He says every patient is a golden trout. We need to go get those trout.

August 20, 2009 9:53 PM

The Deadly Cost of Swooping In to Save a Life (single-page version): Deregulation and America's health care system combine to make medical helicopters increasingly dangerous.
posted by parudox (28 comments total)

It's fun flying in choppers but.
posted by turgid dahlia at 10:11 PM on August 20, 2009

Since 2000... more than 10% of the U.S. air ambulance helicopter fleet crashed.

This is where I would normally say something biting and ironic and clever, but all that's coming to mind is holy fucking shit what in the fucking fuck.
posted by Riki tiki at 10:21 PM on August 20, 2009 [5 favorites]

WTF:

"I'd rather use a carrot than a hammer," said John M. Allen, the FAA's director of flight safety standards. "It's not like we do nothing and then smack them with a rule." ... Allen said the agency has to balance business and safety. "Even one crash is too many," he said. "But there's a fine line on how far does government go to impact business."

I could understand this attitude for some businesses, but these things are supposed to be saving lives. Are the paramedics and nurses, not to mention the patients flying on these things know that the risk levels have been set so high in order to make them more profitable?
posted by delmoi at 10:58 PM on August 20, 2009

"The director of the helicopter program for which Palcic flew called these lucrative patients "golden trout" and pushed pilots to reel in as many as possible."

This 'healthcare', I do not think it means what he thinks it means.
posted by iamkimiam at 10:58 PM on August 20, 2009

lucrative patients

That, right there, is the term that needs to be trotted out every time someone says that the free market is the best way to ensure good health care.
posted by The World Famous at 11:05 PM on August 20, 2009 [14 favorites]

Holy fuck. But seriously, why are helicopters being used to shuttle non-urgent patients 60 miles between hospitals? By the time they've spooled up to running RPM, they've probably burnt more fuel than the ambulance would use.

Not that ambulances run on avgas, but you get my drift.
posted by pivotal at 11:10 PM on August 20, 2009

You know, maybe all those anecdotes add up to a serious problem. But the first-page statistics don't really justify the sensationalistic headline:

What began almost four decades ago as a way to save lives is now one of the most dangerous jobs in America -- deadlier than logging, mining or police work -- with 113 deaths for every 100,000 employees, The Post found. Only working on a fishing boat is riskier. The rate for airline pilots is 80.1.

So, according to this article, this deadly industry has a mortality rate of 0.113% per annum, as compared to the widely-considered-safe profession of airline pilot, which has a mortality rate that is ... only a third lower (0.08% per annum, per the article).

Considering that the job requires lots of night/low-level/adverse-weather/improvised-field flying, a 1-in-900 annual mortality rate for aircrews doesn't really sound outrageous at all. Especially when you consider that, for the average American, just the act of driving a car carries a 1-in-6000 annual mortality rate.
posted by Wufpak at 11:34 PM on August 20, 2009

But seriously, why are helicopters being used to shuttle non-urgent patients 60 miles between hospitals?

So I can get my NASCAR tickets -- duh!
posted by PeterMcDermott at 12:01 AM on August 21, 2009

posted by pivotal But seriously, why are helicopters being used to shuttle non-urgent patients 60 miles between hospitals?

Because suicide is painless. It brings on many changes--and I can take or leave it, if I please.
posted by mattdidthat at 12:58 AM on August 21, 2009 [8 favorites]

"We've been killing ourselves the same way for 20 years," said veteran pilot Ed MacDonald. "There's not a whole lot new about these crashes."

The meh is coming from inside the post!

Good post, regardless of MacDonald's comment.
posted by Kirth Gerson at 3:51 AM on August 21, 2009 [1 favorite]

A friend of mine cut off his finger with a band saw once. His dad drove over in five minutes, they packed the thing in ice, and they were at the St Mike's Hospital in Santa Fe where he lived within ten.

