The Arabic word "haraam" is such an expressive word because it means two things; that something is forbidden and an activity is shocking. Haraam is the word that comes to my mind with the latest development in the plan to operate a helipad atop Children's Memorial Hospital located on Chicago's Lake Michigan.

In the world of aviation, it is a article of faith that all employees must feel free to speak up about safety. So important is the concept that around the world, workers are encouraged to submit confidential or anonymous safety reports - even about their own mistakes - because with safety, you can't fix what you don't know is broken.

Here is where the behemoth air ambulance company, Air Methods apparently took the fork in the road that separates those that wanna be safe from those that don't, according to a news report on ABC Channel 7 in Chicago. In the story, Ravi Baichwal, reports that an unsigned "whistle-blower" letter was sent to the neighborhood group opposing the helipad claiming that pilots who fly into the present ground-based landing zone for Children's Hospital in nearby Lincoln Park, have complained about operating risks at the high rise. But their concerns have been ignored. Further, they were prohibited from "discussing the subject with anyone" the letter says.

I have little doubt that back in the day when the hospital first conceived of the plan to bring helicopters onto their rooftop, 411 feet in the air, in a canyon of high rise buildings commercial and residential, that it had no idea it would be fighting with the neighbors for years. But fight they have as nearly every claim the hospital made about the benefits was challenged by nearby residents concerned about the risks.

The case got quite complicated. Scientists, engineers and meteorologists were hired by both sides.  (Full disclosure: in 2008, the neighborhood group paid for a data search on the Comprehensive Medical Aviation Safety Database in which I have an interest.)

In a battle pitching expert against expert on subjects as dense as atmospheric boundary layers, vorticity isosurfaces and approach path trajectories, it's hard for the general public to know who is right and who is wrong.

But when the very airmen who will be required to fly say the plan is bad, because there is "nowhere to safely land in an emergency" or that "their helicopter does not have the power to successfully fly away on one engine because of the nearness of surrounding buildings" that makes it pretty clear.

So you can see why these people might be under pressure to keep quiet though to their credit, they have not. Instead, the unsigned letter was sent to Streeterville Organization of Active Residents, the neighbors opposing the helipad, a modern-day David fighting two Goliaths; a prestigious hospital and Air Methods Corporation, the nation's largest provider of air medical transport. The letter arrived just as the slingshot-armed-upstart was nearing the bottom of the bag of rocks.

And now, the inspector general of the Department of Transportation has opened an investigation into whether either the Colorado-based and publicly traded Air Methods or the hospital tried to shush those who had something to say about safety.

Of all the things helicopter ambulance companies and their enablers have done in the past decade to turn ostensibly life-saving medical transport into the for-profit multi-billion dollar, over-used and under-regulated sham that it is today, the decision to fight so hard for this location in Chicago seems uniquely arrogant and reckless. But if the inspector general finds that workers were indeed told to shut up about safety that's even worse, that would be haraam.

Photo from Illinois DOT documents

Chicagoans, be prepared for the woomph, woomph, woomph of helicopter blades comin' in from over Lake Michigan once the Children's Memorial Hospital places a helipad on its roof, 411 feet above the street.  At the end of last week, the Illinois Department of Transportation issued permission for the hospital to locate the high altitude helipad in a community of skyscrapers, community and concerned activists be damned. 

It may be noisy, it may cause the values of million dollar properties on Chicago's Miracle Mile to decline but that's not the issue as far as I'm concerned. It's the safety stupid!

The helipad - one of only two this high in the country - will be located in an area dense with potential obstructions. The hospital's application listed 91 high-rise buildings in the vicinity, 12 shorter than and 79 taller than the hospital, with 31 more scheduled for construction in the future. Folks, this is a challenging environment in which to operate a helicopter without the additional factor which is Lake Michigan.

