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.


Anonymous said...

While I don't disagree with a few of your observations Christine, I do feel a majority of what you've cited is misunderstood and misleading. The perception of the three ED physicians you mention does not represent the majority of ED physicians, nor thousands of specialty care physicians who would argue otherwise.
And while the air medical transport industry has seen a shift in business model changes in the last decade, the vast majority of programs and operators are CAMTS accredited and/or consistently meet and often exceed FAA requirements. This includes upgrading aircraft and adding safety enhancements like night vision goggles and terrian avoidance devices. These and other devices and federally regulated and implementation is a bit more complex than installing a new car radio is your Prius.
As someone who has been actively involved in critical care transport over 20 years, I can share countless examples as well as testimonials of when patient transport by helicopter or airplane ultimately made a difference in the patients outcome. Additionally, as someone who currently manages a critical care transport program that includes helicopter, fixed wing and ground transport, I extend an open invitation for you to spend a day with our program. Although our program alone is not a reflection of the industry as a whole, I'm confident we'll clear many of your misconceptions and help you understand really why we do what we do.

Dustin H. Duncan, RN, CEN, CMTE

Anonymous said...

Hugely worrying industry; but why is this only seeming to be a problem in the US? The UK for example has EMS flights but it appears to be better funded equipped, and regulated. Are they for profit? What of single pilot into hazardous landing areas. Fatigue must surely be an issue on some of these flights...

EMS flights are more dangerous to fly in than any other type of flying t seems. That's ridiculous.

Take me by road...

Anonymous said...

How about don't call you a journalist!!! Seriously, your major points of reference in defending your disgraceful attempt to profit from these heroes is a wikipedia reference and a single Class II (poor-moderate clinical significance) review. Even if your one piece of actual clinical review has merit - it was a retrospective review of EMS crews that were employing the Golden Hour concept in some form on critical trauma patients. Oh, and by the way the whole Golden Hour isn't really that relevent in this case. The pt was at an outlying facility waiting for transport to DEFINITIVE CARE. Look that term up miss journalist. I doubt you will find any clinical research defending delays in definitive care for critical trauma patients.
Yes, air ambulance transport gets overused and abused. Yes, ALL AMBULANCE TRANSPORT SERVICES get overused and abused. Here is a reference for you... . So, if a ground ambulance crashes and care providers die are they less of heroes if the person calling them wasn't critical? Or if a EMT/Paramedic/Firefighter/Police Officer is killed because someone was rubbernecking on the highway at an accident and hit them, are they just in it for the money then? So they are not heroes? Well then none of us are. We are just selfless, underappreciated, attacked, abused, vomited/bled/crapped/urinated on, underpayed cot jockeys trying to "bamboozle" you into going to a hospital because some doctor there might actually save your life. If you don't like our Golden Hour why don't you try one for yourself. Next time you write a story, take an hour and think about the Golden Rule (do unto others as you would have them do unto you - just in case you hadn't heard it before).

Anonymous said...

Great write up, except for the fact that you quoted a few doctors who have no love lost for HEMS.But,by and large, a pretty accurate perception.
The operators need to focus on the three T's of HEMS.Temparemnt: not all helicopter pilots are a good fit for this job. Hire theright ones,and pay them well. You should do some research into the average pilot starting salary in HEMS and you will find some interesting facts.Certainly the poorest paid in the world butnot very well paid in comparison to other 135 operations either.
Training: realistic, repetiive and regular training is rare amongst operators and can vary dramatically from one company to the next.
Technolgy:how much is too much? After all, the aircraft have to have the capability to lift all teh bells adn whistles.However, a bare minimum is at times too expensive for companies to invest in.
Unless the companies (not the FAA) self regulate and pay attention to thse issues,teh lowest bidder will continue to be the big winner and lives will be at stake.

Anonymous said...

The truth of the matter is that these flight crews should be called Heroes as well as VICTIMS. They are victims of money hungry for profit companies who constantly try to walk the line between safety, and an extra stock option.

The work of the flight crews is admirable and their work is heroic. Sadly they are victims as well.

Your sources are tainted at best. You need to broaden your horizons and speak to some other doctors. These are the only three sources who seem to consistently come out against HEMS.

I have seen far more cases of lives saves than lives lost as a result of HEMS.

Bottom line is if you want to make a change, go after the CEO's of the companies and force them to answer the questions. Do NOT let Aaron Todd from Air Methods send his cover up Craig Yale to slither their way around facts. Force Aaron to stand up and be accountable. He may be hard to reach because he's probably off optioning more stock at the moment, but be persistent. Do not let off of these guys. USA Today dropped the ball a couple of years ago. Help us to force the big air medical providers to make changes. Hold people accountable and badger them until they provide truthful answers and not the cover ups that they got by with a couple years ago on capitol hill

Anonymous said...