When they got there, he was told that, unfortunately, although St Michael's was the only hospital in a town of 70,000, they didn't really have a surgeon who could handle that, so he'd have to be taken to a hospital in Albuquerque 60 miles down the road.

"Fine," my friend's dad said. "I'll pull the truck around and..."

"No, this is urgent," said the people at the hospital. "We can get him there faster."

"In an ambulance?"

"No," they said. "We have a helicopter; it takes an hour to drive, but it's only about twenty minutes to Albuquerque by helicopter, so we'll save a lot of time."

My friend was really in no mind to argue too much (drugs setting in by then and all) and his dad figured they'd better do what the hospital was recommending. So they sat down to wait for them to fuel it up and get prepped.

An hour and a half later, they called down to say that the helicopter was ready to go.

It's been three years; my friend's pretty happy about the fact that he'll finally be finishing the payments on that $50,000 helicopter ride next year. (He actually got quite a bargain, he says - insurance helped out a lot.)

I live in Colorado. In fact, I live about ten blocks from a hospital with a helicopter pad, and I pass it every day on the way to work. I know that there are situations where a patient must be moved to save a life; but I really can't shake the idea that, nine times out of ten, a helicopter is a shitload more trouble than it's worth. What's the point? Do we really have such horrendous geographical distribution of capable doctors? Why are we jetting around like this?

I know one thing: if they ever tell me to just wait while they get the helicopter, I'm grabbing my keys and running for the door.
posted by koeselitz at 4:52 AM on August 21, 2009 [24 favorites]

Helicopter pilots are, in my experience, a very special breed of crazy.

The idea that helicopters can be used to swiftly transport critically injured patients to trauma centers and other hospitals grew from the experience of surgeons and pilots during the Vietnam War.

Well, the adage goes that there are old pilots and bold pilots, but no old, bold pilots. I wonder if a lot of these crews are living out a little machismo, heroism-laden fantasy by taking extreme risks. By the nature of the business, there's a certain level of readiness that must be maintained, which would preclude things like doing a full pre-flight inspection before rushing off to an accident scene.

In effect, the FAA and Transportation Department treat the companies the same as low-fare carriers to Disney World

This is... not true, I think. Spirit Airlines is much more regulated than your local medevac (as the author states just above this line, air carriers have much more required equipment to carry).

Anyway, it's an interesting situation. As far as revenue-generating flights go (commercial airlines and charters like medical helicopters), the FAA believes that, in general, companies have incentive to be safe because passengers will not willingly fly on unsafe airplanes. If you have a bad safety record, you go out of business. This is a generality, and the FAA does impose very stringent failure rates on equipment and very high levels of qualification necessary for crews.

The problem here is twofold, I think - first, medical helicopters are not "scheduled air carriers", which means that they are held to less stringent safety standards. I'm not talking about rotor blades held on with chewing gum; it's a matter of failure rates on the order of 10e-9 versus 10e-7, both incredibly small numbers. Second, they don't generally have "willing" passengers. It's not like you can turn the helicopter away and request another one at an accident scene. So, the companies are willing to accept extra risk because the negative consequences - loss of business due to bad reputation from bad safety records - aren't really there.

The article also mentions how most medevac flights are done under visual rules, and that's true. Helicopters in general do not fly IFR - it requires two pilots and most helicopters are not equipped for it. And really, there's not much point - minimums for helicopters are much lower than for airplanes, and if it's so bad that you need to fly an IFR approach at the heliport, how the hell are you going to land on a highway next to a car crash?
posted by backseatpilot at 5:18 AM on August 21, 2009

I have no doubt that, as in any system, there are abuses. koeselitz's friend's ride, for example, makes me want to scream. If it was really a 20 min flight, let's be very generous and say that it was 1 hr of total flight time for the helicopter's round trip. There is no way on Earth that should cost $50k. He probably rode in a roomy, turbine-powered ship. Even if it costs ten times what a small, piston-powered helicopter costs to operate, which already seems excessive, we're only up to about $2000 to $3000 per hour. Sometime is seriously wrong to be charged another order of magnitude about that.

