Air Rescue in 2007

Civilian helicopter ambulances first took to the sky 35 years ago and are busier than ever.

JOHN Sidler, 19, was driving to work in Dallas on a rainy Saturday morning in October 2005 when his truck hydroplaned and smashed into a utility pole, crushing his vehicle and knocking him unconscious. Good Samaritans who witnessed the accident rushed to his aid and called 911. Paramedics quickly arrived. Finding he was not breathing, they intubated him, supplying oxygen to his brain. Then they called for a medical helicopter.

Because the hospital was near, the first responders normally might have used a ground ambulance for the transport. Traffic was badly congested that day, and Sidler's traumatic head injuries made time of the essence. A CareFlite helicopter soon arrived; within minutes of landing, the flight team had Sidler aboard, airborne, and away. He sustained multiple skull and facial fractures, underwent brain surgery, and remained in a coma for 17 days. His mother, Joni Sidler, who is both an EMT instructor at a junior college and a paramedic with a fire department 12 miles south of Dallas, said she knew the situation was serious as soon as she was told a helicopter had been called--a step usually taken only in worst-case scenarios.

"My paramedic mode kind of went out the window and my 'Mom mode' took over," she says. "In EMS, what we teach is 'the Golden Hour,' and that's the time from when the accident happens--not from when 911 is called, but from when the accident happens--until that patient can get into the OR. Because of the extent of his injuries, John didn't have even that long. Fortunately, they were able to get him there as quickly as they did."

Quick response on several fronts saved her son's life that day, she says. "He's 21 now and fully recovered, working his way through college, but it was a long road. . . . Being in EMS and responding to other people's emergencies has been my career through and through, but being on the other side of it was just horrific."

Still, she adds, much went right on the day of the accident, when seconds were ticking away. "It was a domino effect," she says. "It was the family stopping to help, it was the fast-acting paramedics getting there and getting him intubated so quickly, it was CareFlite getting him to the hospital so quickly, and it was a lot of prayer. All of that made the difference between life and death."

The CareFlite unit that responded to the Sidler crash scene is one of about 800 medical helicopters, or "rotor-wing air ambulances," in the United States. Some 270 separate companies own and operate these aircraft at about 650 bases nationwide, mostly out of airports or from hospital helipads. Many of these companies also operate a dedicated airplane (or "fixed wing") that is used mainly for long-distance, inter-hospital patient transfers. In 2005, 150 fixed-wing aircraft were in operation; today, the combined helicopter and fixed-wing services account for 500,000 transports each year--an impressive number considering the relative youth of the industry.

Rotor Roots
While military helicopters were used routinely for medical evacuation missions during the Korean War in the 1950s and even more in Vietnam the following decade, non-military uses of air ambulances were extremely rare as late as 1970. In its seminal 1966 white paper "Accidental Death and Disability: The Neglected Disease of Modern Society," the National Academy of Sciences noted that "[h]elicopter ambulances have not been adapted to civilian peacetime needs." Six years later, in 1972, St. Anthony's Hospital in Denver established the first civilian hospital-based medical helicopter service.

Today, that program--Flight for Life Colorado--operates four helicopters, two fixed wings, and three critical care ground ambulances from its four hospital bases in the state. Program Director Kathleen Mayer, MSRN, says it was the first service in the state to be accredited by the Commission on the Accreditation of Medical Transport Systems (CAMTS), the industry's premier voluntary standard-setting group. She says her program and the air ambulance industry in general have come a very long way in 35 years, especially in the spheres of training and technology.

"Flight for Life started with one flight nurse and one pilot, and that nurse was responsible for every aspect of patient care," Mayer says. "Now, you can't even be CAMTS-accredited unless you have two ALS [Advanced Life Support] providers on board. But with the monitors, ventilators, and infusion pumps we now have--all of which are designed with air transport in mind, from a size and weight standpoint and their ability to tolerate changes in altitude--clearly the technological capabilities in the field have skyrocketed.
"In 1972, we could intubate patients, we could put in chest tubes and central lines, but now, in addition, we're capable of delivering some pretty sophisticated local therapy, and the equipment that we have to assist us in managing patients' airways and ventilation just far exceeds anything we had before."

Working in what are essentially flying intensive care units, helicopter flight teams typically deliver that sophisticated local therapy while traveling about 200 miles per hour at 2,000 feet.

The Air Ambulance Business Model
By 1980, the air ambulance industry had grown to include 32 programs with 39 helicopters flying more than 17,000 patients annually. A decade later, the industry had expanded exponentially and included 174 services with 231 helicopters flying nearly 160,000 patients. By 2000, 231 helicopter services with 400 aircraft were flying more than 203,000 patients each year. And now that roughly twice as many are chopping across the nation's skylines, some industry critics say the aircraft supply has exceeded demand and that not all flights are medically necessary. Industry proponents, however, say the demand for air medical services will continue to grow in pace with medical science's increasing progression toward bringing time-critical technology to the patient or rushing the patient to it.

