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Fatal Flights: A Perilous Rush to Profit

Gilbert M. Gaul, Mary Pat Flaherty, Jenna Johnson and Jeff Leen
Washington Post Staff Writers; Investigative Editor
Monday, August 24, 2009; 1:00 PM

Post writers Gilbert M. Gaul, Mary Pat Flaherty and Jenna Johnson and Investigative editor Jeffrey Leen take your questions about the The Post's investigation into the competitive, dangerous multibillion-dollar air-medical business.

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Jenna Johnson: Hello everyone. Thanks for joining us today to discuss the recent series, Fatal Flights. We already have several questions and look forward to others.

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Southern Maryland: Almost a year later and "the cause of the crash has not been determined."

What are they waiting for? To place blame on the dispatcher/controller, the pilot, the EMS ground crew?

Weather is the No. 1 issue in this crash, can't the NTSB and/or FAA document it as "weather related" and close it out?

Jenna Johnson: It's not unusual for the NTSB to take a year -- or in some cases, even more than a year -- to fully study a crash before naming a cause. And often that cause is not just one thing but a combination of several contributing factors. While there was bad weather the night of the Trooper 2 crash, there were a number of other decisions and mistakes that could have contributed to the crash.

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Baltimore: Is any of this helicopter transport really needed? Is there any data to show improved outcomes of the patients? Thank you for your series, it is very informative.

Gilbert M. Gaul: This is an important question, all the more so in the context of today's larger health-care discussions where policymakers are looking at the cost and benefit of many services.

There have been several studies published over time, but they have been relatively limited in scope. There is a real dearth of data on outcomes -- and especially data that are published for all to see. As best as we can tell, the government doesn't collect data and most of the large operators don't publish their outcomes data. We asked several for data on things like 24 hr discharges and ISS scores for transported patients but were told the data were proprietary.

The data gap begs questions about appropriate vs inappropriate use and the value various payers are getting for the transports. Without questions, medical helicopters can play a vital role in the system. We aren't questioning that. The question is what is the appropriate role?

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Philadelphia: Please help me reconcile the allegation that states lack the authority to control the non-aviation aspects of medical helicopters with the changes accomplished by the state of Maryland since last September? Also, please explain to me how Sunday's very sad story about a monopoly provider in a state with virtually no competition does not totally undermine any theory that competition is the causal (not a correlated) factor in air medical accidents and alleged overuse.

Mary Pat Flaherty: Maryland's program is public use, which puts it in a different box from most programs. The constraints that state officials related to us have to deal with their attempts to regulate the economic side of the medical helicopter industry, a private undertaking. That aspect is out of the equation in Maryland's state police program.

The state can make changes more readily in Maryland because it is a public, state program, in other words.

As to overuse, the changes in Maryland's guidelines on when to call for helicopter transport did drive down the number of flights in the state and drove more of them to interfacility flights.

There are competitors in Maryland for those interfacility runs so we are poised now to see how that competition will play out. Beyond that, the series cited competition among the pressures playing out in the industry but not a sole cause, so not sure that highlighting a monopoly operation undermines the other aspects we discussed.

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Kitchener, Ontario: The Maryland State Police HEMS model, which is quite unique for the United States, is similar in many ways to the model that is used with an exceptionally high level of safety in countries including Canada and Australia. Like those countries, the MDSP flies expensive, capable, twin-engine helicopters under a non-profit model. (One key difference is that its operations are single-pilot, not dual-pilot.) The international perspective is that such operations are inherently safer than typical U.S. commercial HEMS flights: single-pilot operations in minimally equipped, single-engine helicopters - helicopters that couldn't even legally take off at night in many countries.

As the nation moves towards more government involvement in health care, where do you see the future of expensive but non-profit HEMS programs such as Maryland's? Has the Trooper 2 crash turned public opinion against such state-sponsored programs, or has it underscored the need for even more funding for the program to hire co-pilots and procure better safety technology?