Now, having said that, I would encourage you, in an idle moment, to occasionally look around and ask: "If I had to land a helicopter here to evacuate a critical case, where would I do it?" All of the sudden you'll see hazards EVERYWHERE. Wires mostly, which are notoriously hard to see from the air, and trees and buildings and stuff. It's a real challenge to stuff a large, delicate flying machine into most places other than a big empty field. So yes, get angry at the abuses, but spare a thought for pilots and EMTs and nurses who will put themselves at risk to get your smashed up self to a trauma unit after a bad car crash.
posted by LastOfHisKind at 5:50 AM on August 21, 2009

Seems like the sort of thing a few firm-killing civil suits with long, drawn-out discovery could fix.
posted by ROU_Xenophobe at 6:05 AM on August 21, 2009 [3 favorites]

The rate for airline pilots is 80.1 [deaths per 100,000 workers]

I'm really suspicious of this number. This sounds much more like the rate for commercial pilots, which is not nearly the same thing as being an "airline" pilot. You have to be a commercial pilot to do just about any sort of flying work-for-hire, including a lot of stuff done with helicopters. This CNN article from 2003 was the first convenient one I found, and it definitely gives a number like this for all commercial pilots, not airline pilots.

Helicopter flying really is a lot more dangerous than fixed-wing flying, in general. Partly it's because the actual flying task itself is much harder. A friend of mine who learned to fly helicopters put it best with this apparently old quote: "There are three rules for making a smooth landing in a helicopter. Unfortunately, nobody knows what they are."

The environment in which helicopters are expected to operate is also far less controlled than would be considered appropriate for fixed-wing operations. As long as they are expected to conduct takeoffs and landings in areas cluttered with very nearby obstacles, their accident rate will likely always be very high. They would do much better if they only had to take off and land at airports, and the rest of the time could be thousands of feet up. But then what's the point of having a helicopter?

I suspect here in Ontario the situation with medical helicopter flights is a little different, in that while the operators in some cases might be private companies that make some money on the deal, the parties who pay the bills (health care system) are also the ones making the decision about when to use a helicopter. They seem to get used in cases of serious traffic accidents where the resulting traffic snarl would make it hard for a regular ambulance to get there and get out again, and in accidents that occur far from hospitals where transit time really would make the difference between life and death.
posted by FishBike at 7:02 AM on August 21, 2009 [1 favorite]

LastOfHisKind: If it was really a 20 min flight, let's be very generous and say that it was 1 hr of total flight time for the helicopter's round trip. There is no way on Earth that should cost $50k. He probably rode in a roomy, turbine-powered ship. Even if it costs ten times what a small, piston-powered helicopter costs to operate, which already seems excessive, we're only up to about $2000 to $3000 per hour. Sometime is seriously wrong to be charged another order of magnitude about that.

I agree completely - and yet you should know that $2000 is a common one-hour fee for a normal ambulance, never mind the helicopter variety.Whenever I ask about this I'm told that it has to do with high liability and the cost of operating the equipment, but I'm still dubious. Medical transport in general is so ridiculously expensive in this country that it's a wonder to me that the helicopters seem to be thriving far beyond how much they ought to be; I know that we'll always have them, and I know that flying a helicopter is naturally a bit less safe than a plane or car, but to me that means we should use as few as possible, and it doesn't seem like we're doing that. Emergency site-to-site transport only, that's what I say.
posted by koeselitz at 7:37 AM on August 21, 2009

It's been three years; my friend's pretty happy about the fact that he'll finally be finishing the payments on that $50,000 helicopter ride next year.

Jesus Christ; I'm honestly speechless. I use hyperbole a lot but I'm being serious when I say that's one of the most disturbing things I've ever read here.
posted by XQUZYPHYR at 7:52 AM on August 21, 2009 [1 favorite]

See also: all of private EMS.
posted by inoculatedcities at 7:53 AM on August 21, 2009

What's the point? Do we really have such horrendous geographical distribution of capable doctors? Why are we jetting around like this?

