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Thursday, January 1, 2009

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Safety Versus Mission

Keith M. Cianfrani only touched the surface of the complexity of carrying out a safe and efficient helicopter medical transport ("Medical Transport: Safety Versus Mission" November 2008, page 60). As an aging Coast Guard aviator with a few too many dark and stormy nights in my memory, I received notification from the rescue coordination center that a high-risk pregnancy patient had gone into labor on a nearby island. The direction came to fly her to Boston. The island had a hospital, but felt it appropriate medical care to evacuate the expectant mom to a major medical center on the mainland. The weather was not good and the civilian medevac operator was not flying.

My copilot Euill said, "Okay let me get this straight; this woman is safe in a hospital. She is definitely going to have a baby and very soon. They want us to pick her up in a helicopter, fly her around some embedded thunderstorms, and then shoot an approach to minimums. The only alternate with an appropriate medical center will have our low fuel lights burning bright." I replied, "You forgot that the weather is getting worse and if we don’t get going we will definitely be spending the night in Albany."

I had discussed the mission with a Coast Guard flight surgeon who was on call to evaluate the medical urgency and necessity of the mission. He responded, "I am not going to second guess a physician who is with the patient."

As we started out, I asked the operations watchstander to confirm the patient was ready to go because we needed to stay ahead of as much of the bad weather as we could. I tasked him to impress upon the hospital the necessity of avoiding any delay.

The first clue that things might not go as planned was after getting a brief, but very clear sighting of the island runway at 1,000 ft, that did not reappear until we were at 300 ft. Just a few miles away we had entered the solid overcast around 700 ft.

Of course, the patient was not ready and wouldn’t be ready for transport for another 45 min. During those 45 min, we updated the weather and picked up our clearance to Boston. We received some good news that the expected thunderstorms had not materialized. Boston weather held solid at 400 overcast, which was slightly better than the forecast.

The patient arrived at the helicopter in labor, but there was no sense of urgency. The flight mechanic secured the cabin. We got our release and climbed to 3,000 ft.

As we dialed up ATIS, the Coast Guard watchstander simultaneously blurted over the radio and we heard in stereo that Boston special weather was now WOXOF. I had read such weather reports, but never actually heard a voice at the airport say that I was headed toward a ceiling that was indefinite zero because of obscuration, and the visibility was also zero because of fog. Thanks to the Category 1 lighting, we actually were able to easily find the runway and land safely. An 80-kt approach speed certainly helped. An awaiting ambulance whisked the mother to be to the medical center where she had a normal delivery the next morning.

Euill had it right at the start. This was a mission that should not have been attempted. There was no medical benefit from the flight. The mother was stable and in the company of a competent physician and fully staffed delivery room. We had a nurse in a vibrating, poorly lit aircraft. With the ragged ceiling, obscuring sky and delay in receiving the patient, I can only imagine the outcome if this emotionally loaded mission of a mother in difficult labor needing to get to a medical center had been attempted other than under IFR.

Studies constantly demonstrate that medical transport by helicopter has little or no medical benefit. One such study found that only about 17 percent of patients actually received some medical benefit from helicopter transport. Other studies have found that even fewer patients benefited. Some patients actually are harmed by helicopter transport. One study found that two percent of patients’ medical conditions were intensified by helicopter transport because of the added handling and delay of further travel.

As Cianfrani pointed out, some patients actually died solely because of helicopter transport. Others died despite transport because of the severity of their injury.

The economics of helicopter transport begs for over-utilization. Fixed costs for helicopter operations are high and the greater the utilization, the more the cost is spread around. The more use, the lower the cost per operation. In essence, we can only afford helicopter transport for those trauma victims who will benefit if we fly patients who receive no medical benefit.

What is a "reasonable" amount to spend to save a life? The family of a trauma victim will always answer that there is no limit.

There are no easy answers. Helicopters do save lives, just not as many or as often as we in the helicopter community would like to believe. Helicopter medical transport flights are over utilized, but the over-utilization helps reduce costs for everyone and make real advanced trauma service available.

As I said it is complicated.

Ed DeWitt

New Bedford, Mass.

Correction:

In a Rotorcraft Report about the Maryland State Police Aviation Division ("Audit and Accident Jeopardizes MSP Aviation" November 2008, page 10), we wrote that the Sept. 27, 2008 crash of one of their helicopters was the second since the unit’s inception in 1970. A reader directed us to a fallen police officers’ Web site that showed a total of three prior MSP helicopter crashes, one in 1972, another in 1973 and the one we cited from 1986. Two crewmembers lost their lives in each of the four accidents.

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