Recent crashes highlight risks that come with medical helicopters
Providers at great liability risk, must take precautions
(Editor's note: This is the first in a two-part series about the hidden risks and liabilities of medical helicopters. This month, Healthcare Risk Management explores the risks and reviews recent crashes. Next month's issue will provide more advice and profile one hospital that has revamped its medical helicopter system after experiencing two crashes over several years.)
A medical helicopter can be invaluable when desperately ill or injured patients need to be transported quickly from remote locations, but risk managers may underestimate the liabilities that come with those benefits. Even a well-run air ambulance program carries significant risks simply by the nature of the activity flying a helicopter in less-than-ideal situations and a program that is not optimized in every way can increase those risks exponentially.
The past year has highlighted the risks and the tragedies that can result when a medical helicopter crashes. Thirty-five people were killed in nine medical helicopter tragedies in 2008, the deadliest year ever for such crashes.
Federal regulators are concerned. The National Transportation Safety Board (NTSB) is focusing on a series of recommendations it has been pushing since the January 2006 release of its call for tighter restrictions on medical helicopters. The Federal Aviation Administration (FAA) is responsible for implementing those changes, but in October 2008, the NTSB board called FAA progress on the recommendations in the last three years "unacceptable." The NTSB is holding a three-day hearing in February to discuss the recent spate of accidents and possible improvements.
The cause of the recent surge in medical helicopter crashes is not yet known. It could be coincidence, experts say, but it also may be that the growing number of medical helicopters is making flaws in the system more apparent. The number of air ambulance programs in the United States has climbed from about 100 in the 1980s to more than 900 now, according to several sources. Some of those medical helicopters (and airplanes, in some instances) are owned and operated by hospitals, while others are operated by independent companies that lease their services to the hospitals.
The NTSB has investigated 65 fatal medical helicopter crashes since 1989. Those data revealed that two-thirds of the helicopters began the mission at night and half in inclement weather or with reduced visibility. The NTSB found that the most common nonmechanical cause for air ambulance crashes was a collision with obstacles, such as mountains and power lines, often related to the weather conditions. Pilots in 21 of the crashes flew too low or directly into terrain. Ten of the pilots were disoriented by fog, snow, or rain.
A majority of the fatal crashes occurred on the way to pick up a patient, rather than on the return. This is an important finding, because current FAA regulations allow helicopters carrying only crew members to fly under less stringent flight rules than those with patients on board.
Some flights unnecessary
One of the most troubling aspects of the medical helicopter crashes is that the flights were sometimes unnecessary. Emergency personnel on the ground often are eager to call on the helicopter because they think, with the best intentions for the patient, that the faster transport will save lives. That is undoubtedly true in many cases, but not always.
Academic studies have concluded that, in many cases, a patient's injuries were not serious enough to have required the faster transport. And even in some serious cases, a medical helicopter actually may offer little or no advantage over ground transportation. It can take time to dispatch the helicopter, find a landing site, load, and return, but one important factor often overlooked in risk/benefit analyses is that the ground transportation still is used in many cases. Many patients are injured in locations where the helicopter cannot land close by, so it lands elsewhere and a ground ambulance takes the patient to the aircraft. Then the helicopter flies to a hospital that does not have its own landing pad, so the helicopter lands in a parking lot or on another building nearby and the patient is loaded into a ground ambulance again.
After all those delays, sometimes the patient would have been better off just taking ground transport, studies have found. In one 1998 incident, a helicopter crashed while en route to pick up a truck driver injured in an accident near La Gloria, TX. The pilot and two technicians were killed. Even after the delay caused by waiting for the helicopter that never showed up, the truck driver fully recovered after being taken to a hospital by a ground ambulance.
There also is concern that medical helicopters are overused and flown in overly dangerous conditions because of financial pressures and marketing concerns. When a hospital spends millions on its own helicopter or the costs associated with outsourcing the service to a charter company, there can be substantial pressure to use it either to recoup costs or simply due to the line of thinking that because the facility has it now, the helicopter should be used. If the facility owns the helicopter and has its logo emblazoned all over it, there can be pressure to use the helicopter as a marketing tool, to get it out there in front of the television news cameras.
The flight crews, who must make the final decision whether to fly in adverse conditions, often feel pressure to take risks because they think a patient's life is at stake. Many pilots will fly "mercy missions" under conditions they never would risk otherwise. And they sometimes are eager to log more flight hours.
