You would have to live in a cave to not know that the air medical industry is out of control. As of this writing, there have been 14 crashes/incidents resulting in 29 deaths and nine injuries in 2008. (Any time you have to add the phrase “as of this writing” to an article, it usually indicates a bad situation.) Any discussion of the air medical industry evokes an emotional response in the EMS community. But with people dying all too frequently, emotion must be moved to the back of the queue of importance.
I’ve studied the air medical industry for years. In addition, I’ve been a flight paramedic and helicopter EMS medical director. I’ve never claimed to have the solutions to this issue, but I have some ideas.
Helicopter EMS (HEMS) must be dispatched through the local/regional EMS system.All calls for HEMS must go to a centralized dispatch center that will send the closest helicopter regardless of the operator. This would put an end to “helicopter shopping,” which has been a factor in several HEMS accidents. This would also stop the practice of calling for another helicopter after another service turned down the flight because of weather concerns.
We need minimum airframe requirements for HEMS.All helicopters should be larger, dual-engine aircraft with full Instrument Flight Rules (IFR) capabilities. All aircraft should have fire-retardant fuel tanks to minimize the chances of post-crash fire.
All helicopters must have two pilots at all times.Most highly developed industrialized nations require dual pilots for safety. Most of us would never get on a commuter airliner that had only one pilot — but it occurs many times daily in the HEMS industry.
Helicopters should not attempt scene responses after dark.Many of the incidents and crashes have occurred during night operations. Landing a device as complex as a helicopter in an uncontrolled environment, like an emergency scene, is an accident waiting to happen. Many other countries, including Canada, forbid (or strongly discourage) nighttime scene flights.
Helicopters should only attempt interfacility flights at night if both the transferring and receiving hospitals have IFR approaches to their helipads.Several crashes have occurred on approach to hospitals. IFR approaches will make this much safer.
No helicopter crew should attempt a night flight without night vision goggles. I’m not a pilot, but I’ve been told by many pilots and HEMS crews that night vision goggles have been a significant safety improvement. These must become mandatory.
Air ambulance operations (rotor wing and fixed wing) need their own rules and regulations within Federal Aviation Administration (FAA) statutes.Currently, HEMS is considered an “Unscheduled Air Taxi” and falls under the airline deregulation act. These criteria are often not appropriate for the HEMS environment.
Allow individual states to require more stringent HEMS regulations than those required by the FAA. Currently, states have absolutely no authority to regulate HEMS. The State of Tennessee tried, only to be sued by a HEMS operator. The federal judge ruled that HEMS regulation is purely a federal issue. Whatever happened to the Tenth Amendment to the U.S. Constitution? Also, we need to consider requiring a “certificate of need” prior to an HEMS operator placing a new aircraft.
Usage protocols for trauma must be significantly and immediately changed.Mechanism of injury criteria needs to be removed or minimized as an indicator for HEMS usage. The American College of Surgeons (ACS) should immediately revise its Trauma Center usage criteria (on which much of the helicopter usage criteria are based). I call upon my colleagues at the ACS to act on this immediately — please give up the dogma and make these criteria evidence-based. And, while I’m casting stones, how come the two professional organizations I belong to, the American College of Emergency Physicians (ACEP) and the National Association of EMS Physicians (NAEMSP), have remained quiet on this crisis? Come on, guys — your silence is deafening.
Weather minimums for HEMS operations must be stricter.Bad weather and night operations appear to be significant factors in several crashes. Sometimes, pressure from management (and occasionally medical personnel with a sick patient) will push pilots to take risks. Pilots must never know anything about a patient’s condition when making weather-related decisions.
Medical flight crew members must have limited work periods and mandatory rest periods as pilots do.Why would we rest pilots but work HEMS medical crews to death? The medical decisions they make are just as critical as the aviation decisions made by the pilots. This might also help prevent untoward incidents, like leaving electrical cables connected during takeoff, aircraft doors open or rotors tethered, and might help reduce rotor strike accidents.
All requests for interfacility transport must first be evaluated by an independent physician for necessity before a helicopter is launched.Even the public recognizes that many of the recent HEMS crashes occurred while transporting patients who could just as well have gone by ground. When a call for an interfacility transfer is received, it should be evaluated medically; the EMS communications center, based on independent physician review, could then determine whether to dispatch a helicopter or ground CCT unit. The transferring physicians and hospitals have shown they’re incapable or unwilling to determine the proper usage of HEMS for interfacility transfer.
All HEMS transports, both scene and interfacility transports, should have 100% quality review for appropriate usage.Because HEMS is a very expensive and dangerous endeavor, it should have 100% post-usage review just like we would expect with other high-risk procedures, such as endotracheal intubation and surgical airways.
HEMS “subscription plans” must be outlawed.HEMS subscription programs are nothing but a marketing tool that plays to the entitlement mentality that exists in our country. People with subscriptions believe that, because they wrote a check for a membership, they’re entitled to HEMS transport, even for minor injuries and illnesses. This serves to promote inappropriate usage and risk.
The FAA must act — and act now.Almost two years ago, the National Transportation Safety Board (NTSB) issued recommendations to the FAA to enhance HEMS safety. To date, the FAA has done nothing. Finally, after the recent spurt of crashes, they decided to have “hearings” in 2009.
I call upon every member of the EMS community to communicate their concerns about the HEMS industry to their senators, congressional representatives and local officials. I call upon my physician colleagues — especially intensivists, emergency physicians and trauma surgeons — to do the same.
The HEMS crews who are needlessly dying are our friends and colleagues. Their lives and their contributions to the EMS system are too important to allow the current system to continue unimpeded. It is time to stop the carnage!
