Medical Copters--Are They Worth the Risks?

For Alice Schott, what began as a pleasant family fishing trip on Lake Castaic turned abruptly into disaster when wind-whipped waves swamped her small boat and pitched the 71-year-old grandmother overboard.

By the time Los Angeles County’s Air Squadron 9 responded to the emergency call, Schott’s body had already been pulled from the water. Her eyes were shut. Her face was ashen. And her pulse was barely discernible as rescuers worked quickly to try to revive her.

As paramedics prepared to lift her onto the helicopter, Schott suffered a cardiac arrest that sent them scrambling for the aircraft’s defibrillator to try to jolt her heart back to a life-saving rhythm.

Once under way, it took less than six minutes for the helicopter to reach the Henry Mayo Newhall Memorial Hospital--it would have been a 20-mile drive by road--where Schott arrived in critical condition. Two days later, she was back home with her family in Sylmar.

A Rare Occurrence

“This is one of the success stories,” said paramedic Dan Coffman moments after the crew delivered Schott to waiting doctors. “It doesn’t happen that often where you actually save the life of someone you thought was gone. This was rare, and it was nice.”

Last Sunday, barely two weeks after Schott’s successful rescue, a similar airborne mission was under way in San Bernardino County where a private medical helicopter had picked up an injured motorcyclist. This time, however, the rescue attempt ended in tragedy when the aircraft clipped a power line in the fog-shrouded Cajon Pass and plummeted into an embankment.

The pilot and nurse on board were killed. The patient, who had been strapped to a gurney, survived the crash.

The two life-and-death events, each stemming from a dramatic rescue effort, underscore an intense, often impassioned debate that surrounds aeromedical helicopters: the aircraft’s high-tech ability to save lives versus the safety risks inherent in airborne emergency operations.

Expansion Considered

For Los Angeles County officials, that debate is crucial as they consider whether to greatly expand the use of helicopters as a way to cope with a steadily shrinking network of trauma centers that use sophisticated equipment and specially trained physicians to save lives.

The county, which once boasted 23 trauma center hospitals, now has just 16 to serve a sprawling region of 4,083 square miles and 8.4 million people. There are added fears that several of the remaining hospitals may abandon the trauma care network when the county’s current funding commitment ends in the fall.

Los Angeles County’s 4-year-old trauma system was built on the premise that ground ambulances must take no more than 20 minutes to transport patients in critical condition to trauma centers. But with the loss of further centers, the premise--and thus the system--threatens to break down.

To keep trauma care viable, county officials are saying that helicopters may be the answer to the under-20-minute trip as the centers become fewer in number.

“There certainly is a more definite role for helicopters now that we have a smaller number of trauma centers,” said Virginia Price Hastings, the county’s trauma care director.

“I don’t think helicopters were needed when we had all of our hospitals in place,” she added. “Now that we don’t have the system covered in 20 minutes, I think there is a role for them. Their use may be restricted, but the number of (helicopter) flights will proliferate.”

The county’s air paramedics responded last year to more than 1,000 medical calls, according to Fire Department officials, with trauma patients making up about 70% of the passengers. With the addition of just one helicopter, to be used exclusively for trauma emergencies, the number of medical flights and trauma victims transported by helicopters could easily double, Hastings said.

Belief in the benefits of an expanded aeromedical service is shared by other county officials who point to a growing population increasingly choked by snarled freeways and streets.

“We don’t want people to see this as an absolute panacea. It isn’t the answer to the trauma center problem,” said James Sanchez, chief of air operations for Los Angeles County’s Fire Department. “But with fewer trauma centers and more gridlock problems, helicopters will become more important.”

Not everyone in the trauma field applauds what has become a nationwide movement toward emergency medical helicopters, and some critics caution against Los Angeles County’s enthusiastic embrace of the helicopter philosophy.

Doctor Disagrees

“That’s the worst thing they can do,” said Dr. Kenneth Mattox, chief of surgery and director of trauma activities at Houston’s Ben Taub General Hospital.

“Fire chiefs, police chiefs and even the public think birds (helicopters) are sexy and that they can swoop in and save people from instant death.” In fact, Mattox said, there is at least one study that shows helicopter transport of patients is not substantially faster than ambulances. Given the safety questions, he said, helicopters “may actually increase the mortality rate rather than save people.”

Mattox argues that, too often, hospital administrators and politicians are swayed more by the sales pitches of helicopter manufacturers and the glamour of air ambulances than by the actual needs of their patients.

“It’s a fad, and it’s simply because people who sell the helicopters are doing a damn good job,” he said.

The responsibility for airborne trauma care in the county rests with the Department of Health Services, and the county Fire Department provides the air ambulance service in addition to its firefighting mission. Sheriff’s helicopters also fly occasional rescue missions, but the Fire Department with its rotating shift of pilots, air paramedics and volunteer physicians handle the bulk of airborne medical emergencies.

At times, both sheriff and Fire Department helicopters are called to the scene of a major accident. A day after rescuing Alice Schott, for instance, paramedics on board Air Squadron 9 joined a sheriff’s helicopter crew in airlifting critically injured victims of a four-car crash in Palmdale and taking them to trauma centers.