I lived in Chicago for 10 years but it took me 10 minutes to realize why its monikor The Windy City, is so apt.  Forget long-winded politicians, this is a city on a lake with winds that blow through the downtown area with such strength,  ropes are strung from building to building to give pedestrians something grab to keep from being blown down. 

The debate over how to calculate the effect of Chicago winds took years. In granting permission to locate the helipad in this environment, state officials required a lower wind limit for operations than what the hospital requested. 

Its way too little. What roasts me and others who haven't bought the myth that helicopter transport saves lives,  is the hospital's continued insistence that this perilous location is good for its future patients. This despite an accident rate that makes helicopter ambulances the most dangerous form of aviation next to flying in combat. The National Transportation Safety Board has held four investigations into HEMS (that's the handy acronym for helicopter emergency medical services ), concluding that the "accident record is unacceptable". 

What's really behind the push, push, push for more woomph, woomph, woomph,  is the fact that helicopters make money for hospitals and for air ambulance companies like Air Methods, the for-profit corporation that is responsible for flying to the on-the-ground helipad at the present Children's Memorial Hospital in Lincoln Park. Air Methods, by the way, has about 22% of the $2.5 billion U.S. helicopter ambulance industry.

Helipad on hospital construction from IDOT document

The hospitals incautious  request to perch a helipad in a valley of skyscrapers - residential, commercial and educational - should have fallen on ears deafened by the woomph, woomph, woomph of all the other ostensible life-saving helicopters in the past that were, in fact, life-taking. 

That air ambulances can save lives is possible though various studies suggest otherwise. What's unambiguous is the fact that  patients and medical workers have been killed in these helicopters by the score. 

And here to help you visualize that is former air ambulance pilot, Randy Mains who spent this morning bringing the truth on home at the Air Medical Transport Conference in St. Louis. First he distributed to the audience hundreds of envelopes telling the medical aviators to just hang on, they could open them shortly.

Randy is on a mission  making speeches and writing about how to make HEMS operations safer.  

"I have watched in despair for over 32 years as the HEMS system in the U.S. has become more and more dangerous to where it is now officially the most dangerous job in America ."

Finally, the people in the audience with envelopes were asked to stand, 346 of them, about half of people in the room. Inside each envelope was the name of someone who died in a medical helicopter crash. 

Randy's wife Kaye described what happened next. "All you could hear was the tearing of envelopes.  People really were in the moment and looking around, absorbing it. It was about two minutes with people standing. There was an overwhelming feeling."

 
"It was very satisfying, " Randy said, describing the stunt - a bit of dramatics intended to energize the people who do not want to imagined their own names on such a slip of paper in the future.

"We must design our programs in the States like they do it in Europe and Canada where they have excellent safety records," he said ticking off the requirements outside of the United States;  two pilots with current instrument-ratings and night vision goggles, in twin-engine aircraft. "Aviation safety doesn't care about egos, bottom lines or competition.  It only works if it is done right."

Crystal clear to an audience in St. Louis perhaps, but in Chicago what it looks like is safety done wrong.

There's a frightening sameness to the accidents that continue to plague the helicopter ambulance industry, but the crash that killed 58-year old Terry Tacoronte in in Missouri last Friday is notably different. Tacoronte, of McFall, Missouri was a patient, and though there have been 19 helicopter ambulance accidents in since 2009, this is the first time a patient has been killed since October 2008 when the toddler, Kirstin Reann Blockinger died in a crash in suburban Chicago.

A mother of three and grandmother of eight, Tacoronte was killed on August 26th along with the pilot, flight paramedic and nurse, so you may be wondering why am I am focusing so much attention on her.  The reason is this; When pilots or medical personnel go down in an air ambulance crash, there is  little legal recourse. Workmens' compensation precludes them or their families from suing their employer. Unless they can prove the accident was a due to a defect in the aircraft, there is no way for them to sue for compensation.

Say what you will about lawyers, the fact that the people most likely to be injured or killed in  helicopter ambulance accidents never get their day in court has to be contributing to the industry's dismal safety record.

