the patient, citing confidentiality rules, it is not clear why doctors thought he needed to go by air. Had he been moved by ground at the start, he could have been at the Clinic within an hour.
Moving patients from one hospital to another has become the staple of the medical helicopter business, accounting for about 60 percent of flights nationwide.
In Greater Cleveland, transfers make up an even larger share of the runs. Nearly all of MedEvac's 692 flights last year were from one hospital to another. Two-thirds of MedFlight's 3,824 chopper runs statewide flew patient transfers.
Even Metro's Life Flight, based at the state's busiest trauma center, logged just 30 percent of its 3,112 flights last year plucking victims from accident scenes - the reason hospitals started flying 30 years ago.
The business of health care has helped drive the shift from trauma to transfers, said Ed Marasco, vice president of CJ Systems Aviation Group, which operates the choppers that fly under the MedEvac name.
Sprawling health-care systems frequently move patients among distant hospitals, some two counties away.
New medical technology that can ride along on helicopters has made flights more useful for moving non-trauma patients, particularly cardiac arrest cases. And swift treatment is needed for patients to benefit from advances in treating stroke.
"A fair number of patients we transport [by air] are strokes or suspected strokes," said Dr. Catherine Keating, director of clinical operations at UH.
But marketing also is a reason why helicopters are flying more patients.
Nothing conveys quality care like video of a helicopter lifting off from the scene of a wreck on the evening news. With the name of a hospital emblazoned on its sides, the helicopter has come to represent the highest level of care imaginable.
"It's a flying billboard," said Dr. Kenneth Mattox, vice chairman of surgery at Baylor University's medical school and chief of surgery and chief of staff at Ben Taub General Hospital, a top trauma center in metro Houston. "Huge marketing, huge marketing, huge marketing."
Public relations visits with community rescue squads are part of any chopper service's routine, along with standing offers of ride-alongs. Life Flight has invited the news media to cover "reunions" of trauma survivors, with the helicopter as a backdrop. Medical choppers touch down at the Cleveland National Air Show and at community fairs, where stroller-pushing families can tour the treatment bay.
Marketing aside, medical helicopters play an important role in critical care. They can be a lifeline in rural communities, where medical resources are limited, and in urban areas, where traffic can delay ambulances. They also offer more sophisticated care than community EMS squads.
"I truly believe that aeromedical services probably benefit a group of critically injured trauma patients," said Dr. Jeffrey Salomone, a trauma surgeon at Grady Memorial Hospital in Atlanta, which anchors the largest public hospital system in the Southeast.
Still, he said, "There are a lot of scientific questions that we should be asking."
At the top of the list is the question of when it makes medical sense to call for a chopper.
Guidelines seem clearer for trauma victims than transfers between hospitals, whose mode of transport is determined by the patients' physicians.
Fallon, who also directs Metro's division of trauma, burns and critical care, said all Life Flight runs are reviewed for appropriateness. Any run to pick up a patient who was well enough to leave the hospital three days later - as the LakeWest patient did - would "absolutely" trigger a review at Metro, he said.
With each call, a calculated decision must be made: Does the patient's predicament warrant the risks of sending a chopper?
"We who are medical directors of these programs have this in the back of our mind, that we are putting people in harm's way," Fallon said. "Nobody wants to put them in harm's way."
Plain Dealer Washington bureau reporter Elizabeth Marchak contributed to this report.
