Friday, July 23, 2010

Please Don't Call Them Heroes

Please don’t call them “heroes” or “fallen angels” or any of that other pap. Last night, pilot Allan Dale Harrison and flight nurse Ryan Duke were killed in the crash of an air ambulance in Kingfisher, Oklahoma. Their flight paramedic was injured.


Shortly after dropping off a patient at a hospital about 7:30 yesterday evening, the helicopter went down into a rural area and caught fire. Unlike the majority of helicopter crashes, the flight was being operated in daylight and in clear weather. It’s too early to know what caused the accident. But please, please, please, air crash investigator, when considering the factors that contributed to this latest air ambulance accident, take a broader look at whether this industry is it’s own disaster.

In the December 2009 issue of Emergency Physicians Monthly (What, you don’t subscribe?) three doctors put it bluntly. What if, several times a year there was medical procedure that - when it went wrong - killed the medical team along with the patient? There would be an outcry, the doctors say. Things would be scrutinized, things would change. Yessir! BUT, here is their point, “Although such a scenario may seem outrageous, it is essentially the same risk that helicopter EMS crews face on a daily basis,” and it is the only medical procedure that is more likely to kill the medical provider than the patient.

Ok, so Drs. Bledsoe, Abernethy and Carrison surely got the attention of the emergency room physicians with that opening paragraph. I wish I’d written it. But how to get the attention of everyone else, everyone who continues to believe that air ambulances are a benevolent public service, offering valuable time-saving transport for the critically injured and that the cost of saving these lives means that a few paramedics or pilots will die every now and then.

I want to take another stab at altering this perception because I think it is dangerous. I think the facts are persuasive enough to get the public past the dramatic made-for-TV-movie version of the story.

1. Helicopter medical transport is a multi-billion dollar industry.

2. It makes its profits by putting people into helicopters.

3. It maximizes profits by cutting costs.

Putting patients into helicopters begins with convincing the public that faster is better. For years we've been hearing about the "Golden Hour" that critical time between injury and medical treatment that is the difference between life and death. A number of published emergency physicians think its a myth. (Read more about this here and here.) Nevertheless, we are convinced that speed equals better outcome. Thus we expect that everything from car crashes to broken bones, are worthy of a trip to the hospital by air. The next thing you know, every fire department, rescue unit and hospital is partnering with an air ambulance provider to bring in the casualties.

Like a well-powered rotor the air ambulance industry spins into an ever bigger enterprise, requiring ever more riders. In 2009, nearly half a million people in the United States were moved by air ambulance. Since 2002 the number of helicopter ambulances has quadrupled. Score a big one for the companies; an addiction to helicopter transport has been achieved.

But business success depends not only on generating revenue - costs must be controlled too. Oh yeah, it’s a challenge to operate helicopters and employ highly trained aviation and medical professionals while keeping a tight hand on the checkbook. On the other hand, air ambulance operators are in a unique situation. The rates they charge aren’t linked to the quality of the equipment they use or the personnel they hire.

Say what? That’s right, a company using an old single engine aircraft with a low-time pilot and fresh-out-of-school medical crew gets paid the same as a company with a brand new, twin-engine, two pilot, highly experienced nursing team on board. (And since you were probably wondering, that’s about $8,000 - $16,000 per flight. More on who gets to pay the tab in a future blog.)

So not unexpectedly, the vast majority of helicopter operators in the United States are flying single-engine, single-pilot helicopters. Safety equipment like terrain awareness, auto-pilot, or night vision goggles are left to each operator’s discretion, who’s feelin’ generous?

So please don’t call the casualties “heroes” or “fallen angels”. Call them evidence that the public has been bamboozled into believing we need to be flying around by air even when the injury is not life threatening, just in case. And call them victims of an industry that’s off-the-radar, fueled with cash and powerfully incentivized to keep on doing it just this way.
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