But here comes Mr. Tacoronte armed with aviation attorney Gary Robb and a civil lawsuit that claims it was the practice of Air Methods to fly with reduced fuel as a weight and money saving tactic. The consequence in this case was to cause the helicopter to run out of fuel and crash, according to the suit.

Did it happen that way? Who can say? It really is too early, but fuel exhaustion is not difficult to detect at a crash scene. Lack of a fire or no fuel smell on the ground are good indicators. 

Tacoronte tells reporters as his wife was boarded onto a helicopter to be transferred the seventy miles from from St. Joseph to Liberty Hospital, he kissed her good bye - fully intending to meet her there after traveling by car.  When he arrived a doctor told him his wife of 8 years was dead.

Yes, his story is tragic. As tragic as the stories from the families of paramedic Chris Frakes, flight nurse Randy Bever and pilot James Freudenberg.  And as tragic as what the families of dozens of pilots and medical workers who died in the accidents prior have experienced. 

Unlike them, this widower is free to press his case and use the cudgel of the judicial system to put pressure on the helicopter EMS operators. 

Perhaps things will change because of this accident. Perhaps it will result in a closer examination of the risks versus the benefits of helicopter transport of patients. Perhaps this one minor difference will make all the difference in the world.

The grounding of Airbus A380 airplanes sporting Rolls Royce Trent 900 engines was certainly warranted following the in-flight disintegration of an engine on a Qantas flight from Singapore. But what has made global news for more than a week now, also demonstrates a dramatic disparity in aviation safety. The Airbus near-disaster is being treated with tremendous respect. 

Yet, across the United States, another sector of the aviation industry is crashing aircraft at a rate equal to an airline disaster every day and unbelievably, this carnage is accepted as the cost of doing business.

I'm talking about business of medical transport and the price paid by patients who are moved by air.

Last week, Nanci Wilson of KXAN in Austin, Texas reported on the case of Oscar Vaz. His 12-year old daughter bumped her head at summer camp in June. Now that's not news; everyone knows that bumps, bruises and bug bites are part of the camp experience like campfires and ghost stories. Only in this case the camp called for an ambulance, and it wasn't the four-wheeled variety that showed up it was a helicopter. After a brief visit to the hospital, the girl was released back to camp with a clean bill of health and not long after that, Oscar Vaz received a bill for $16,000.

What the better-safe-than-sorry philosophy costs

Oscar is one smart daddy and he started to wonder just what motivated such a drastic response to a simple bump on the noggin. What factors led to the decision to bundle the child into a helicopter and on to Dell Children's Medical Center? 

Critical attention from a doctor couldn't have been the issue since the helicopter flew right past two hospitals located closer to the camp. And there was no stated need for some highly sophisticated medical technology only available at the medical center in Austin. Oscar was mystified.

"If it is important enough to call an air ambulance, then why not go to the hospital that's 30 minutes away?" he asked me rhetorically when he called this summer. 

I didn't know Oscar then. He came across some of the many articles I've written on this subject when he started researching air ambulances. He got in touch because he was trying to understand the money machine that is today's for-profit air ambulance business. 

But Oscar didn't need much from me. He was already asking the right questions. When the bill arrived, Oscar asked why the 9-11 dispatchers called - then cancelled - Starflight, the Travis County public service helicopter, a taxpayer-supported service which would have cost considerably less, and instead dispatched the for-profit air ambulance Air Evac? If speed was the issue, why did it take the 90 minutes to get the child to the Austin hospital which is only a 50 minute drive from the camp?

Surely, Oscar thought, there must be some standard operating procedure used for determining when an air ambulance is needed and when it is not especially considering that medical helicopters are themselves, not particularly safe. 

