In the early hours of Oct. 4, Air Evac Lifeteam helicopter pilot Zechariah Smith and his Duncan, Oklahoma-based flight crew received a call from their company’s dispatch center to pick up a patient in Waurika, Oklahoma, and fly him some 40 miles to the United Regional Hospital in Wichita Falls, Texas.

The medical helicopter had just returned from a flight to Oklahoma City, but Smith accepted the flight, telling the dispatcher they would need 15 minutes on the ground to prepare.

They picked up the passenger, a gunshot victim, at Jackson County Hospital and departed at 1:33 a.m. in clear weather for Wichita Falls. But as Smith approached the helipad 20 minutes later, he felt he was coming in too fast and too high, and decided to abort the landing. As he tried to regroup for another attempt, the helicopter suddenly turned violently to the right. He would later tell investigators it was the fastest he had ever spun in a helicopter.

He told the crew to hang on as he tried to fly out of it. But the aircraft continued to spin, rotating at least five times before hitting the ground upside down and exploding. The crash killed the patient, 26-year-old Buddy Rhodes. Flight nurse Leslie Stewart, 27, and paramedic Johan van der Colff, 51, were admitted to the hospital but later died of their injuries.

According to the National Transportation Safety Board, the accident was the 184th crash of a medical helicopter in the U.S. since 1998, and the three fatalities brought the combined death toll to 174 patients and crew.

Several industry insiders believe the Wichita Falls crash highlights many of the disturbing trends in the industry, which has increasingly seen operators trying to cut costs on equipment and crews while skirting safety to maximize the number of patients flown.

Fueled by high reimbursement rates and scant regulation, the rapid growth of the helicopter EMS industry over the past 15 years has transformed what many consider a life-saving service into an industry fraught with safety concerns but little oversight.

“It’s sort of the perfect storm,” said Dr. Michael Abernethy, chief flight surgeon for University of Wisconsin Health’s Med Flight. “It’s great money, it’s unregulated and there’s really no utilization criteria.”

Growth industry

While neither of the two Central Oregon air ambulance services, the for-profit AirLink Critical Care Transport in Bend or the not-for-profit LifeFlight in Redmond, have experienced any helicopter crashes since 1998, the addition of a second operator in 2012 created a competitive market, mirroring some of the trends seen nationwide.

Prior to 2002, helicopter emergency medical services, or HEMS, programs were mainly owned and operated by hospitals, flying medium-sized twin-engine helicopters with experienced emergency physicians and critical care nurses. Hospitals often lost money on the operation but made up for it with payments for the extensive trauma care these patients required. After much lobbying by hospitals, Medicare officials agreed to rebase payment rates to more accurately reflect the true costs of running a high-quality helicopter EMS program.

In 2002, Medicare more than doubled its payment for air ambulance transport, expecting that the increased reimbursement would help HEMS programs upgrade their equipment and invest in training and safety.

“It did almost the opposite,” Abernethy said. “Companies figured out that there are no stipulations to get this reimbursement. If we go on the cheap, if we started flying single-engine helicopters and using minimally experienced crews, we could save a hell of a lot of money.”

As a result, for-profit operators have added hundreds of new HEMS programs nationwide over the past decade. According to the Atlas & Database of Air Medical Services, in October 2003, there were 545 helicopters flying out of 472 HEMS bases in the U.S. By September 2014, those numbers had nearly doubled, with 1,020 helicopters at 846 bases. Some states have more medical helicopters than all of Canada or Australia. And annual Medicare spending on HEMS transport between 2002 and 2009 grew 434 percent.

Now more than a third of HEMS programs are owned by three large for-profit operators: PHI Air Medical, Air Methods Corporation and Air Medical Group Holdings, the parent company of Air Evac Lifeteam.

In 2004, only 41 percent of the U.S. HEMS fleet consisted of single-engine helicopters. By 2014, single-engine aircraft outnumbered twin-engine models 513 to 485, and that trend is being driven primarily by for-profit operators.

