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A Safe Ride to Health

Trauma is a term used to describe severe injuries, including injuries due to motor vehicle accidents, falls from a significant height, blunt force injuries or wounds from violence. Trauma is the leading cause of death for Canadians under the age of 45 and accounts for the loss of more potential years of life than any illness or disease. More than 200,000 Canadians are hospitalized due to trauma each year. There are also significant financial costs – Canadians spend nearly $20 billion each year on the direct and indirect costs associated with injury.

STARS’ prime concern is delivering appropriate medical care to the critically ill or injured patient in the timeliest way possible. (Photo courtesy of STARS)

There is clear evidence that dedicated trauma services and systems of trauma care save lives. Major advances in trauma treatment and care in the civilian world over the past four decades have come from the lessons learned from the military, especially in Vietnam, where survival rates of battlefield casualties increased exponentially with rapid medical intervention.

In Canada, there are 32 Level 1 and Level 2 trauma centres located in major population centres. Hospitals are rated from Level 1 down to Level 5. Level 1 involves specialized trauma centres with a full range of specialists and equipment available 24/7/365 and Level 5 is at the other end of the spectrum being small rural clinics with limited staff.

A study released by the American Medical Association in April 2012 states that the odds improve even more significantly for those patients transported by helicopter rather than ground ambulance.  The study included data on more than 200,000 adults who had suffered major trauma and required transportation to a Level 1 or Level II trauma centre.

The authors found that while there was a slightly higher rate of death amongst patients transported by helicopter (12.6 per cent) versus ground transport (11 per cent), patients taken by helicopter were more likely to have more severe injuries. When comparing patients who suffered similar injuries, they discovered that patients delivered to Level I trauma centres by helicopter actually had a 16 per cent better chance of survival compared to those transported by ground.

The authors, led by Dr. Samuel Galvagno of the University of Maryland School of Medicine, said that it isn’t clear exactly what element of helicopter transport is responsible for the increased survival rate – whether it’s the medical teams or facilities available on the aircraft, or speed of transport to the hospital. But they did call for more research to investigate the various components of helicopter EMS. The goal of further research is to be able to more quickly and easily identify those injured adults that would be most likely to benefit from helicopter transport.

Military Influence
The use of helicopters as medical transport dates back to the very beginning of their military service, with the U.S. Army utilizing them in Burma at the end of the Second World War. The helicopter came of age during the Korean War, immortalized by the movie MASH and the subsequent TV show, delivering front-line casualties to battlefield medical units and then later transporting patients from the aid stations to hospital ships off-shore.

The concept of the Golden Hour in emergency medicine came out of the Vietnam War with the realization that the sooner a critically injured soldier was delivered to a medical centre that could deliver the required level of care, the greater the chance he or she had of surviving; and a patient that who was delivered to the trauma surgeons by helicopters within that first “golden” hour had the greatest chance of surviving.

As military doctors, medics and helicopter pilots returned stateside from Vietnam, the first dedicated air medical helicopter services were established in the U.S. in 1969, in Hattiesburg, Miss. As the concept was proved, services grew across the U.S. to where today there are more than 800 helicopters in the air medical classification, with more than 400,000 patients transported in 2010. Randy Mains, a Vietnam-veteran pilot, wrote his autobiographical novel The Golden Hour, based on his experiences flying HEMS in California in the early 1970s.

The Canadian Way
Canada took a slightly different route in establishing air-ambulance services, a reflection of the differences in health-care delivery between Canada and the United States. The difference is not so much in the actual health-care delivery as in the administrative and financial models of the two countries. Ontario established Canada’s first medical helicopter service in 1977 with a single aircraft. Development of service in Canada differs from that in the U.S. where air ambulance service is a mix of not-for-profit and for-profit services, often with more than one operator in a market.

In Canada, pre-hospital emergency medical care falls under the jurisdiction of the provinces, with two basic models for service. In British Columbia, air ambulance (fixed-wing and rotary-wing) come under the direction of the BC Ambulance Service, with contractors operating the aircraft with BCAS paramedics. STARS (Shock Trauma Air Rescue Service) is a not-for-profit foundation that operates its own medical helicopters, staffed with its own paramedics, under agreements with the governments of Alberta, Saskatchewan and Manitoba.