What Oscar didn't know - and if you ask me, it's a good thing for his peace of mind that he did not - is that the period of time in which his daughter was flown; the hours between 10 pm and 6 am or what's called "backside of the clock" are the most dangerous hours to fly by helicopter medivac. Nearly half of all the EMS helicopter crashes take place during this time and they are almost four times more likely to result in fatalities than helicopter accidents occurring during the day. So Oscar and his daughter had two things to be thankful for; No medical problems and no unhappy landing.

But there is that whopping bill from Air Evac. And I think that Oscar, and others who have been transported by air unnecessarily feel companies like Air Evac are playing them for fools. 

Their complaints, however, always get reduced to the argument that they are better-safe-than-sorry, that air transport is worth the cost because, after all, a life is on the line. This is the bread and butter scare tactic used by the helicopter ambulance industry and you don't have to go farther than the comment section on this blog to read the endless varieties on that theme.

But one thing aviation does well is the cost benefit analysis and this better-safe-than-sorry argument doesn’t hold up to that scrutiny. So before Americans go any farther embracing the booming business of air ambulances, its critically important to analyze how the industry got cross-wise with safety and study the programs that seem to be doing things right.

And with that I’ll leave you with the promise that these are the subjects I discussed recently with Dr. John Morris Jr., director of Vanderbilt's Lifeflight program, which will be featured in an upcoming post.

I have more news on the underpinnings of the helicopter ambulance industry. Over the past five years I’ve been focused on the aviation side, the operational stresses that cause emergency medical aviation to be the most dangerous kind of commercial transport in America. You can read more about my work with Patrick Veillette on that subject here.



But as the esteemed investigator John Fawcett always says, you never go wrong when you follow the money and I was lax in not paying more attention to the business side - how the for-profit air ambulance companies like PHI, Air Methods and Air Evac chase the dollars to make it all work.

Sure, I’d been told how some of these companies parked their helicopters in shopping center parking lots, using the considerable sex appeal of a gussied up medivac to convince Walmart shoppers they’d be wise to plunk down $50 a year in exchange for a guarantee they'd never have to fork over a dime if they ever needed to be moved by air. So the pitch is relatively simple, fifty bucks against a $20,000 bill in the event of an emergency.

Wait a minute, did I just write $20,000? Yes, loyal readers,that's what I wrote, and you know I've never pegged the cost that high before. But today I learned that's the figure being tossed around in Alfalfa County, Oklahoma where efforts are underway to sign up county workers for memberships with Air Evac and county commissioners are being urged to help make it happen by auto deducting the Air Evac membership fee from employee paychecks.

Now $20,000 is a scary figure and Phoebe Engle signed right up. She works for Alfalfa County and not only that, both her mother-in-law and father-in-law needed to be moved by air to big city hospitals some distance away from Alfalfa County, population 6,000. Medicare paid in both cases, but still, that $20,000 figure got her worried because her insurance only pays 80% she told me.

I was busy blogging about Life Evac's sale of helicopter ambulance services to the athletes at San Marcos Baptist Academy in Texas, while Air Evac salesman Doug Little was selling this product to Phoebe and others in Oklahoma.

“We need to get some more information on this,” Chad Roach told me by phone this afternoon. He's the chairman of the County Commission and he came right out and said he knows zip about Air Evac and less about helicopter medical services. He's not ready to put the touch on employee paychecks without first finding out more.

"We get so many offers, some are great and some..that’s not the case.”

Roach may want to reach out to nearby Woods County, Oklahoma where I’m told county executives have already approved a program to process the payments for county employees who wish to enroll in the Air Evac membership program. Or he can talk to the executives of Alfalfa Electric, who also opened their doors to the medivac salesman.

But he might also want to find out more about an industry operating in such crisis that the National Transportation Safety Board has held three separate special hearings, the most recent in 2009 after 28 people were killed in a series of helicopter ambulance accidents the year prior. Or he could take a look at the list of 15 Air Evac accidents over the past 12 years that I posted on an earlier blog.