But as the number of helicopters flying increased, so did the number of crashes. In 2008, the industry had its worst year ever, with 11 crashes and 28 fatalities. And many are pointing fingers at the for-profit segment of the industry.

“The corporate for-profits make up less than 40 percent of the industry, yet they’re responsible for 80 percent of the crashes,” Abernethy said.

This month, researchers led by Fort Lauderdale trauma surgeon Dr. Fahim Habib published an analysis of the link between for-profit status and the risk of helicopter crashes. From 1998 to 2012, for-profit HEMS operators averaged seven to eight crashes per year, while not-for-profit or public operators averaged one crash every year or two. While the researchers couldn’t account for differences in hours flown between different types of operators, crashes appear to be happening much more frequently among for-profit operators.

“While HEMS missions are undoubtedly getting safer, the increased number of missions being flown is likely offsetting gains in safety,” the authors wrote.

Industry representatives maintain there’s no reason to believe that for-profit operators are any less safe.

“I don’t think you can point to a specific business model and say that raises a safety concern, because all business models, for-profit and not-for-profit, have to pay attention to revenues and expenses,” said Rick Sherlock, president and CEO of the Association of Air Medical Services. “You have to operate in a way that’s sustainable.”

Sherlock said HEMS operators have invested between $500 million and $700 million in safety equipment and training, including adding night-vision goggles, helicopter terrain awareness and warning systems, flight data monitors and dual-access autopilots.

“2008 was a tough year in the industry,” he said. “But I think the commitment of the industry to safety is one that’s very strong.”

The numbers suggest the industry has made gains on safety. From 1999 through 2008, there were at least 10 crashes per year, killing anywhere from three to 28 people per year. Since the NTSB held a four-day hearing on HEMS safety in 2009 and issued recommendations for the industry, accidents have remained in the single digits all but one year. Still, 2010 and 2013 were bad years for the industry, combining for 21 accidents and 38 deaths, leading many to wonder whether any permanent gains have been made.

Older aircraft

The Air Evac helicopter that crashed in Wichita Falls, for example, was a single-engine Bell 206 Longranger. According to the online helicopter database, Helis.com, that aircraft was built in 1981 and sold to Nigeria, where it was flown for 25 years. In 2006, the helicopter was registered in the U.S. by Heliworks Leasing of Wilmington, Delaware, before being acquired and presumably refurbished to serve as an air ambulance by Air Evac in 2010.

Company documents posted online by Air Evac, which declined multiple requests for an interview, indicate the company flies more than 100 Bell 206L helicopters, and many appear to have colorful pasts.

According to data provided by the NTSB, Air Evac has had at least 20 helicopter accidents since 1998, 18 of which involved the Bell 206 model. Of those, 14 involved aircraft built between 1975 and 1983 that were at least 25 years old at the time of their accidents. Many of those helicopters were bought used, stripped down and refurbished with new components to serve as air ambulances.

“When you’re hauling people for exorbitant amounts of money, they should expect something better than a 33-year-old aircraft,” Abernethy said. “But it’s a lot cheaper. Something like that could be had for $700,000, whereas the EC135 that we fly could cost $7 to $8 million. Quality costs money.”

The NTSB has warned that the Bell 206 is particularly susceptible to a problem known as loss of tail rotor effectiveness, or LTE, that can cause the aircraft to spin uncontrollably to the right. After the Wichita Falls crash, pilots posting on online helicopter bulletin boards said the details of the crash fit the description of an LTE problem.

“The 206 is an aircraft that is a little more prone to that,” said Guy Maher, who spent 24 years as a HEMS pilot and now consults on helicopter safety issues. “If you know the limitations of the equipment and you think ahead of what you’re doing, (it’s manageable). But it’s always when someone is trying to push it a little bit that they’ll get themselves caught in the situation and when they try to get out of it, they hit the limits of the aircraft.”

Maher said when operators buy and refurbish old aircraft, often little more than the airframe is left from the original model.

“It’s really like a Mr. Potato Head. You connect all these parts to the frame and the parts have time-limited restrictions,” he said. “Sometimes it’s nothing more than a roll-cage with the serial number on it. So a 30-year-old helicopter, it would be incredibly rare to have any critical component on that aircraft be 30 years old.”