The industry's current growth is largely the result of changes in the overall health care system. The closure of many rural hospitals or their conversion to facilities offering reduced services and fewer specialty physicians has created the need for transport--often rapid transport--to where those services and specialists remain, which is usually in urban centers. "Air ambulance services are big operations, but as much as it costs for the equipment, the training, and the people, it still costs less to fly patients to, say, a region's one burn center than it does to build multiple burn centers in more locations, so that's kind of how this business works," explains Jim Swartz, president and CEO of Grand Prairie, Texas-based CareFlite.

Early on, nearly all medical helicopters were affiliated with hospitals. In recent years, because of the expense to the hospital of owning and operating even one aircraft and because of changes in Medicare and other federal reimbursement programs for airlifts, about half of the service providers nationwide now are public corporations or privately owned smaller companies. Many of these set up bases strategically located to serve rural areas. Rural areas are where, according to the National Highway Traffic Safety Administration, most serious car crashes and 60 percent of auto fatalities in the United States occur, at a rate nearly double that of urban and suburban areas. According to the Center for Excellence in Rural Safety, which Congress created in July 2005, crash victims are five to seven times more likely to die if arrival time to a hospital exceeds 30 minutes.

The average time between a crash and arrival at a hospital is 52 minutes in rural areas, the center says. Helicopter operations in rural outposts are seen as helping to close the time and space gaps between these remote vicinities and the tertiary care hospitals situated in metropolitan areas.

On average, the price of an airlift is about $10,000, or roughly 10 times that of a ground ambulance. Depending on the patient's condition and the distance the helicopter travels once the patient is retrieved, the price can be even higher. Swartz says insurance usually covers about 80 percent of the total. CareFlite, like many other providers, has begun offering company "memberships" to help defray the remaining costs. For nominal annual fees, these allow participants, whether otherwise insured or not, to be emergency airlifted for reduced or no out-of-pocket costs. But if another helicopter service happens to be called to the scene for the transport, the patient is not covered by the program.

Crowded Skies
The proliferation and profitability of helicopter services has in some regions of the country led to "air wars" among competing providers. The Federal Aviation Administration, CAMTS, and other groups are trying to prevent this because it is conducive to bad judgment and poor safety.

2006 Summary of Helicopter Assets by State
AL 12
AK 33
AZ 53
AR 12
CA 79
CO 10
CT 2
DC 4
DE 5
FL 44
GA 21
HI 6
ID 9
IL 20
IN 19
IA 10
KS 10
KY 19
LA 9
ME 2
MD 17
MA 4
MI 12
MN 13
MS 6
MO 32

MT 5
NE 7
NV 6
NH 2
NJ 5
NM 10
NY 29
NC 13
ND 2
OH 27
OK 15
OR 5
PA 46
RI 0
SC 9
SD 4
TN 24
TX 64
UT 8
VT 0
VA 22
WA 9
WV 5
WI 11
WY 1
TOTAL: 792
SOURCE: Atlas & Database of Air Medical Services (ADAMS), September 2006

Hartford, Conn.-based Life Star operates the only two medical helicopters in that state. The company's chief flight nurse, Jim Marcelynas, RN, CFRN, CCRN, says the New England Air Alliance formed among rotor-wing programs in the region for the express purpose of encouraging collaboration and avoiding competition. "Providers throughout New England saw this competitive culture happening in different parts of the country. So we got together, decided to meet quarterly, and early on agreed to operate in a non-competitive environment," Marcelynas says. "We're not going to put an aircraft on another program's back step and say, 'Sorry, we're here.' "

Despite such collaborations, 2003 and 2004 were turbulent years for the industry from a safety standpoint. 2004, in particular, was the deadliest year in more than a decade for helicopter crews and patients, with 18 people killed in 11 accidents. Federal regulators stepped in. The FAA issued a report in January 2005 proposing steps to improve flight safety. Citing the industry's rapid growth and an "unacceptable" number of accidents, the agency recommended that operators increase the use of technologies such as radar altimeters, night-vision goggles, terrain-awareness warning systems, and other measures to help crews assess risks.

By March 2005, the Association of Air Medical Services, in concert with the FAA Helicopter EMS Task Force and other groups, had launched Vision Zero, an initiative calling for zero tolerance for incidents and accidents in the air medical transport community. Addressing industry operators, a document on the initiative posted at the AAMS Web site (http://visionzero.aams.org/V0_WhitePaper.pdf) says, "It is imperative that we recognize there is a crisis, and that it is accompanied by both danger and opportunity. The danger is found in the fact that the public is on the verge of losing confidence in the trust they place upon us. Instead of being viewed as 'heroes' who save lives, we are in danger of being viewed as simply a transport option that is just too risky."

Fewer crashes have happened since mid-2005. But the lack of statistics on the number of flight hours logged or even the number of flights conducted has caused an ongoing debate about what the industry's true accident rate is. Mayer, of Flight for Life Colorado, says that in one way, the actual rate is immaterial: "If there's even one crash, regardless of the rate, it's too many.

Safety First
"We consider air ambulance transport to be a medical intervention. And like every medical intervention, there are risks and there are rewards," says AAMS Executive Director Dawn Mancuso. "If you're at work and have to go to a cath lab because of a cardiac issue, there are some risks of going under anesthesia, of having angioplasty done while you're inserting a piece of medical equipment into an artery or vein--all of those things carry risks, and so does air medicine. Our community spends a lot of time working on mitigating those risks so that we're as safe as we possibly can be, and we believe that we are as safe as just about any other medical intervention that's out there."