“That’s the first I’ve heard about that," Roach said, sounding genuinely surprised. "Like I said, I haven’t had a chance to do the research."

I am dazzled by the sheer moxie of Air Evac's business plan to involve government executives in processing payments for a profit-making company with a questionable safety record, selling a service of questionable value.

And here's the kicker. According to what the folks in Alfalfa County were told by Little, one million people have already purchased Air Evac memberships, providing the company with a $50 million annual revenue stream. Little claims some 10 to12 percent will actually have need of an air ambulance in the future. I think this  figure is inflated. But if its true and insurance pays at a reimbursement rate conservatively estimated at $5,000, that's another $550 million in revenue. And we haven't even touched on transports of patients not in the program, the $20,000 kind.

John Fawcett is right. To understand what's really going on in this industry, you have to follow the money.

So when my son walks into my office and sees me in front of my computer watching an animated short film, I can’t expect him to believe me when I say, "Really honey, mommy's working."

Animated stories of the FREEWAY PATROL

In fact, I was working, watching this You Tube video sent to me by a gentleman in Texas who found himself in practically this same situation, the latest victim of an epidemic of overuse of medical helicopters.  

In the video, a young driver is hit from behind and when she gets out of her car there descends upon her a virtual army of first responders insisting she’s seriously injured and in need of medical attention. No amount of eye rolling or shoulder shrugging can change their minds, and so whiplash collar firmly around her neck, and safely secured to a stretcher, the driver is airlifted from the highway to the hospital -- across the street from the accident site. 

“What’s this going to cost me?” she asks the ambulance attendant. 

“Let me ask you this” he answers, “wouldn't you say your life is worth a mere $17,000?” 

As the credits roll, I’m not laughing and my son, Joseph, asks why not.  “Because it too true,” I tell him, right down to the budget-breaking price tag. 

I’m sometimes told that questioning the use of EMS helicopters is on par with encouraging people to play Russian roulette.  “Wouldn't you say your life is worth a mere $17,000?” 

But who, faced with an expensive medical procedure they will pay for from their own pocket, doesn’t want to know “How much will it cost?” and “Do I really need it?” 

There are too many instances where medical helicopters are called for people who are not critically injured or do not have time-sensitive medical need. (Read my previous posts on this here  and here.) They will be shocked when the bill arrives. If you’ve got a few minutes, I urge you to watch this excellent investigative report by Amy Davis of KPRC in Houston exposing the unethical arrangement between EMS provider PHI and a Houston-area fire house.

According to her report, PHI made a deal with a local emergency service provider in 2008 in which PHI would build a helipad and crew lounge, provide a helicopter, pilots, a mechanic and pay $77,000 per month to the Harris County rescue district. In exchange, PHI would have the exclusive right to carry patients and bill for its services. 

Davis interviews Jason Boatswain - one of the patients transported by the PHI helicopter under the new agreement. Like a character out of a YouTube video, Boatswain, injured in an auto accident, was loaded into a helicopter for the hospital, even though he was not seriously injured. The bill he received for his short ride by air was $12,400. A ground ambulance would have cost less than $700. 

The year prior to the partnership between PHI and the county, the rescue unit moved 12 people by air, according to Davis’ report. With the PHI contract in effect, it moved 106.

I wouldn’t be rehashing a scandal from 2009, if I hadn’t heard of two eerily similar stories, one just a few months ago, also in Texas, about which more later.

The Association of Air Medical Services will hold its 2010 Air Medical Transport Conference in Ft. Lauderdale in a few weeks. Between viewing the product displays, whooping it up at the MASH BASH banquet and enjoying the MedEvac Foundation Charity Golf Classic, let’s hope attendees spend some time trying to figure out how to rein in an industry eager to know “Recovery Marketing after an Air Medical Accident” (Tuesday session 9:45) and intent on “increasing flight volume” (Monday session 11:00) whether patients need those flights or not.