When asked about the 18 Air Evac crashes involving the 206 model, Maher said, “That jumps out to me that there is a cultural problem within the organization, more than there is a problem with the helicopter.”

Pilot shortage

The rapid growth in HEMS has also put pressure on the supply of helicopter pilots. Where 10 to 15 years ago operators generally required 3,000 or more hours of flight time from prospective candidates, the demand for more pilots has led many to lower that standard.

“Some companies have dropped back to 1,500 or 1,200. They’ve lowered the minimums, and it’s purely out of necessity,” said Kurt Williams, president of the National EMS Pilots Association and an air medical bay supervisor with PHI Air Medical Group in Clinton, Missouri. “The military isn’t turning out as many pilots, and the ones they do don’t have as many hours.”

Williams stressed, however, that there was no definitive link between flight hours and accidents, and certainly pilots with thousands of flight hours have crashes as well. According to the preliminary NTSB report, the pilot in the Wichita Falls crash had logged about 1,810 total flight hours, of which 1,584 were in helicopters and 214 in the Bell 206 model.

Air Evac lists a minimum of 2,000 hours required in several HEMS pilot job postings on its website and is accredited by the Commission on Accreditation of Medical Transport Systems, a voluntary accrediting body. The group generally requires pilots to have a minimum of 2,000 flight hours, but it does list some exceptions.

The bigger concern may be how much authority pilots have to decline flights in questionable conditions.

“Pilots are fairly well insulated — and deliberately so — from the medical side of the condition. We just need to know how many people and the location,” said Bill Conklin, chief pilot at AirLink in Bend.

“Because of our familiarity with the business, we know they’re medically related,” he said, “but our decisions are supposed to be based on the capability of the aircraft and the weather.”

But HEMS operators typically have high fixed costs that account for up to 80 percent of a base’s monthly expenses. While some operators sell memberships to provide a more stable revenue base, operators generally don’t get paid unless they transport patients.

“Unfortunately, everybody in the business knows that if your base isn’t flying much then your employment is going to be at risk,” said Williams, the pilot group president. “So as hard as we try to regulate that out of the equation, it obviously comes in.”

Many helicopter operators determine how many flights they need to break even each month and keep pilots apprised of their progress in meeting that number. It’s a subtle but unmistakable message.

“It’s the ‘fly or you’re fired’ syndrome,” Maher said. “The industry has become so driven by the dollar and it’s not looking at the bigger picture. You don’t have to take that flight. They can take somebody by ground if the weather is iffy.”

There is similar pressure on mechanics, he said, to complete maintenance quickly and get the helicopter flying again.

“The more downtime you have, the less revenue you make, so mechanics are under incredible pressure now to perform as much as the pilots,” Maher said. “Get it done fast, get it done cheap and don’t let the other guy beat you to it. It’s like the Wild West out there. Somebody’s got to stop it.”

Tarek Loutfy, director of safety for Metro Aviation, which owns AirLink, said their pilots know they’ll get support from management when they decide conditions aren’t safe.

“Instead of you pushing your luck trying to save a patient, you might end up making four more,” he said. “It’s not worth gambling to make a buck and then ending up on somebody’s doorstep telling their family they won’t be coming home.”

While the recent expansion of the HEMS industry has brought air ambulance services into new areas, much of the growth represents a duplication of services in large metropolitan areas. With so many competitors, operators can’t afford to pass up a flight.

“It’s a for-profit business. You’ve got to face the facts. You’re putting a $2 to $3 million helicopter in service, and you have to pay the bills,” Williams said. “When there is such a huge number of competitors in a limited market, every single flight counts.”

When the NTSB held hearings on HEMS safety in 2009, the agency heard of rampant problems stemming from this ultra-competitive environment. Helicopters were flying in bad weather, stealing dispatch calls from other operators and flying to accident scenes even when no one had called them in. Some operators would accept a second dispatch call before they had completed their first, leading to unnecessary delays in transporting patients. Others would create close ties with ground EMS services, even hiring an ambulance company’s staff member knowing the paramedics would be more likely to call their friend.

