Dan­ger in the skies

To curb emer­gency he­li­copter crashes, fo­cus on pilot haste, ex­pe­ri­ence

Modern Healthcare - - OPINIONS / COMMENTARY - Scott Brooksby

Adramatic national con­ver­sa­tion erupted fol­low­ing the U.S. National Trans­porta­tion Safety Board find­ing that smart­phone tex­ting was a con­tribut­ing fac­tor in the crash of a fa­tal med­i­cal-he­li­copter flight in 2011.

The dis­cus­sion has con­cen­trated on ev­ery­thing from con­nect­ing the event to the dangers of tex­ting while driv­ing to calls for a ban on tex­ting by pi­lots in air med­i­cal op­er­a­tions.

Ab­sent from the dis­cus­sion, how­ever, is a larger is­sue that’s well-rec­og­nized by he­li­copter in­dus­try safety or­ga­ni­za­tions, and what should be of great con­cern for hos­pi­tal ad­min­is­tra­tion and other or­ga­ni­za­tions that con­tract emer­gency he­li­copter ser­vices. The is­sue has to do with the egre­giously high in­ci­dence of fa­tal and crit­i­cal he­li­copter emer­gency med­i­cal ser­vices (HEMS) crashes, and re­sult­ing in per­sonal in­juries.

In com­par­i­son to nearly ev­ery other type of com­mer­cial avi­a­tion, there is an in­or­di­nate rate of ac­ci­dents within med­i­cal he­li­copter avi­a­tion, with the 2010 NTSB data proof in point.

The NTSB seg­re­gates avi­a­tion op­er­a­tions into hun­dreds of cat­e­gories, the largest be­ing all U.S. ma­jor do­mes­tic air car­rier flights. In 2010, NTSB re­ported only 14 ac­ci­dents among ma­jor air car­rier avi­a­tion, none of which were fa­tal. By con­trast, in 2010 there were 13 HEMS ac­ci­dents, in­clud­ing seven fa­tal crashes.

Med­i­cal he­li­copter pi­lots are heroic and driven in­di­vid­u­als who are among the best­trained and high­est-skilled pi­lots in the world and fly what ar­guably are the most danger­ous mis­sions out­side of mil­i­tary avi­a­tion. HEMS pi­lots pos­sess the grit and courage to go forth in danger­ous con­di­tions any time of night or day, in icy con­di­tions or great heat, in storms, in densely traf­ficked ur­ban con­trolled airspace and re­mote un­con­trolled airspace.

Op­er­at­ing with­out the ben­e­fit of for­mal flight plans with take­offs and land­ings in un­con­trolled lo­ca­tions rang­ing from roads to ball fields to the tops of build­ings, the chal­lenges are in­cred­i­ble. Speed is crit­i­cal. But it comes with great risk. In fact, ac­cord­ing to a Univer­sity of Chicago re­port, crew­ing a med­i­cal he­li­copter is the most danger­ous pro­fes­sion in Amer­ica.

Clearly, it takes a spe­cial in­di­vid­ual to ac­cept the chal­lenge. But ac­cord­ing to the In­ter­na­tional He­li­copter Safety Team, the same at­tributes of risk tol­er­ance, con­fi­dence

There is an in­or­di­nate rate of ac­ci­dents within med­i­cal he­li­copter avi­a­tion, with the 2010 NTSB data proof in point.

and dogged de­ter­min­ism re­quired of a HEMS pilot com­monly are the very fac­tors that, when ex­ces­sive, lead to he­li­copter pilot er­ror.

But what com­pli­cates the is­sue of haste to meet crit­i­cal needs is the fact that the ma­jor­ity of HEMS ac­ci­dents oc­cur not when pi­lots are fer­ry­ing a pa­tient to emer­gency treat­ment, but in­stead take place when pi­lots are rush­ing to the scene to pick up a pa­tient, or the trans­porta­tion of or­gans.

NTSB data shows that fully 58% of the 31 med­i­cal flight ac­ci­dents oc­cur­ring from 2007 to 2009 took place when the HEMS air­craft were en route to pick up an in­jured pa­tient, or in­volved or­gan trans­port. Only 42% of HEMS ac­ci­dents oc­curred with pa­tients on board.

Haste and pilot er­ror un­der har­row­ing con­di­tions are ex­ac­er­bated in the case of less ex­pe­ri­enced HEMS pi­lots. Al­though on the whole HEMS pi­lots rank among the most ex­pe­ri­enced and ca­pa­ble pi­lots in the world, NTSB records in­di­cate that flight hours of HEMS pi­lots not in­volved in ac­ci­dents have logged 19 times as much air time in a par­tic­u­lar air­craft as those in­volved in ac­ci­dents.

Since 2005, there has been an in­creas­ing call for greater safety re­quire­ments in HEMS avi­a­tion, fo­cus­ing largely on nav­i­ga­tion equip­ment and flight dis­patch and mon­i­tor­ing sys- tems. We ex­pect to see con­tin­ued progress in that area.

In the mean­time, to re­duce the in­ci­dence of HEMS crashes as well as to ex­er­cise pru­dent risk man­age­ment, here are some steps for hos­pi­tal ad­min­is­tra­tors to con­sider:

Re­view your HEMS con­trac­tor pilot train­ing pro­gram, with a pref­er­ence for pro­grams that not only meet, but ex­ceed FAA com­pli­ance lev­els.

Re­quest doc­u­men­ta­tion of con­trac­tor avi­a­tion risk as­sess­ment pro­grams, and re­view the spe­cific crew check­list pa­ram­e­ters to as­sess risk level of each flight.

Stip­u­late that pi­lots have a min­i­mal level of fly­ing hours on the spe­cific type of air­craft to be used in life flight op­er­a­tions. Stip­u­late that pi­lots have a cer­tain level of mil­i­tary fly­ing ser­vice, or equiv­a­lent civil­ian train­ing.

Re­view pilot his­to­ries and en­cour­age con­di­tion-spe­cific train­ing that cor­re­sponds to lo­cal con­di­tions.

To limit claims against your hos­pi­tal or or­ga­ni­za­tion, en­sure that your HEMS con­tracts con­tain solid in­dem­nity pro­vi­sions.

Al­though the hu­man con­se­quences of a fa­tal med­i­cal he­li­copter crash are clear, there’s less recog­ni­tion of the mas­sive risk of lit­i­ga­tion, which while prin­ci­pally fo­cused on the flight ser­vice com­pany eas­ily can be­come a deep, years-long is­sue for the con­tract­ing hos­pi­tal or­ga­ni­za­tion.

HEMS op­er­a­tors are the first line of de­fense in one of the great­est chal­lenges of emer­gency care, op­er­at­ing un­der dili­gent train­ing ex­e­cu­tion and best prin­ci­ples of safe flight as es­tab­lished by the Fed­eral Avi­a­tion Ad­min­is­tra­tion and con­trac­tor safety poli­cies. How­ever, perfection is an as­pi­ra­tion, and rec­og­niz­ing the record of ac­ci­dents, hos­pi­tal or­ga­ni­za­tions should look be­yond smart­phone bans to limit the oc­cur­rence and risk of med­i­cal he­li­copter ac­ci­dents.

Scott Brooksby is a part­ner with Ol­son Brooksby in Port­land, Ore., which has an ac­tive avi­a­tion and per­sonal in­jury de­fense prac­tice with a fo­cus on

helicopters.

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