All of those factors can result in a medical helicopter flying in conditions that result in a tragedy.
Substantial liability risks
Health care providers face substantial liability from any lawsuits following a crash, says Don Maciejewski, JD, an aviation attorney with the Jacksonville, FL, law firm of Zisser Robison. He also is a certified aircraft accident investigator, and before practicing law, he was a U.S. Army helicopter pilot. He now specializes in litigation related to helicopter and airplane crashes.
Though 2008 was a particularly bad year for medical helicopter crashes, Maciejewski says medical helicopters always have had a higher accident rate than that of military or nonmedical civilian helicopters. Risk-taking explains the disparity, he says. The crews flying medical helicopters take more risks, often flying in more dangerous conditions, he says.
"2008 was bad, but it's a trend," he says. "What happens is you have a patient who may not really need urgent transport, you make the decision to fly in crummy weather, into an area that may have all kinds of hazards wires, mountains and you fly the mission at night. So instead of one person injured, you end up killing four people the pilot, co-pilot, nurse, and patient."
Maciejewski points out that the risks are not uniform. For a hospital in an area with flat terrain, good weather, and its own landing pad, the risks will be lower than for a hospital in a mountainous region, frequently beset with fog and storms, and with no dedicated landing pad at the hospital. The recent accident of two helicopters that crashed into each other near Flagstaff (AZ) Medical Center illustrates how medical flights can be far more hazardous than other aviation. In that incident, two medical helicopters were approaching the hospital to land and simply crashed right into each other. Medical helicopters take off and land without the aid of air traffic control, and Maciejewski says the only possible explanation he can imagine is that the pilots were overeager to land what they thought were critical patients and became distracted.
"There's this false sense of urgency when you don't have critical patients on board," he says. "That's what's driving this trend."
Once a tragedy occurs, the hospital's liability will depend in part on whether the helicopter was owned and operated by the hospital or leased from a separate company. The most common scenario is that the aircraft is leased, the flight crew are independent contractors to the hospital, and the medical personnel are employees of the hospital, he says. If leased, much of the liability will fall to the helicopter owner and not the hospital, but that does not mean the hospital gets off scot-free.
"A lot of times we find that the insurance of the leasing company is inadequate, particularly when someone is catastrophically injured or killed, to compensate the family for that loss," Maciejewski says.
Risk manager must step up
Steve Marks, JD, an attorney with Podhurst Orseck in Miami and one of the nation's leading aviation attorneys, cautions against contracting with local helicopter pilots for ad hoc flights. This can be tempting, particularly for smaller rural hospitals that can't afford their own helicopter services.
"Sometimes a local helicopter pilot will offer to do an emergency flight for a few hundred dollars whenever you're desperate, and it can sound like a good idea. The pilot's trying to be a Good Samaritan, and you're trying to save your patient," he says. "Don't do it. It's easy to lull yourself into thinking it's safe and fine, but it can go terribly wrong and then you're the one responsible in the aftermath."
The downside of having a medical helicopter often is underestimated, Maciejewski says. In the excitement of being able to get such a high-profile, life-saving service, the risks can be minimized. Part of the reason is that people apply the same mentality to medical helicopters that they apply to commercial air travel: "Sure, accidents do happen and they're tragic," they think, "but they are so rare that there's no need to worry about it."
That is not the case with medical helicopters, and Maciejewski says it is the risk manager's responsibility to explain the facts.
"We see hospitals go out and get a helicopter and think, 'Wow, it's a great marketing tool; we've got to use it as much as possible, and our PR is going to go through the roof,'" he says. "The risk managers aren't involved. The [individual] who has the master's degree in safety and risk reduction has to step up and say, 'Wait a minute. There's a lot of liability here. There's a lot of crashes.'"
Sources
For more information on medical helicopters, contact:
Don Maciejewski, JD, Zisser, Robison, Brown, Nowlis, Maciejewski & Cabrey, Jacksonville, FL. Telephone: (904) 353-3222. E-mail: [email protected].
Steve Marks, JD, Podhurst Orseck, Miami. Telephone: (305) 358-2800. E-mail: [email protected].
Jeffrey Kroll, JD, The Law Offices of Jeffrey J. Kroll, Chicago. Telephone: (312) 676-7222. E-mail: [email protected].
This is the first in a two-part series about the hidden risks and liabilities of medical helicopters.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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