Another crash last night in Tucson. This is bloody madness. A common theme seems to be lack of a second pilot - would you get on an airliner if it only had one pilot?

Anonymous said...

why would a second pilot be needed? just so the body count goes up? EMS Air transport saves more lives than ever but that gets left out. just like airliners, no one talks about how many people were transported but how many people died in the 1 out of a million flights. christine your humble opinion is sadly mistaken!

Christine Negroni said...

Here's why a second pilot is needed. Flying a helicopter is more difficult than flying an airplane, and EMS helicopters often do not have the kinds of equipment that assist a pilot like auto pilot, terrain avoidance and wire strike alarms.

The pilot is busy from start to finish and to this already higher workload you can add a 24/7 flight schedule, lack of a weather information for the route or destination, operations in and out of non standard landing zones including rooftops, highways and parking lots and flights that take them through obstacles and obstructions.

Of the more than 200 accidents over the past 20 years, one in of three - involved the aircraft hitting something. How much help would a second pair of pilot eyes have been? Well, with the exception of a pilot-check ride in Michigan several years ago, all the others were operated by a single pilot.

Medical helicopters in Canada and air rescues conducted by the U.S. Coast Guard already require two-pilots. What do they know that America's air ambulance operators do not?

Flight Medic said...

While I agree with your basic premise, I feel it's unfortunate that you chose to characterize the entire industry as a for-profit machine. It is undeniable that the for-profit operators have placed their air crews in harm's way for the sake of a dollar; however, there are also non-profit operations that place safety above all. You need look no further than the New England states to see the difference when air medical operators cooperate and support rather than compete with each other.

The other area that I found disappointing is tying air medical to the Golden Hour. While we do offer speed to definitive care, we also offer critical care interventions that can, and do, make a difference in outcomes--as shown in numerous studies. These interventions cannot be performed by ground personnel and often cannot be performed at rural facilities.

So thanks for your interest in making our jobs safer, but please do a little more research before throwing the baby out with the bathwater.

Ditch Doctor Gabe said...

Unfortunately there are a number of services that are strictly for profit and feel pushed to take the flights and it usually ends up making the news. The facts that Dustin mentioned are very true; you have cited one physician who is against the aeromedical industry (Bledsoe), there is a time and place for the helicopter EMS. While there are some patients that after being evaluated at a trauma center are found to have minor or no injuries EMS is justified in calling to have the patient transported to a higher level of care.
I am disappointed that you have only one-sided views and did not interview anyone from the air ambulance industry. Yes the number of patient flights have increased but there are again those folks out only for a profit. There are many services in the states that provide transport that are not in it for the money. Another aspect to look at is that there are services who put the safety of the crews and patients above making a dollar (duel engines, IFR, NVGs which are a tool, terrain avoidance and weather radar, as well as auto pilot). Next time do some research before you begin to blast away at something you are not a part of nor have the knowledge of.

Anonymous said...

Finally! Someone addresses the "same reimbursement for a crappy helicopter, with bare bones clinical and aviation equipment in contrast with brand new, all the bells and whistles, actual room to get to the patient, keep the patient alive and get home!!" issue. The equipment on the control panel and clinical in the back of these community based, for profit jippo jobs is a joke!

I would like to see some statistic that show Hospital not for profit- vs- community based quality (type size and age of heli) (training of crew) (clinical equipment) ( do they make room to transport babies?)(NVG?.

Then the crash statistics for Hospital not for profit VS community based for profit.

These growing for profit outfits have too big a voice. People like myself (medical crew) need to be heard....but who speaks for us? Our large organizations are controled by for profits. Most people who are involved work for them in some capacity. The biggest voice for safety is the NTSB (thankyou so much), and family of dead crew.

If the reimbursment for a flight would reflect the quality of helicopter ect THINGS WOULD IMPROVE! At least level the playing field when two programs are competing for patients. We are feeling the sqeeze as we provide an 8 million dollar heli vs a 2 million, single engine.

Thank you so much for your candid thoughts!

Anonymous said...

You speak like you are from New York and have no clue as to the distances covered by HEMS in rural America. New York has Burn Units, Pediatric ICUs Cardiac catheter labs, etc., around every corner.
In places like Oklahoma, many ground based ambulances are volunteer and lack critical care skills and the staffing to let an ambulance go for hours out of district.

You cannot judge the industry based on a narrow airline industry mentality, as you have. Not all operators are profit oriented. Many, such as my employer, have up-to-date training, night vision goggles, survival training, highly qualified and trained pilots, auto pilot systems and the like. In your narrow analysis, you attack the people who are putting their lives on the line, who are dedicated to health and well being of Joe Public (yes, that's you). The pilots, paramedics, and nurses who climb into an air medical helicopter or plane are dedicated health professionals.

