HOUSTON -- When a medical helicopter crashed last week, killing its three-member crew and a patient near Huntsville, it seemed like a rare event.
But it was the third fatal medical helicopter crash so far this year for the nation's fleet of about 1,000 such helicopters. Three other 2008 EMS helicopter crashes left five people injured.
The crash rate for the fleet has been rising this decade, according to government agencies, fueling a long-simmering debate over the safety and effectiveness of such flights.
"It's about as dangerous as combat," said Bryan Bledsoe, a Midlothian physician who specializes in trauma care and teaches emergency medicine at the University of Nevada.
Hospitals and companies that operate medical helicopters say the benefits outweigh the risks. The flying ambulances can whisk patients to hospitals faster than ground ambulances, giving some a better chance to survive, they say.
"If you can afford to buy a Cadillac, are you going to buy a Ford?" said Tom Flanagan, chief operating officer at Memorial Hermann-The Texas Medical Center, which operates the Life Flight service.
But other trauma-care specialists say studies show that ambulances often get patients to hospitals about as fast as helicopters and that many patients taken by ambulance have about the same chance of surviving as those flown in.
"Given the rate of our air medical tragedies, can we continue to say the benefits outweigh the risks?" asked William Mileski, senior chief of trauma care at the University of Texas Medical Branch at Galveston.
The number of medical helicopter crashes has been increasing since the early 1990s, in part because more companies are putting medical helicopters in the air, according to a 2006 report from Congressional Research Service.
The size of the U.S. fleet has increased from about 300 in the early part of this decade to about 1,000 today, said Bledsoe, who has published studies on the helicopter services.
1 in 50 in a crash
The rate at which medical helicopter accidents occur also is on the rise, more than tripling per 100,000 flight hours from 1993 to 2004, the Congressional Research Service report said. During the same period, the accident rate for medical helicopters was nearly twice that of helicopters that ferry businessmen and industrial workers.
From 2002 to 2005, one of about every 50 medical helicopters in the U.S. fleet, which then numbered about 750, was involved in a crash, the Congressional Research Service report said.
If passenger jets crashed at the same rate, more than 80 airliners would go down each year across the country, said Bart Elias, the aviation safety specialist who wrote the report.
In the 1990s, there were 14 fatal medical helicopter crashes, including a 1999 Life Flight accident south of Houston that killed the three-member crew. This decade, 29 such crashes have occurred, according to National Transportation Safety Board records.
So far this year, 10 people have died in crashes.
Killed in the PHI Air Medical crash in Sam Houston National Forest on June 8 were patient David Disman, 58; pilot Charles Wayne Kirby, 63, of Bryan; paramedic Stephanie Waters, 27, of Cedar Park; and nurse Jana Bishop, 28, of Magnolia.
In February, a three-member crew perished when a helicopter crashed off South Padre Island while making an approach to pick up a patient. Last month in Wisconsin, a pilot, doctor and nurse were killed when their helicopter collided with trees.
The rate of on-the-job fatalities for medical helicopter crews - 74 workers per 100,000 from 1995 to 2001 - exceeded that for nearly all other occupations, according to Susan Baker of the John Hopkins Center for Injury Research and Prevention. The rate for all types of workers was 5 per 100,000 annually.
"The accident rate is out of control," acknowledged Flanagan, who served as a Life Flight nurse and director.
Medical helicopters would crash less often, the NTSB says, if more aircraft were equipped with night-vision goggles and "terrain awareness warning systems" - instruments that signal when aircraft are approaching land.
PHI's Bell 407 crashed about 2:47 a.m. The crew had accepted the assignment after a Life Flight crew abandoned the same mission. Life Flight cut the flight short 10 miles from Huntsville, because crew members said the cloud ceiling had dropped to 700 feet- 300 feet below the Federal Aviation Administration minimum for night flight by helicopters.
The PHI Air Medical pilot agreed to pick up the patient in Huntsville because all of his weather reports - and those reviewed by a PHI pilot at the company's national dispatch center in Phoenix - indicated that the cloud ceiling was at least 1,000 feet, said Jennifer Kaiser, the NTSB's lead investigator of the crash.