Gilbert M. Gaul: The MD model is somewhat similiar to the Canadian model but not exact. For example, MD uses a single pilot while Canada uses two. In America, operators and policymakers are largely silent on the issue of using two pilots. We ran out of room to write about this issue but there are a number of large hospital-based programs that are currently exploring the two-pilot issue because they think it can help to improve safety. The idea being that two pairs of eyes are better than one. I think it's also true that in some areas of Canada, the programs decline to fly at night if the weather is bad -- eg, snow or ice.

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Reston: Can you please address more regarding pilot proficiency and experience, particularly as it relates to the decision to fly or not to fly. Any correlation between safety records of firms and the percentage of former military aviators?

Gilbert M. Gaul: Couple of quick thoughts.

We looked at pilot experience and there seemed to be no convincing correlation to fatal crashes. That is, some of the pilots who were involved were older, say, in their 60s, and some were quite young, in their 20s and thirties. There simply isn't enough information in the investigation reports to determine how age played into the decision to fly, bad weather or good weather. Ditto on the second observation about military experience. Many of the older pilots flew in Vietnam and some of the pilots flew in the CG or for other arms of the military.

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Warrenton VA: What is the correlation between the number of accidents and the number of flights? Did fatalities increase in direct proportion to the number of flights made?

So far this report doesn't make a clear connection between number of flights vs. accidents/deaths. Even when I drill down in a chart or graph this data is limited.

Mary Pat Flaherty: Thank you for bringing this up. The industry does not have to report its flights hours, etc., so from the outside that is not a question readily answered. GAO investigators (see link, that I hope I pasted correctly) have raised this point first in 2007 and again this April during testimony on the Hill, encouraging required reporting that would enable you, I and regulators to get at better analysis and answers.

As the study laid out and testimony since has, knowing more about flights, flight hours, flights with patients and without all would allow a better sense about rates of accidents but also allow a more informed discussion about whether safety guidelines are having their intended effect--or which ones are and which are not.

http://www.gao.gov/products/GAO-07-353

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Elkins Park, Pa.: One of the problems the article brings out is that different agencies interpreted coordinates for the lost aircraft in different ways. Some agencies interpreted them as degrees and minutes, others as GPS coordinates, which caused great confusion and lost time.

I did not read in the article any recommendation or of a newly established policy in response to this accident regarding a protocol for standardized communication of coordinates. Has this changed?

Jenna Johnson: The night of the Trooper 2 crash the state police and the FAA controllers had a number of ways that they could have immediately identified the helicopter's last known position in Walker Mill Regional Park -- but they either did not have training in how to use the software or they did not know how to communicate the information accurately.

While I am not aware of any policy change, there has been a lot of retraining.

Syscom has installed new software on their tracking system that allows them to drill-down to the street level, rather than just looking at a broad statewide map, and many dispatchers have learned the difference in traditional coordinates vs. GPS coordinates. Some FAA controllers were also given a quick lesson in how they can find an aircraft's last coordinates.

After one of the police officers who helped with the ground search did an interview with the NTSB investigators, they took him out to his squad car and showed him how to use the GPS system that was already installed.

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San Antonio: South Texas has had over 50 days of 100 degree heat, yet many for-profit programs in the area don't even have air conditioning. The state should be able to mandate such a basic level of service. While the bigger hospital based programs have already or are implementing the NTSB's safety recommendations, the for-profit models are not. Unfortunately, the general public does not realize the vast differences between programs and huge differences in safety enhancements between programs.

Gilbert M. Gaul: The issue of air conditioning came up in several states in the context of state vs federal regulations and the ADA. Some of the state health regulators say they have been pre-empted by the Airline Deregulation Act, or are afraid to even try to regulate the AC issue because they think they will lose if they are sued.

Several of the large hospital-based operators have banded together in an attempt to get Congress to recognize the differences among operators. They point out that Medicare and other payers don't distinguish between operators who are heavily investing in safety and others are using a more streamlined approach. Some of the latter would argue that it is appropriate to use a more stripped down helicopter in certain situations, and there is no need for a flying ICU.