Please don’t call them “heroes” or “fallen angels” or any of that other pap. Last night, pilot Allan Dale Harrison and flight nurse Ryan Duke were killed in the crash of an air ambulance in Kingfisher, Oklahoma. Their flight paramedic was injured.


Shortly after dropping off a patient at a hospital about 7:30 yesterday evening, the helicopter went down into a rural area and caught fire. Unlike the majority of helicopter crashes, the flight was being operated in daylight and in clear weather. It’s too early to know what caused the accident. But please, please, please, air crash investigator, when considering the factors that contributed to this latest air ambulance accident, take a broader look at whether this industry is it’s own disaster.

In the December 2009 issue of Emergency Physicians Monthly (What, you don’t subscribe?) three doctors put it bluntly. What if, several times a year there was medical procedure that - when it went wrong - killed the medical team along with the patient? There would be an outcry, the doctors say. Things would be scrutinized, things would change. Yessir! BUT, here is their point, “Although such a scenario may seem outrageous, it is essentially the same risk that helicopter EMS crews face on a daily basis,” and it is the only medical procedure that is more likely to kill the medical provider than the patient.

Ok, so Drs. Bledsoe, Abernethy and Carrison surely got the attention of the emergency room physicians with that opening paragraph. I wish I’d written it. But how to get the attention of everyone else, everyone who continues to believe that air ambulances are a benevolent public service, offering valuable time-saving transport for the critically injured and that the cost of saving these lives means that a few paramedics or pilots will die every now and then.

I want to take another stab at altering this perception because I think it is dangerous. I think the facts are persuasive enough to get the public past the dramatic made-for-TV-movie version of the story.

1. Helicopter medical transport is a multi-billion dollar industry.

2. It makes its profits by putting people into helicopters.

3. It maximizes profits by cutting costs.

Putting patients into helicopters begins with convincing the public that faster is better. For years we've been hearing about the "Golden Hour" that critical time between injury and medical treatment that is the difference between life and death. A number of published emergency physicians think its a myth. (Read more about this here and here.) Nevertheless, we are convinced that speed equals better outcome. Thus we expect that everything from car crashes to broken bones, are worthy of a trip to the hospital by air. The next thing you know, every fire department, rescue unit and hospital is partnering with an air ambulance provider to bring in the casualties.

Like a well-powered rotor the air ambulance industry spins into an ever bigger enterprise, requiring ever more riders. In 2009, nearly half a million people in the United States were moved by air ambulance. Since 2002 the number of helicopter ambulances has quadrupled. Score a big one for the companies; an addiction to helicopter transport has been achieved.

But business success depends not only on generating revenue - costs must be controlled too. Oh yeah, it’s a challenge to operate helicopters and employ highly trained aviation and medical professionals while keeping a tight hand on the checkbook. On the other hand, air ambulance operators are in a unique situation. The rates they charge aren’t linked to the quality of the equipment they use or the personnel they hire.

Say what? That’s right, a company using an old single engine aircraft with a low-time pilot and fresh-out-of-school medical crew gets paid the same as a company with a brand new, twin-engine, two pilot, highly experienced nursing team on board. (And since you were probably wondering, that’s about $8,000 - $16,000 per flight. More on who gets to pay the tab in a future blog.)

So not unexpectedly, the vast majority of helicopter operators in the United States are flying single-engine, single-pilot helicopters. Safety equipment like terrain awareness, auto-pilot, or night vision goggles are left to each operator’s discretion, who’s feelin’ generous?

So please don’t call the casualties “heroes” or “fallen angels”. Call them evidence that the public has been bamboozled into believing we need to be flying around by air even when the injury is not life threatening, just in case. And call them victims of an industry that’s off-the-radar, fueled with cash and powerfully incentivized to keep on doing it just this way.

