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Thu Mar 3 19:20:15 GMT 2005

Air Ambulances Are Under Fire 

Critics Say Emergency Medical Helicopters

Are Overused and Offer Few Benefits to Patients 

By KEVIN HELLIKER and VANESSA FUHRMANS 

Staff Reporters of THE WALL STREET JOURNAL

March 3, 2005; Page D1 

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. 

[ ]IN THE AIR 

Some research on medical air transports: 

. A 2002 paper showed a 24% reduction in mortality for seriously injured

patients, but nearly 60% 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.

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 5% 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 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 multicasualty 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. 

[xxxx]

Critics say air ambulances are overused and offer few benefits to patients

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 transport -- 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.

Write to Kevin Helliker at < <mailto:kevin.helliker at wsj.com>
mailto:kevin.helliker at wsj.com>

kevin.helliker at wsj.com1 and Vanessa Fuhrmans at

< <mailto:vanessa.fuhrmans at wsj.com> mailto:vanessa.fuhrmans at wsj.com>
vanessa.fuhrmans at wsj.com2 

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