Two private hospitals in the county, Long Beach Memorial and UCLA Medical Center, also have operated helicopters for years.

Growing Use

The scope of the aeromedical industry has widened since the first emergency medical services programs began using helicopters in the early 1970s. Last year, the number of medical helicopter programs nationwide climbed to 149, representing a 10% jump from the previous year, according to Hospital Aviation magazine.

Among the most prominent programs were:

- The Maryland Institute for Emergency Medical Services Systems, a statewide trauma program that transported nearly 3,000 patients by helicopter to regional trauma centers last year. Admired by Los Angeles County officials as a model program, Maryland recently won state legislative approval to spend $31 million to replace its 10-helicopter fleet.

- The Air Evac program in Phoenix, which flew 3,992 helicopter transports and 1,945 fixed-wing transports as the nation’s busiest aeromedical service.

- The San Diego County trauma system, now almost 4 years old. More than 1,100 of the 3,500 patients taken to local trauma centers during the 1986-87 fiscal year were transported by helicopter.

Compared to those programs, helicopters play only a minor role in Los Angeles County’s trauma care system. But that would change if the Board of Supervisors approves a plan now under study by the health and fire departments.

The specific proposal would commit about $3 million to buy and operate a helicopter solely for medical missions. Although the financial commitment is relatively small for a county whose annual health services budget exceeds $1.3 billion, there could be wider implications.

The helicopter acquisition is seen by some as a pilot project that could determine whether an expanded aeromedical fleet is needed in the county and whether the county will reach into areas beyond merely transporting trauma patients from the scene of an accident.

Specialized Care

For example, with its own medical helicopter, the county could transport critically ill or injured infants and children to special pediatric clinics. The county also could compete with private firms for the job of shuttling patients such as burn victims from one hospital to another--not a welcome prospect for private helicopter and ambulance companies.

Supervisor Pete Schabarum, who introduced the helicopter proposal before the board, said his purpose was not to supplant private programs but to update the Fire Department’s aging fleet of five helicopters, some of which date back nearly two decades. He added that the purchase would also reflect the county’s “commitment to the emergency response business” at a time when the trauma system is under enormous strain.

“I was visiting with some hospital folk several mornings ago,” Schabarum said last week, “and the observation that trauma facilities are on the decline is a very realistic fact.”

Although no decision is imminent, the supervisors have already heard from helicopter manufacturers interested in bidding for a county contract. One firm even flew one of its customized models to a parking lot adjacent to the downtown Hall of Administration and invited board members and their aides to inspect the aircraft.

If the county signs, it will mean finding new millions to pay the bills.

Earlier this year, the board approved the $2.6-million purchase of a heavy-duty Bell Helicopter as part of a Fire Department replacement program. The department also has estimated that a similar Sikorsky model for medical services would run about the same including the cost of crew members.

Cost Per Trip

According to various hospital administrators, helicopter costs in California run about $2,000 a trip, and a one-helicopter program can cost in the neighborhood of $2 million to operate annually.

But to some, the financial burden of helicopters is dwarfed by safety concerns.

In a report released last February by the National Transportation Safety Board, the federal agency found that the accident rate of medical helicopters was twice that of other non-scheduled helicopter flights between 1980 and 1985. The board, which reviewed only private carriers, also reported that the fatal accident rate for that period was more than three times higher for medical helicopters than for other helicopters.

The board blamed most accidents on pilot error and said weather was a major contributing factor in most fatalities. It also noted “the high stress environment in which (emergency medical service) pilots operate” and said the pilots were frequently under intense pressure to complete their rescue missions, a factor that often affected their judgment.

Despite those findings, industry officials maintain that the accident rate is declining and that 1987 marked the overall lowest accident rate in their history.

Nina Merrill, executive director of the American Society of Hospital Based Emergency Air Medical Services, said her Pasadena-based organization has developed safety standards for its members, upgraded pilot training and avoided situations that court trouble.

“I don’t know of any program that is doing a lot of urban, downtown, crowded metropolitan work,” she said. “It’s too damn dangerous.”

In Los Angeles, county officials also hope to keep such urban flying to a minimum to avoid the dangers of heavily populated areas, vehicular traffic and unseen power lines. Fire officials say they have already identified dozens of “heli-spots” throughout the county where pilots can land their crafts safely during an emergency. They stress that pilots also can turn down rescue calls during risky weather.

Reaction to Accident

Hastings, the county’s trauma director, said her own air ambulance program has suffered no major accidents, but she said it was disheartening when she learned of the medical helicopter crash in San Bernardino County. “You always hate to see these things because they tend to bring out all the criticisms of air ambulances. Yet accidents happen to ground transports as well,” she said.

The industry’s new emphasis on safety comes at a time when authorities are trying to improve what has been spotty oversight of air ambulance services.

In its report, the NTSB called on the Federal Aviation Administration to establish new procedures to govern emergency medical helicopter operations, train crew members and improve the craft’s crashworthiness--guidelines that FAA officials say they are now working on.

In California, state regulations establishing safety, pilot training and flight dispatching standards are expected to go into effect next month, applying to both public and private services.

But even with regulations in place and safety records improving, the question remains whether helicopter teams make enough difference to justify their risk and expense.