The PHI helicopter didn't have the terrain awareness warning systems recommended by the NTSB. The pilot hadn't received his night-vision goggles, yet. Most of the devices are going to the U.S. military, said Jonathan Collier, spokesman for PHI Air Medical.
Transporting patients by helicopter is costly.
Life Flight recently paid $36 million for six new helicopters, increasing its fleet by two, Flanagan said. Each will cost more than $1 million annually to operate. Flying a patient to the hospital costs $8,000 to $16,000, he said.
A trip in a Houston ambulance costs about $500, said David Persse, physician-director of Houston EMS. Trips by other ambulance services are generally five to 10 times cheaper than those in a medical helicopter, said Kenneth Mattox, chief of staff at Ben Taub General Hospital.
According to the Congressional Research Services report and Bledsoe, Medicare and some private insurers may pay a portion of the patient's bill for the helicopter service.
The speed debate
Despite the cost, the helicopter flights are invaluable because they transport patients quickly to top trauma centers in the region and, as a result, save lives, said Red Duke, medical director of Life Flight and a founder of the 32-year-old service.
"Many patients die because they are bleeding. We can stop this bleeding faster by relying on the helicopter," Duke said.
A 2002 study at Santa Clara Valley Medical Center in California concluded that nearly a quarter of patients brought to the trauma center by helicopter from 1990 to 2001 may have had better medical outcomes than they would have if an ambulance had brought them. It also found that more than half of those patients arrived more quickly than they would have by ground.
A 2005 study published in the Journal of Trauma concluded that when patients were more than 10 miles from a hospital, medical helicopters were faster than ambulances if both were dispatched simultaneously.
The problem is that helicopters and ambulances often are not simultaneously dispatched. The request for a helicopter sometimes comes from a paramedic serving on an ambulance already at the scene.
A number of studies have concluded that ambulances are as fast or almost as fast as helicopters in such instances.
UTMB studied transport times and patient survivability rates before and after it disbanded its medical helicopter fleet in 1997. Discontinuing the service did not increase transport times or increase patients' mortality rates, the hospital reported in a 2002 Journal of Trauma article.
"In fact, transport times went down slightly," said Mileski, a co-author. "Discontinuation had no negative effect as far as we could determine."
Those in the medical helicopter industry acknowledge that they transport some patients whose injuries or illnesses don't warrant such a flight.
One-third of the patients brought to the Santa Clara Valley Medical Center by helicopter were discharged from the emergency room without being admitted to the hospital, the 2002 study found.
Not always necessary
Patients still arrive by Life Flight or PHI helicopters at UTMB. Last year, 14.5 percent of such patients were treated in the emergency room and released, Mileski said.
Houston EMS generally chooses to use ambulances instead of helicopters, Persse said.
"Even if the patient is in Kingwood or Clear Lake, we don't use (helicopters)," he said. "Even if you save a minute, it's an expensive minute. In many situations, such as a patient with a broken leg, it won't matter if an ambulance is slower."
Helicopters typically are used when a patient is at least 45 to 60 miles from a trauma center, Mattox said.
On June 8, Disman, who had a ruptured aortic aneurysm, was to be transported 75 miles from Huntsville Memorial Hospital to Memorial Hermann.
Life Flight received the request for a helicopter flight at 12:45 a.m., but its crew called off the mission at 1:18 a.m.
PHI Air Medical didn't take off with Disman aboard until 2:45 a.m. and would have arrived at the Houston hospital about 3:15 a.m.
"If they're calling (two) helicopter services, a ground ambulance could have gotten him there long before a helicopter," Mattox said.
Flanagan estimated that it would have taken an ambulance about 80 minutes to make the 76-mile trip in the middle of the night, counting the time that an ambulance crew would need to drive to the hospital and load.
If it had been dispatched at 12:45 a.m., when the call came to Life Flight, an ambulance might have arrived at Memorial Hermann about 2:05 a.m., by Flanagan's calculations.
The Life Flight helicopter, had it completed its mission, likely would have arrived five minutes earlier, he email@example.com