In October 2008, an EMS crew and a 1-year-old patient were killed in Illinois when a medical helicopter reportedly clipped a radio tower and crashed. That incident was the ninth fatal medical helicopter crash in the United States in 2008. The month before, a Maryland State Police helicopter went down, killing the crew and one patient. Another patient survived the crash.

While 32 dead made 2008 a record year for crash fatalities, crashes have been on the rise this decade. I had a good friend killed in a medical helicopter crash in 2000. It was a beautiful day in St. Petersburg, Fla., when for some unknown reason it hit a high power transmission line and went down. There were no patients on board, but all three crew members were killed.

The National Transportation Safety Board investigated 55 crashes that resulted in 54 fatalities between January 2002 and January 2005. In its 2006 “Special Investigation Report on Emergency Medical Services Operations,” the NTSB said 29 of the accidents could have been prevented. The report is available at www.ntsb.gov.

In the report, the agency noted that emergency medical operations are unique in their inherent danger because of the high-pressure circumstances to which they respond, unfamiliar landing sites, and 24-hour emergencies, often in inclement weather. Investigators also identified several safety issues: less stringent requirements for emergency medical operations conducted without patients on board; a lack of aviation flight risk-evaluation programs and of consistent, comprehensive flight dispatch procedures; and no requirements to use technologies — terrain awareness, warning systems — to enhance flight safety.

Still, more than 50 people have died in medical flight accidents since the NTSB made its recommendations.

In addition to unsafe practices, medical helicopters are expensive. Service providers charge a hefty fee to meet the cost of doing business, and deregulation has created a competitive environment. In addition, if a hospital owns the craft, it is a great marketing tool for the hospital and an incentive for patients to go to that particular hospital. This may seem harsh, but when you look at services, you need to look at the entire picture.

So why do we continue to use air transport? Are they necessary, or do fire/EMS agencies continue to use them because they are cool? Do we use them simply because we have become complacent?

Air transports are an essential part of EMS and are vital to patient survivability. There is a time and place to use air transports, however, and fire/EMS agencies have strayed from using them solely out of medical necessity. It often takes longer to use a medical helicopter than to transport a patient via a ground ambulance. In addition, medics' ability to provide patient care becomes more limited in an aircraft versus the back of an ambulance.

Fire chiefs need to ask themselves if they are creating liability potential for their organizations by requesting air transport and when the benefits outweigh that potential. Chiefs need to ask their personnel about the protocols for calling for a medical helicopter.

On June 30, 2008, the Federal Aviation Administration released a fact sheet on EMS helicopter safety, available at www.faa.gov. It provides a variety of information on the FAA's actions and identifies a number of ways to improve EMS helicopter safety.

The first area of concern is inclement weather. Air transport often is most needed in weather that makes it very dangerous for helicopters to fly. If one air service determines it is unsafe to fly, responders tend to request a different service. If the weather is not conducive for one agency, why would it be safe for another agency to take the risk?

The first area of concern leads directly to the second: technology. The only exception to weather-restricted flight would be the type of safety equipment the unit may have on board.

In March 2006, the FAA and the University Corporation for Atmospheric Research hosted a weather summit in Boulder, Colo., to identify the helicopter EMS-specific issues related to weather products and services. Attendees explored possible regulatory improvements, weather product enhancements and operational fixes specific to HEMS operations. Attendees included the National Weather Service, National Center for Atmospheric Research, Helicopter Association International, American Helicopter Society International, Association of Air Medical Services, National EMS Pilots Association, National Association of Air Medical Communications Specialists, manufacturers and many operators.

Following the summit, the FAA funded the development and implementation of a graphical flight planning tool for ceiling and visibility assessment along direct flights in areas with limited available surface observations capability. Its use improves the quality of go/no-go decisions for HEMS operators. The tool was fielded in November 2006, and the response from users continues to be very favorable, according to the fact sheet.