In fact, yes. Sort of. For example, if you were to suffer a serious, life-threatening traumatic injury, your choices in Colorado are: Denver Health Medical Center or Saint Anthony Central Hospital in Denver, or Swedish Medical Center in Englewood. That's it.

Presenting a serious but viable trauma patient to anything less than a Level I Trauma Center (as defined by the American College of Surgeons) is substandard care because Level IIs and IIIs may not have the appropriate staff, equipment, surgical suites, etc. The same goes for burn victims and potentially lethal pediatric emergencies; EMS has to bring the patient to the appropriate facility, not just any place that has some doctors in it.
posted by inoculatedcities at 8:00 AM on August 21, 2009 [1 favorite]

Did you know the typical recommended maintenance ratio for a turbine ship is about 4:1? That is four hours of maintenance per hour of flight. There's a reason that there are large crews assigned to the maintenance of a single military rotorcraft. There's also a reason that the mechanics that work on helicopters are generally of a very high caliber.

Do you think that all of these private ships are competently maintained to the levels that are assumed during the design of the craft? I, for one, doubt it.
posted by bz at 8:33 AM on August 21, 2009

Interesting article. I actually know the LifeFlight of Maine guy quoted in the article. (Not very well or anything, but we've met. He's a good guy as I recall. Almost got to take a ride on one of their birds down to Boston Children's a few years ago when I was doing clinical time at CMMC, but—ironically—they scrubbed the flight due to bad weather.)

I have mixed feelings about the issue. There does seem to be an overreliance on helicopter transport, which probably boils down in large part to the air ambulance companies wanting to make money. That is bad, and if it's influencing go/no-go decisions then it really needs to stop. But it should be understood that there's a financial aspect to other flying-related industries, too: if Delta cancels a flight, that has a cost to them. It may not be as direct as when LifeFlight doesn't go out on a call, but it's still a cost. I'm sure there are other industries where the costs are as direct. I'm not sure that it's necessary to remove all financial incentive in order to improve safety—and that's even assuming that you ever could remove all financial incentives, which I think is unrealistic. What we need to do is make sure the people whose asses are on the line are the ones making the call of whether to fly or not, and that they're not getting bullied by some asshole on the ground who only cares about making numbers.

But once we do that, we need to step back and let those people make the call, and not second-guess them. Air rescue services are always going to be inherently dangerous. Hell, flying in a helicopter at all is always going to be somewhat more dangerous than to fixed-wing aircraft, just because of the nature of the machine. (They're much more complex, mechanically, and although they can autorotate and land without power, there are just a lot more things to go wrong and they're more difficult to fly. I can't think of any heli pilot who would claim differently with a straight face.)

I'm not sure that it's automatically indicative of a problem that flying in an air ambulance is one of the most dangerous professions around. It might just be that it's an inherently dangerous job. If we're willing to let people go out and take significant personal risks for goddamn fish in the Pacific, then we certainly should let people greater relative risks when what they're doing is unquestionably saving lives.

And that, I think, gets lost a bit in the article. A fair number of people have gotten killed in medical helis over the years. But a far, far greater number of people are alive today because of helicopter transport than have died in them. That's the metric that you need to look at; comparing flying rescue helicopters to logging or fishing is stupid. If you tell people that they can't log or fish, you end up without lumber or fish at the end of the day. If you take away air ambulance service, people are going to die, or are at least going to have worse outcomes. All decisions about medical helicopter service needs to be viewed through that lens.

We need to make sure that helicopters are being used prudently and that their inherent risks are minimized and factored into the decision to use them, but treating them and the people that fly them like any other occupation does a disservice to both the personnel who fly and to the patients they serve.
posted by Kadin2048 at 11:13 AM on August 21, 2009

"No," they said. "We have a helicopter; it takes an hour to drive... An hour and a half later, they called down to say that the helicopter was ready to go.