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Scottsdale, Ariz.: You guys really did your homework on this one. Very complex subject to all but those of us who live in it. You're to be commended for your excellent research and impartial delivery. We can only hope that someone that can make a difference, like the 453 folks in that big building in your town, will read and respond.

Mary Pat Flaherty: Thank you very much. On any complex topic--even in this world of Internet news space--we will never have the room to satisfy the need and curiosity of each reader. We may well not have asked every question some of you would have posed. But that's what the chat is for. And that's what ongoing conversations among the players in the business can do--drive the discussion.

Again, thanks for recognizing the effort that has gone into the series.

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Pittsburgh, PA: Is there any discussion in the industry about tort reform? I'm convinced many patients are flown because while they may not have any apparent serious injuries, no ambulance company wants to risk a lawuit if the person has a head bleed and they die in a 45 minute ambulance ride. I believe helicopters are sometimes called for the same reason physicians run so many tests, because they're afraid of being sued if they don't do "everything" in their power to get the patient to the hospital as soon as possible.

Gilbert M. Gaul: Well, there may some truth in what you are contending, but I have never seen or heard anything on the question. Nor am I aware of a spate of lawsuits where patients weren't flown. I'd like to look at those if you have any additional information.

On a related subject, some operators argue that under EMTALA they are obligated to provide patients with the most sophisticated levels of care -- and hence are obligated to put them on helicopters. the flip side of this question is without national standards or reliable data on outcomes what do we know about the marginal calls in which patients are inappropriately flown. How many? what types of instances? Who are making those calls? etc etc.

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DC: We keep hearing about Canada. What lessons are there from the Europeam model(s) for HEMS?

Gilbert M. Gaul: We didn't have time to learn the European model deeply. but from what I have read, it is closer to the Canadian model than to the US model.

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Washington, DC: On the issue of competition, credible statistics discussed during the February 2009 NTSB hearing on HEMS safety demonstrated that the level of fatal accidents in this sector was not affected by the level of competition in a state. This fact might have added balance to your report.

Gilbert M. Gaul: We were at the hearing. Which "credible" statistics are you referring to?

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DC: What would be safer: A few big HEMS operators or more niche providers?

Gilbert M. Gaul: That's a question that is more appropriate for the regulators and members of Congress. We don't get to make recommendations or design the best systems.

That said, we can tell you that a number of pilots we spoke with said they would favor a "regionalized approach" in which operators and regulators determined the number of helicopters based on medical need -- as opposed to the current free-market approach.

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Charlottesville, Va.: While picking on 2008 accidents, how could any serious, responsible investigative journalist neglect to point out that 2009 has been the safest year for medical helicopters to date, with zero fatal accidents in the last nearly 10 months, encompassing approximately 350,000 transports (and likely over 1 million total flights, including those not involving patients)?

Gilbert M. Gaul: Couple of thoughts.

First, we looked at fatal crashes involving crews over 28 years -- 1980 through and including 2008. It's unfair to say we focused exclusively on 2008.

Two, yes 2009 has been free of fatal crashes thus far. And if you go back over time and study periods of peak crashes, you will often see that the year(s)immediately afterward see a sharp decline in crashes. This is probably because everyone is paying a lot more attention to the issue.

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Alexandria, VA: With respect to the discussion on air conditioning, there is nothing in the Airline Deregulation Act that prevents a state from establishing a required ambient temperature in an aircraft as a part of the state's air ambulance licensing proceedure. Certain types of helicopters may require that air coonditioning systems be turned off for ascents and decents when taking off/landing, but the establishment of an ambient cabin air temperature is not prohibited by the ADA. Many jurisdictions already make such requirements.

Gilbert M. Gaul: We didn't say ADA preempts air conditioning. We said that because of the ADA lawsuits, several of the EMS or health officials said THEY believe ADA could be a problem and/or they fear that they would be sued if they required air conditioning. We spoke with at least 4 state regulators who brought up the subject. If the industry believes air conditioning isn't pre-empted or could promise it wouldn't sue, maybe it should put such a statement up publicly?