The FAA has a solid record of facilitating safety improvements and new technologies for EMS helicopters, including certification of night-vision goggles. According to the fact sheet, the FAA has worked 28 projects or design approvals, called supplemental-type certificates, for installation of night-vision goggles on helicopters since 1994. This number includes EMS, law enforcement and other helicopter operations. Of the 28 projects, the FAA has approved around 15 night-vision goggles STCs for EMS helicopters. The FAA initiated and wrote the minimum standards for NVGs/cockpit lighting (Technical Standard Order C164).

One set of goggles costs around $7,000, and an operator must carry multiple sets per flight. The FAA has hosted workshops to help applicants work with the FAA to obtain night-vision goggles certification. But certification is just one step. The operator also must have an FAA-approved training program.

The FAA has revised the section on night-vision goggles in the Operations Inspectors Handbook. Produced with considerable industry input, the revision includes the establishment of a cadre of national resource inspectors.

Another technology to consider is flight- data recorders. Black boxes aren't required for HEMS operations, but they offer value in any accident investigation by providing information on aircraft system status, flight path and altitude. The boxes' weight and cost are factors. Research and development is required to determine the appropriate standards for FDR data and survivability in the helicopter environment, which typically involves substantially lower speeds and altitudes than airplanes. Funds are currently best invested in preventive training.

However, the FAA is studying alternatives to expensive and heavy airliner-style FDRs, especially in light of the relatively low-impact forces in most helicopter accidents. By establishing a standard appropriate for helicopter flight, the FAA may be able to make meaningful future FDRs.

The FAA supports the voluntary implementation of Terrain Awareness Warning Systems and did consider the possibility of including rotorcraft in the TAWS rule-making process. Through this process, however, the FAA concluded that there are a number of issues unique to visual flight rule helicopter operations that must be resolved before the use of TAWS can be mandated in this area, such as modification of the standards used for these systems. For example, helicopters typically operate at lower altitudes, so TAWS potentially could generate false alerts and “nuisance” warnings that could negatively impact the crew's response to a valid alert. TAWS application to HEMS would require study of TAWS interoperability within the lower altitude HEMS environment and possibly a modification of system standards.

At the FAA's request, RTCA Inc. established a special committee to develop helicopter-TAWS standards for use in future FAA rule-making projects. The RTCA delivered its report in 2008, and those standards are being reviewed by the FAA's Aircraft Certification Service for the development of an helicopter-TAWS technical standards order.

Fire departments have little to no control over these areas. Pilots typically decide whether it's safe to fly in certain weather conditions. Fire departments only can control whether they call for the helicopter in poor weather. Departments also can do nothing more than discuss safety equipment with the air transport agencies and note what safety devices they have employed.

But fire/EMS agencies can control their criteria for using air transport. Chiefs can provide all the safety tools, but if they do not have solid standard operating guidelines and medical protocols, the rest of this is useless.

Not all patients who have been in motor-vehicle accidents require helicopter transport. Fire departments need to establish a solid set of protocols that govern when a medical helicopter is called to the scene. Convene a team to establish this criteria. The team should include the EMS chief, the department's medical director, a trauma surgeon from the area's trauma center and an emergency room physician, as well as medical directors of the helicopter agencies. Many agencies also use medical helicopters to transport stroke and cardiac patients. If this is the case, include a physician representative from both areas on the protocol-development team.

The team should consider the distance to the receiving facility and the geographical area in which medical helicopters are more appropriate to use than ground transport. The patient's condition should be the primary deciding factor for air transport. The distance to the receiving facility needs to be a secondary component.

These are a few steps fire chiefs can take to start to change responders” mindset about air transports in the prehospital setting. It comes back to fire chiefs to make sure their agencies are performing in a prudent and safe manner. Would you send a $1 million ladder truck to a dumpster fire just because there may be a chance the fire could spread to the structure? The same thought process needs to be applied to helicopter use. Departments need to be prudent with the equipment they send to medical calls, especially when they start to use multi-million dollar aircraft for those calls that were not medically necessary.

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Jeffrey T. Lindsey, Ph.D., EMT-P, CHS IV, is the director of graduate studies at George Washington University in Washington, D.C. He also is the education coordinator for 24-7 EMS. Lindsey has more than 29 years of experience in the emergency services and retired as fire chief from Estero (Fla.) Fire Rescue.