Among the many challenges medical helicopter flight crews face are the unscheduled scene calls coming in at all hours and sending them to all types of terrain--usually with limited planning time, often having to set down on makeshift landing zones in fickle weather.

"Night flying without NVGs [night vision goggles] can be particularly hazardous, but weather is the great equalizer," says Jonathan Collier, national director of business development for Phoenix-based PHI Air Medical, which has operations in 16 states. "I would say, outside of human error, weather is the number one risk to safety, so our crews are monitoring it closely all the time."

The vast majority of helicopter programs in the United States operate under Visual Flight Rules (VFR), meaning safe flights can happen only when certain weather minimums prevail. In effort to make their programs safer and to increase the number of flights possible when conditions make navigation by VFR unreliable--during periods of reduced visibility, for example--a small but growing number of programs are shouldering the additional expense and training time to be Instrument Flight Rules (IFR) certified, allowing them to fly by methods similar to those of fixed wings.

These are steps in the right direction, but nothing replaces the creation of a "fundamental culture of safety" practiced at all levels of the organization, says Swartz of CareFlite. "Our helicopter fleet is IFR, but if it is an ice storm or a thunderstorm, we're not going out," he says. "If it's just a question of reduced visibility, then we can and will go. I've been flying for 31 years now, flew helicopters in the military, and I can tell you: In this industry, when accidents happen, they're always for the same reason--people try to go out when they shouldn't, and they get killed. . . . Our number one responsibility is not to hurt anybody--our teams or anybody else."

Safety is emphasized to new team members at Life Star from day one, Marcelynas says. "The first thing new employees get taught here are safety features of the aircraft, how to keep themselves safe in it, how to put on their helmets appropriately, how to take care of their Nomex suits so that they provide fire protection through the life of the garment, how fire suppression systems at the hospital work, where the escape routes are, where the resources are around the institution. Safety comes first in everything we do, and in this industry it has to."

In the interest of keeping flight crews as safe as possible, the industry has adopted a catchphrase ubiquitously posted in ready rooms across the nation: "Three to go, one to say no." The "three" refers to the flight crew, typically comprised of a pilot, flight nurse, and flight paramedic.

"It's a catchphrase that is very much a part of the industry's culture," Marcelynas says. "It means that there is no second-guessing or questioning on the part of the administration or anyone else if any crew member decides, for whatever reason, that a mission is not safe and needs to stop. I don't know of a program anywhere that does not support that philosophy. You know, there's a lot to be said for intuition sometimes, especially when it comes to safety and making sure that the mission gets done without anyone getting hurt.

Securing the Landing Zone

It is up to the first responders (usually fire department personnel) to take on-scene command after requesting a medical helicopter. The task includes scouting the area for a safe landing place and serving as the incoming aircraft's ground guide. Typical protocol highlights include these, from a section of the Fort Worth Fire Department's Standard Operating Procedure manual, "Operations, Helicopter EMS Support":
• Always consider the wind direction. Helicopters land into and take off into the wind.
• Determine if the area is large enough to land a helicopter safely. Medium-size helicopters require landing zones 100 feet by 100 feet; larger helicopters require landing zones 120 feet by 120 feet.
• The landing surface should be flat and firm, free of debris that would blow up into the rotor system.
• The landing site should be clear of people, vehicles, and all obstructions, such as trees, poles, and wires. Keep in mind that wires cannot be seen from the air. The landing site must be free of stumps, brush, posts, and large rocks.
• If there are obstructions, advise the helicopter crew on initial radio contact.
• During nighttime operations, the handheld strobe light will be placed in the center of the landing zone and turned on. Rotor wash may cause the strobe light to be moved somewhat but, due to its weight, there is no safety concern.
• After landing has been completed, the ground guide should secure the rear portion of the landing zone to keep bystanders from approaching the aircraft.
• Once the helicopter has landed, DO NOT approach the helicopter unless asked to do so.
• When working around helicopters, NEVER approach from the rear. ALWAYS approach and depart the aircraft TOWARD THE FRONT so you can see the pilot and the pilot can see you.
• When approaching the helicopter, remember to keep low to avoid the main rotor, because winds can cause the rotor to flex down.
• If the helicopter has landed on a slope, approach and depart from the down-slope side only.
• When explosives, poisonous gases/vapors, or chemicals in danger of exploding and burning are onsite, helicopter landing zones must be prepared UPWIND, at least ONE MILE from the hazardous material accident site, and never in low-lying areas. The toxic gases or vapors may be heavier than air and gather in these low-lying areas.
• When hazardous material accidents involve radioactive materials, the helicopter landing zone must be prepared UPWIND, at least ONE-QUARTER MILE from the accident, unless there are radioactive gases (steam or smoke), and, in that case, the landing zone must be at least ONE MILE UPWIND of the accident site.

This article originally appeared in the June 2007 issue of Occupational Health & Safety.

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