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Ashton, Md.: I see many of the problems with helicopter based ambulances identified in your article as being common in the US health care system. Some piece of technology is bought and it must be used to cover its costs, even when its use is inappropriate or injurious. It's the same with MRI machines, which are over-utilized simply because there has been so much invested in their purchase.

Is there any hope of limiting use of helicopter ambulances to true emergencies that demand that fast a transport?

Mary Pat Flaherty: Gil, I believe, may have addressed already this in part above(below?)but you touch on an issue that has in fact been at the heart of litigation over state EMS attempts (using EMS broadly there) to control the number of medical helicopters services through use of CONs or certificate of need programs. (CONs in fact have been used to control the placing of MRIs in the past by some communities). CONs, to pare this down, essentially ask a health care provider to demonstrate the public health/community need for an expensive piece of equipment or technology before it will be licensed for use by state/local regulators.

Air medical representatives have successfully sued over that attempt saying that the federal Airline Deregulation Act prevents states from interfering with the business side of their enterprises, that is it an economic not medical resource issue. A North Carolina case is the most recent on this.

Local patterns of use vary around the country, but as we noted in the first day's (Friday's 21-Aug) story helicopter bases have been sited in spots solely to plant the flag in competitive markets and fend off or take the fight to competitors. So that arguably could be seen as a decision based more on economics than community medical need. And that is the argument now in courts.

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Canyon Lake, TX: Is there any reason why a state cannot determine a certificate of needs before other services are allowed to enter an area wher services are already providing air medical transport.

Gilbert M. Gaul: If you mean, can a state say to an operator, sorry, we believe we already have enough medical helicopters to meet our need, therefore, we won't approve your application for a CON -- the answer would probably be no, based on our reading the operators' lawsuits using the ADA. Especially the North Carolina decision last September. the courts have consistently sided with the operators on this question.

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West Hurley, N.Y.: Looking at the timeline information, the ETA at the level 1 trauma hospital by land ambulance and helicopter was close to identical give or take 1 or 2 minutes. When the helicopter provides no additional life saving value add over road transportation, why don't state protocols require patients be transported to level 1 trauma centers in the SAFEST method possible, which is by land in an ambulance?

Jenna Johnson: It does take the helicopter a while to get in the air, arrive at the scene, load up the patients and then head to the trauma center. But in places like Charles County, calling a helicopter is still quicker than going by ground ambulance. Plus, it allows an ambulance crew to continue responding to emergencies in the county, rather than driving up and down the beltway.

For decades in Maryland there has been a push to get patients to the highest level of care within their "golden hour." Ground responders don't have an MRI machine out on the side of the dark highway and cannot predict what sorts of internal injuries a patient might have.

But Maryland has a high rate of patients who arrive by medevac and are then released from the trauma center within 24 hours.

The state agency that oversees EMS care in Maryland has slowly tightened guidelines for flying patients with low-level trauma injuries. Last summer they released a map with 30-minute drive time circles around all of the trauma centers -- anyone within those circles needs a really solid reason to call a medevac.

After the Trooper 2 crash, ground providers everywhere started consulting with trauma doctors before flying Category C or D patients.

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Miami, Florida: If the authors are going to selectively poach Dr. Ira Blumen's presentation presented over 7 months ago at the NTSB hearings under the banner of "the Post found," such as the purported relative danger of the job, I am wondering why Friday's article failed to "find" that:

(i)In fact, the overall accident rate and fatal accident rate for medical helicopters has declined over time, including since the new Medicare fee scheduled was introduced in 2002, as demonstrated in Dr. Blumen's presentation?

(ii)In fact, the medical helicopter accident rate per 100,000 flight hours is almost half that of General Aviation and approximately 75% of all helicopter operations (oil and gas, tour, homeland security, etc. - none of which share the author's allegations about the role of competition in safety), as demonstrated in Dr. Blumen's presentation?