The crash Thursday morning of an emergency medical helicopter in Tennessee is another tragic reminder of the crisis in medical aviation. Three people were killed when a Eurocopter AS350 operated by Hospital Wing crashed near Brownsville, Tennessee after delivering a patient in Jackson. While the crash happened shortly before 7:00 a.m., the bulk of the flight occurred during what is considered "the backside of the clock" the hours between ten p.m. and six a.m.. This is the most dangerous time to fly by helicopter medivac. Nearly half of all the EMS helicopter crashes take place on the backside of the clock.


This statistic comes from the Comprehensive Medical Aviation Services Database (CMAS) which was compiled by Dr. Patrick Veillette and myself. Fatigue is a pervasive problem in these accidents, according to Dr. Veillette, a commercial pilot and former EMS pilot. The situation seems to be getting worse. "In just the last 8 years there have been 48 accidents that occurred on the back side of the clock."

Reviewing the so-far-incomplete details of the accident, it appears notably and tragically typical. The aircraft had already delivered the patient and was returning to base, there was bad weather in the area and the flight was being conducted under visual flight rules, without the assistance of enhanced visibility instruments. Our database shows these are the consistently reoccurring factors in helicopter medivac accidents.

What's so frustrating is that it is no mystery how to make air ambulances safer. When EMS helicopters are required to carry two pilots and equipment to help them fly in limited-visibility conditions safer flights will result.

Since 1987, nearly half of the EMS helicopter accidents occurred either at night or in weather that obstructed the pilot's vision. Our statistics also show that people are twice as likely to die in limited-visibility accidents as in those occurring in good weather during the day. Considering the layers of risk in reduced-visibility flights, one would expect operators of air ambulances to make sure their aircraft are equipped to fly in these conditions. But only a small portion are equipped with enhanced-visibility systems.

The EMS helicopter industry has boomed from a few hospitals in Colorado in 1972 to a multi-million-dollar business which operated nearly half a million flights in 2009. This phenomenal growth has been based on a disturbing business model; fly the helicopters as inexpensively as possible - meaning one pilot and a minimum of safety equipment - even though these are inherently more hazardous missions. As one EMS pilot told me, "If they knew what I knew, even the nurse and paramedic wouldn't get on board."

In a study of turbine engine airplane accidents, a noted aviation research company Robert E. Breiling Associates of Florida, concluded that single-pilot flights are riskier than those with two pilots. The statistics show the risk of a fatal accident is 3.7 times greater with a single-pilot. In publishing these findings, AOPA Pilot magazine wrote "single-pilot operations create higher workloads and greater demands on pilot skill when the chips are down and stress levels run high."

Flying a helicopter - any helicopter- is not like flying an airplane. The pilot is busy from start to finish. To an already higher workload and often under time pressure the EMS pilot has additional concerns, a 24/7 flight schedule, a lack of a weather information for the route or destination, operations in and out of non standard landing zones including rooftops, highways and parking lots and flights that take them through obstacles and obstructions.

It is this last factor that makes the need for two pilots most obvious. Of the accidents over the past 20 years, one in of three - involved the aircraft hitting something. With the exception of a pilot-check ride in Michigan in May 2007, all the others were operated by a single pilot. Medical helicopters in Canada and air rescues conducted by the U.S. Coast Guard already require two-pilots. What do they know that America's air ambulance operators do not?

When it comes to making air-ambulance flights safer, the elephant in the room is money. Nobody wants to talk about it because to do so would be to puncture the myth that no expense is too high when it comes to rescuing those in need.

Bringing complicated medical equipment and highly trained professionals to the skies is already an expensive undertaking. Most EMS helicopter companies are businesses with bottom lines to consider. Often a hospital contract will go to the company that offers the lowest bid, which is why additional equipment and doubling of pilots is such a hard concept to sell.

It is imperative that the industry equip all EMS helicopters for reduced visibility conditions and put two qualified pilots in the cockpit to fly them. It's expensive. But once again, investigators have been called to the scene of the crash that is a tragic reminder of the alternative.

Read more about medical aviation here.