The profit-driven environment meant HEMS operators often flew patients who could have been safely transported by ground, costing both patients and taxpayers thousands of dollars per trip.

In Bend, AirLink conducts strict reviews of each flight to consider whether the flight was medically necessary and works to educate EMS providers on what conditions are appropriate to fly. If an AirLink crew flies to the scene of accident and the crew realizes that patient can be safely driven by ground ambulance, they are encouraged to fly back to their base empty. Even though AirLink loses money on that flight, program manager Kevin Schitoskey gives his crew a Starbucks gift card every time they make that call.

“I think it’s important for those guys to make those decisions solely on patient care. I want to promote an organizational culture that promotes the right tools for the right job,” Schitoskey said. “If we’re flying somebody with a (minor foot injury), they’re not available for a higher acuity patient that needs them. We do have an obligation to serve Central Oregon.”

In order to avoid the competitive dynamics between AirLink and LifeFlight, local EMS providers have devised protocols for when to call for air transport and what service to fly.

“We’ve worked really closely with dispatch to create an algorithm so that the most appropriate air resource comes, and I think that’s worked out well,” said Doug Kelly, division chief at Redmond Fire and Rescue and chairman of the Deschutes County Ambulance Service Area advisory committee. “Rather than choosing one provider over the other, we’ve taken the standpoint of, ‘Let’s get the closest resource there.’”

The lack of such regional coordination in other parts of the country as well as the fiscal pressures to fly a certain number of patients per month mean HEMS operators could be flying patients for whom there is little benefit over ground transport. Benefits could include getting patients with time-sensitive injuries or conditions to the hospital faster or being able to provide care en route in a helicopter that is beyond the capabilities of a ground ambulance.

A recent analysis in Arizona, however, found that nearly half of patients transported by helicopter weren’t even admitted to the hospital, suggesting their injuries weren’t all that severe.

“There are patients that they are transporting to hospitals that we wouldn’t have remotely considered just 10 years ago,” Abernethy said. “Right now, the utilization criteria are so vague that almost any flight (is covered).”

It’s resulted in some scenarios that strain the limits of credulity. A 2012 assessment of HEMS services on behalf the Oklahoma State Department of Health, for example, cited a case in which a ground ambulance crew handed off a patient to a helicopter crew at a trauma scene and then met the helicopter at the landing pad after the flight to transport the same patient to the receiving center.

That review, authored by emergency physicians at the University of Oklahoma School of Community Medicine, also underscored that with no publicly owned HEMS services, the state had left the task of providing air medical transport to the free market and so had to expect some degree of competitive behavior.

“It is problematic to expect corporate entities,” the authors wrote, “to do more than aim to optimize profits within the context of legal and regulatory compliance.”

This year, the FAA issued new rules for HEMS operators that would implement many of the aviation recommendations made by the NTSB. Those requirements will be phased in over the next four years. Industry representatives had been urging the FAA to finalize those rules so operators could know what would be expected of them, and many companies are already compliant. But some in the industry have been resistant to implementing those, and there is speculation that some outfits will go out of business if they can’t meet the regulations and their bottom line.

“Every operator has different resources and different abilities to pay for the amount of technology that is now being put on helicopters. And so those that have more resources are doing it more quickly than those with less resources,” said Dr. David Stuhlmiller, chairman-elect of the Air Medical Transport section of the American College of Emergency Physicians. “But now those who can’t afford to comply will no longer exist.”

Others believe the industry is fighting regulations to keep them from eating into profit margins . Even beyond safety equipment and other changes under the new FAA rules, operators must invest in training, staffing and other quality improvement measures — all of which costs money.

“Everybody is always worried about spending money, but what is the cost of an accident?” asks Denise Landis, critical care and transport manager for the University of Michigan’s Survival Flight program and a board member of the Association for Critical Care Transport. “So for me, it comes down to the dollar. I hate to point the finger, but you don’t know how people want to invest.”

— Reporter: 541-617-7814, mhawryluk@bendbulletin.com

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