Air Ambulances are Under Fire

By KEVIN HELLIKER AND VANESSA FUHRMANS, Wall Street Journal
Published: March 3rd, 2005

Emergency Medical Helicopters Are Overused and Offer Few Benefits to Patients

FOR WEEKS NOW, federal regulators have been investigating the safety record of the air ambulance industry, which has experienced four deadly crashes this year.

But an increasing body of evidence suggests there is a larger question to be asked about emergency-medical air transports: Do they benefit most patients?

The conventional wisdom is that air ambulances save the lives of patients who are too critically ill to withstand a slower ride in a ground ambulance. Yet some observers of the industry say medical air transports actually save very few lives while costing as much as 10 times more than ground ambulances. A number of published studies including research at Stanford University and the University of Texas. show that the flights often transport minimally injured patients when ground transport frequently could get them to a hospital faster, and with less risk to others.

"In 20 years of experience in urban critical-care helicopter transport, I can count on the fingers of one hand the number of times I thought flying a patient to the hospital made a significant difference in outcome compared to lights and siren," says David Crippen, an associate professor of critical care and emergency medicine at University of Pittsburgh Medical Center.

Inspired by images of helicopters evacuating wounded soldiers in Vietnam, the air-ambulance industry took root in the 1970s and has grown steadily ever since. The industry fleet has nearly doubled since 1997, and patient transports are rising an estimated 59% a year, according to Tom Judge, president of the Association of Air Medical Services, a trade group. The current probe of this year's fatal crashes, begun in January, comes as the industry has drawn increasing scrutiny over not just safety, but also efficacy and possible overuse. Also in January, the journal Prehospital Emergency Care published an abstract reporting that a study of 37,500 helicopter-transported patients determined that two out of three had only minor injuries. One of four had injuries too minor to require hospital admission. "The evidence says too many patients are being flown, and yet they keep flying more," says Bryan Bledsoe, a physician who co-authored the Prehospital Emergency Care abstract.

Among other recent research critical of air-transport use, Stanford University trauma surgeon Clayton Shatney conducted a study of 947 patients flown to Santa Clara Valley Medical Center and concluded that helicopter service potentially saved the lives of only nine of them-while potentially serving as detriment to five who could have arrived faster by ground. Travel by helicopter often is slower in urban situations, in part because of a lack of places to land. "In multi-casualty, situations, it has not been uncommon that ground ambulances arrive before an airship with patients from the same event," says the Stanford study, published in 2002 in the Journal of Trauma, Injury, Infection and Critical Care.

To be sure, there are situations where there is little debate that medical air transport has clear benefits, such as in rural areas where patients must travel long distances quickly. Some smaller hospitals that fly patients to bigger facilities say they must err on the side of caution with a patient they aren't equipped to handle themselves. And there is research that shows a value for patients. A 2002 study, conducted by an air medical service in Boston compared patients flown with patients driven and showed a 24% survival benefit among the most seriously injured who were flown. "That's an enormous benefit," says Mr. Judge of the Association of Air Medical Services.

The cost of air ambulances varies generally from $5,000 to $10,000 a trip, and sometimes as much as $25,000, according to industry experts. That is typically five to 10 times as much as ground ambulance. But ground transportation also can be not just less expensive, but faster: A 1995 study of air transport of potential organ donors in Houston, conducted by trauma surgeon Christine Cocanour, found that 27 of 28 would have arrived faster by ground ambulance. Air-transport industry leaders, including Stephen Thomas, a physician and associate medical director of Boston MedFlight, an emergency medical air-transport service, attribute the high rate of minimally injured patients to the difficulty of conducting accurate injury assessments at the scene of accidents-especially considering that such calls often are made not by physicians but by paramedics and even police.

But the majority of air transports occur not from accident scenes but from hospitals, according to the Association of Air Medical Services and others. Frequently, doctors at a smaller hospital assess and stabilize patients before dispatching them to larger medical centers.

Insurance companies-which often must pay for the costly transports-say they are reluctant to second-guess the decisions of these doctors, who may view air transport as the least-risky choice for both the patient's health and the hospital's liability.

Consider the decision on Jan. 11 to fly Ryan Memering out of Memorial Hospital of Carbon County in Rawlins, Wyo. Mr. Memering had two fractured vertebrae and a deep gash inside his mouth from a car accident. Doctors at Carbon County made the decision to fly him to a larger trauma center in Casper, 120 miles away.

Hospital officials in Rawlins say that ordering the air transport was a clear-cut decision: Though the 45-bed rural hospital has a small intensive-care unit, it lacks full-time specialists for higher-level acute or trauma care. "Any time you have something out of their scope of practice, that's a liability for anyone. Do you want to take that risk?" asks Candace Hofmann, the hospital's ambulance director.

The plane dispatched to retrieve Mr. Memering attempted to land in the dark at Rawlins Municipal Airport. It crashed three miles away, killing three of four crew members on board. Not until the next day did Mr. Memering get flown to the Casper hospital, where doctors performed no surgery and released him in four days. "The staff there said Rawlins had panicked basically;" says Serena Memering, the patient's wife. Her husband, she says, "feels guilty that three people died because of this. In my opinion, it was a waste of lives."

The Rawlins crash represented the third fatal accident of an air ambulance during the first two weeks of 2005, prompting federal regulators to open a probe.

Safety experts say the industry's crash record is less a threat to patients than to crew members, who if they worked 20 hours a week for 20 years would face a 40% chance of being involved in a fatal crash, according to Johns Hopkins University epidemiologist Susan Baker, a professor in the Johns Hopkins Bloomberg School of Public Health who has studied the industry. Possible outcomes of the federal probe include a requirement that pilots wear night-vision goggles. The four fatal crashes so far this year of air ambulances have killed six crew members and one patient.

Patients can end up paying for helicopter transport that wasn't medically necessary. After 9-year-old Tyler Herman fell and broke his jaw in the wilds of Arizona, doctors at a community hospital decided the boy should fly to Phoenix to undergo plastic surgery for a gash on his face. During the flight he was well enough to sit up and remark on the scenery. Upon arriving in Phoenix, he waited nearly 20 hours to undergo surgery. "We could have driven him there in four hours," says Sharon Herman, the boy's mother. Her insurance didn't cover air transport, leaving the Hermans with a bill for $25,000.

On its own, the air ambulance doesn't appear to be a huge money maker. Earnings at the industry's largest player, Air Methods Corp., climbed to $5.1 million from $3.4 million during the five years ended in 2003. But a 2003 Journal of Trauma study conducted by the University of Michigan Health System, which runs a flight service, found that flown-in patients had better insurance and generated significant "downstream revenue" because the patients developed a relationship with the hospital and often returned years later.

Amy Schatz contributed to this article.

In the Air

Some research on medical air transports:

A 2002 paper showed a 24% reduction in mortality for seriously injured patients, but nearly 80% of patients actually had lesser injuries.

A 1995 study of potential organ donors flown by transport found that an estimated 27 out of 28 would have arrived faster by ground ambulance.