How do Mr. Gaul and Ms. Flaherty respond to the obvious conclusion from this data that the air medical industry has become safer over time as a trend, as demonstrated by Dr. Blumen's research? How do the authors respond to the implication from this data that the medical helicopter industry as a whole is safer than general aviation and other helicopter operations, again as demonstrated by Dr. Blumen's research?

Gilbert M. Gaul: Dr. Blumen came up with the fatality figure for medical helicopter crews and we acknowledged that. However, he compared the per 100K figure to one year. We took his idea and compared it to 10 years. That's hardly selectively poaching.

We framed our analysis around the number of crews who died in crashes, not accidents. Using your methodology, what is an appropriate rate for crew fatalities?

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Pittsburgh, PA: Thank you for your series. What I find stunning is that the industry has known for a couple of decades how to make helicopter EMS operations safer. Study after study, including pilot surveys, have told operators what is needed to improve safety: NVG's, instrument training and PROFICIENCY, collision avoidance systems, terrain warning systems, eliminating pressure on pilots to accept flights in marginal weather, etc. For every program who invests in safety, there's a low-cost operation who ferociously defend any attempt to force them to improve.

Is there any indication the FAA is willing to mandate MINIMUM industry standards for equipment and pilot experience and training?

Mary Pat Flaherty: Hey Pittsburgh (my hometown--and pre-season games don't matter)

There has been no shortage of reports as you note suggesting methods for improving safety or minimizing risks.

In interviews with us and more importantly in testimony before Congress, FAA officials said they will begin rulemaking to make some of those improvement mandatory, but also note it will be 2011 at the earliest before those rules could be set and take effect. And the exact details would evolve during rulemaking, so what rules will result and what those rules will say cannot be predicted.

Given some of the debates and testimony this spring over proposals floated on the Hill, I feel confident there will be very animated discussion about what those rules should cover.

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Re Pittsburgh: Some years ago, one of my coworkers was in a fairly minor car accident while coming home from the beach. Despite his protests, he was airlifted to a MD hospital because of the traffic jam. I believe he missed one day of work and showed no sign of injury when he returned.

Gilbert M. Gaul: We heard about a fair number of flights like this. It goes again to this larger question about appropriate use. Without any meaningful public data it is currently impossible to say either way that the amount of inappropriate use is minimal or common. conversely, it's hard to say, as the undustry sometimes implies, that are flights are life-saving? We just don't know.

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DC: Is there any sign that the HEMS industry is really prepared to improve?

Gilbert M. Gaul: The industry, I think, would contend that it has been moving consistently to improve safety, and takes safety very seriously. But the industry isn't monolithic. there are a lot of different models and varying opinions about what needs to be done going forward. Some operatorsd would like to see dramatic changes, a full embracing of new technology, better and more consistent oversight from the FAA and more involved discussion from state EMS and health ofifcials that would allow them to better integrate medical helicopters with ground ambulances in their emergency response plans.

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Michigan: It it would have been interesting/eye opening for you to show the profit of the big aviation vendors comparing the profit between the hospital based and community based models... That might have lent some validity in the pressure to fly to make more profit argument

Gilbert M. Gaul: I agree. But the hositals don't make their data public and given that hospitals can "make money" but on transport and in downstream revenue, it would be a little tricky to calculate.

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Washington, D.C.: Is the FAA a competent, adequately resourced and proactive regulator?

Mary Pat Flaherty: Ok, I'll take a shot at this although it has the feel of a "use both sides of the paper if necessary" in that any answer will be wholly incomplete.

FAA folks who are out there now reading may be best positioned to answer in a comprehensive fashion. But in the series we raised some of the needs for inspectors and equipment that FAA itself said it recognizes for its medical helicopter oversight.

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Mary Pat Flaherty: Gil, Jenna and I appreciate all of your questions and for asking us to further explain things. Always a good exercise.

If you didn't get your question in, our emails are linked at the washingtonpost.com site on the stories.

Thanks again.

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