D-oh.
posted by five fresh fish at 11:35 AM on August 21, 2009

There are few cases where a helicopter can get a patient to the correct hospital faster than an ambulance in a situation where the difference in speed actually matters. Most actual emergency cases are either doomed from the beginning no matter how quickly they get to the hospital (e.g. sudden cardiac arrest) or not particularly time-sensitive (i.e. on a scale of tens of minutes).

In the case of extremely rural areas, for example, there is often no good place for the helicopter to land, so the patient must be transported to an appropriate landing area first. If the transporting ambulance has to come from far away, then that time tends to overwhelm the speed gain from the helicopter leg of the trip.

For the most part the private helicopter ambulance business is about selling peace of mind to people who don't know any better. Does it ever help? Sure. Is it worth it for the cases it does help? Probably not in its current (private, poorly-regulated) form.

The whole thing smacks of the days when ambulances used to speed like maniacs trying to get patients to the hospital faster. Then they realized that, on the whole, doing that was killing more people in crashes than it was saving.
posted by jedicus at 11:44 AM on August 21, 2009

In the case of extremely rural areas, for example, there is often no good place for the helicopter to land, so the patient must be transported to an appropriate landing area first. If the transporting ambulance has to come from far away, then that time tends to overwhelm the speed gain from the helicopter leg of the trip.

It's not like people just wait around at the scene for the heli to arrive, though, in the case of very rural areas. Up in Maine, it's fairly common for the local rescue squad to begin transport, and then meet the LifeFlight heli out of Lewiston or Portland somewhere en route. This is common to the point where they have known landing sites in some areas to meet at.

They generally try to pick a landing area that's about as far away, driving-time, as it takes to get the heli in the air and for it to fly to that location.

It actually works pretty well. The local service will go to the scene and begin transport, and will send someone on ahead to the LZ as soon as they know or think that they're going to get LifeFlight. That person will light flares or a strobe and generally make sure the landing area is clear. If all goes well, the heli and the truck get to the location at about the same time, they do a quick handoff, and away they go.

I can't claim to ever have been involved in one of these personally (because I worked in Lewiston, which is right next to CMMC), but it was a common thing to discuss in training, and my understanding was that it happened with reasonable frequency. They also sometimes flew people direct down to Boston (I think most frequently to the burn center, but also in one case I'm aware of, to the hyperbaric chamber at Tufts due to CO poisoning, which happens a few times a year apparently). That's a capability that you really wouldn't have with ground ambulances, at least not nearly as rapidly.
posted by Kadin2048 at 12:12 PM on August 21, 2009

Re: So, according to this article, this deadly industry has a mortality rate of 0.113% per annum, as compared to the widely-considered-safe profession of airline pilot,

Annual age-adjusted all cause mortality rates (per 1000 workers) were highest for roofers (13.1) followed by painters (12.5) and airplane pilots (11.3).

I think you might be assuming that airline pilots refers to flyers of large commercial aircraft for major carriers. The majority of deaths are among smaller aircraft pilots.
posted by Mental Wimp at 1:12 PM on August 21, 2009

The former chief of surgery at the university that employs me was a world famous transplant specialist (he has since been deposed after exposure of his neglect of FDA regulations and dishonest accounting practices, and double dipping). His sole reason for acquiring a heliport and 'copter on the top of the hospital building was purely competition with other tertiary referral, academic medical centers. Keeping up the Dr. Joneses. It doesn't upset me in the least that these things are worthless at saving lives and take off from the roof just across the way from my office and are so damn loud...
posted by Mental Wimp at 1:18 PM on August 21, 2009

Choplifter agrees.
posted by RobotVoodooPower at 10:05 PM on August 21, 2009

Remember Airwolf? When the show finished the chopper eventually ended up as a medical helicopter in Germany... where it crashed killing three people. (But not before some guy had sex with it...)
posted by fearfulsymmetry at 1:39 PM on August 22, 2009