Maybe - instead of insulting those health professionals who lost their lives saving the lives of others, your should have focused on the for profit operators. Shame, shame, shame on you for not having enough respect to recognize the ultimate sacrifice those people made - for everyday people like you.

Before you address HEMS/ Rescue issues, you need to spend a day in our shoes. You, a family member, or dear friend might be the next one to need these services...and wouldn't you be thankful to know that such a quick and qualified response, such as HEMS/Rescue, was the factor that saved their lives?

Bite booger eating moron.

Anonymous said...

Christine -
Did you actually interview anyone involved in flight EMS or did you just interview ER physicians? Any flight nurses, paramedics, or EMS pilots? Your story was so subjective on lopsided and seems to be in a knee-jerk reaction of the recent crashes over the last year. I wonder if you compared them to the amount of ground crew traffic accidents if you would have had a different tone.

OR -

I wonder if you would feel differently if you or your children or loved ones actually NEEDED to fly to a trauma center or a burn center while you were on vacation or something. It is a necessary form of EMS, and it does have flaws - but to attack the reputation of those working in the industry and not the owners of the specific flight operation is pretty low and ignorant to the situation out there in flight EMS operations.

Christine Negroni said...

Either my readers were dashing off on a 9-11 call or I failed to convey my thoughts adequately in this blog.

Let me be clear. --
HEMS pilots and medical personnel do important work and deserve the highest respect. The level of respect they deserve, in fact, is greater than the level of concern they get from a number of air ambulance operators. The reckless disregard for the safety of HEMS crew members and their patients is not acceptable but so long as these workers allow the perpetuation of the myth that they are "heroes" there is no pressure for the industry to change its unsafe ways.

I might add that since I have been studying and writing about the HEMS industry in 2005, I've spoken to dozens of EMS pilots and read hundreds of accident and incident reports. The results of this work has shaped my opinions. You can find a detailed assessment of the work here

Anonymous said...

Ms. Negroni clearly only wants to create a sense of fear and panic among the population. There are more medical crews and patients killed during ground transport than during HEMS operations. She clearly has a personal interest in attacking the air medical community. Her opinions are extremely biased and poorly researched. As a "journalist" she should be ashamed of herself. As for the comment about the UK's HEMS operators, they don't even come close to touching the number of hours flown by American operators. Also, a lot of those companies are sponsored by other companies, such as Virgin, so they make millions of pounds per year whether they fly or not. Ms. Negroni, you have over stepped with your opinions and have somehow managed to make it to a place where you can reach a lot of people with these opinions. For that reason you should put more thought behind what you say. Does HEMS need reform from the government, yes. That they are getting. Does HEMS need reform from you, NO. You should also cease your fear tactics or they will do irreparable harm to the industry, to people that need that service one day, and to insurance rates. Your words very well may end someones life one day.

Anonymous said...

I have worked for a hospital based HEMS for 15 years. 10 years ago there were only 3 helicopters in our state. Now there are 15. We are the one using new IFR twin engine helicopters, and utilizing the IFR ability frequently, NVGs, Isolette for newborns, airconditioning. We have historically only flow level one trauma patients and ICU to ICU type flights. Our competition use 25 year old Bell 206 aircraft, no climate control, underpowered, and transport broken arms and other less acute type patients. I agree our competition is in it for the money and will eventually put us out of business. It will be a sad day because in the end the citizens will suffer when our competition says they cant transport you because you weigh too much, are a newborn or the weather is bad and we dont fly instrument equipped aircraft.

I would like to see reimbursment tied to the age and Conklin & de Decker estimate of airframe operations cost. Then the market and playing field would be even.

Unknown said...


Please post a picture of yourself. That way when your dying at the scene of an accident we "non hero's" will know it's you and won't put you in our worthless helicopter. Not that we hold a grudge, because we don't. We'd save our worst enemies life because it's our duty. We are just wanting to respect your obvious wishes pertaining to air medical.

Christine Negroni said...

Photo appears at right.

Anonymous said...

Your unique vantage point these past 15 years doesn't seem to give you enough altitude to write what you have written here.

This writing/opinion is simply blather from someone who hasn't done much in the way of research. Speaking specifically from the pilot's vantage point:
A pilot does not, cannot look at a patient as a patient, but must keep his/her head in the game and focus on the flying at hand. The medical team in the back is to provide medical services. Pilots do their jobs and do them well. Heroes they all are, along with the medical teams who are transported with the sick or critically injured patients. As for our team, many many MANY parents are quite grateful we were there to transport their newborn babes to a hospital that could provide them the services needed so they could enjoy their wonderful gift of life.

And no, I'm not dashing off on a 9-1-1 call nor am I neglecting a patient or my sleep. Honestly, I don't even want to read yet another article with your name on it such as the address you posted for us to read, because I've seen enough bashing as it is without evidence.

Find something else to report on and make certain you do a bit more research than you attempted here in this article.