In Ontario, Ornge was created in 2005 as a not-for-profit society to take over responsibility for fixed-wing and rotary-wing air-ambulance service from the Ministry of Health. However, the organization is in serious turmoil, as in the past year it has come under extreme scrutiny for mismanagement on several levels. It is currently under a criminal probe for financial irregularities amid allegations of questionable business practices, and excessively high executive salaries, and questions as to whether public money may have been used for private gain. There are also hints that mismanagement of resources and staffing shortages may have led to several deaths.

Nova Scotia operates a single-helicopter air ambulance from Halifax, operated by Canadian Helicopters with paramedics from Nova Scotia Emergency Health Services. Nova Scotia EHS provides service to Prince Edward Island and New Brunswick under mutual-aid agreements. While Newfoundland has no dedicated helicopter air-ambulance system, the province operates four helicopters in its own fleet that can be used for air-ambulance service on an ad hoc basis.

The death of actress Natasha Richardson in 2009 from injuries sustained in a fall at a ski resort in Quebec highlighted the fact that Quebec has no government-mandated helicopter air-ambulance service. The Quebec government did acknowledge the situation under severe media scrutiny, but after several months deliberation the minister responsible stated that the government would still not be instituting a helicopter air-ambulance service. Airmedic, a new company created from AirMédic Air Ambulance, a 12-year-old company started in 2000, operates in Quebec as a subscription based service with clients buying memberships as with an auto club. In April 2012, AirMédic announced that it had found a strategic partner in Capitale Hélicoptère of Quebec City and would be expanding operations (see Angels from Above,” page 14).

Strategic Differences
One major difference between American and Canadian helicopter air-ambulance operations is the safety record. Over the past decade, USA Today has run a number of investigative features questioning the safety record of helicopter EMS in the U.S. In its edition of April 2, 2009, the newspaper quotes Dr. Ira Blumen of the University of Chicago Medical School, testifying before a special hearing of the NTSB in Washington, DC. Dr. Blume said, “air-ambulance helicopters have the worst fatal crash record in aviation, and their crews are among the most likely to die on the job, an expert told a panel of federal investigators.
The rate of fatalities per 100,000 air-ambulance employees over the past 10 years exceeds other dangerous professions such as logging or deep-sea fishing. He was further quoted as saying that, “since 1972, 264 people have died in air-ambulance crashes (in the U.S.).” This was in stark contrast to testimony later in the proceedings that Canada has not had a fatality in air-ambulance operations since operations commenced in 1977.

Tom Judge, executive director of LifeFlight of Maine and a past president of the Association of Air Medical Services, spoke with Helicopters from Washington DC this past April where he was observing an extraordinary four-day series of hearings convened by the FAA on the subject of helicopter EMS operations. He offered some comments on the differences between operating philosophies in the U.S. and Canada.

“I think it’s attributable to a number of things,” he said. “One, it’s attributable to the way the Canadians have chosen to finance the system. Take STARS, it’s a private non-profit, but there’s still some fundamental pieces from the provincial governments that are involved. In the United States, unfortunately, and this not true of just air ambulances but for all ambulances, the only way an ambulance is reimbursed in the U.S. is if you transport somebody. So, the motivation is to put people on stretchers and any kind of vehicle you can and transport them.

Judge also noted that the financial motivation or model is that you have to put people in the vehicles in order to pay the bills. In the Canadian system, you have block funding and the expectation is that you are going to take care of patients. “The lights are still going to be on and the salaries are going to be paid regardless of how you choose to transport a patient, so you end up with a better risk-management ratio,” he said.

Calculated Risk
Another critical difference between operations on both sides of the border involves the risk-management issue. Canadian air-ambulance operators – HeliJet, STARS, Ornge and CHL in Nova Scotia – fly twin-engine medium helicopters with two pilots, IFR and strict regulations regarding adverse weather conditions. Many American operators, especially in the for-profit sector still operate single-engine light helicopters with single pilot under VFR, pushing the safety envelope on virtually every flight.

BC Air Ambulance flight paramedics deliver a patient on the pad at Vancouver General Hospital. (Photo courtesy of BC Air Ambulance)

Scott Young, Director of Aviation Operations at STARS, concurs with Judge’s assessment of the situation. “[As a not-for-profit] we have the luxury of being able to put the patient first,” Young said. “Everyone in health care does, but there are certain realities and even with us there are economics. We have to be sustainable and by not having to consider shareholders and their interests we truly do put the interest of our patients first. Not every organization is able to do that.”

A strong safety focus and commitment to hiring the best pilots is also important, Young notes. “We always fly two pilots, multi-IFR capable pilots and our captains have to have an Airline Transport License. Our co-pilots have to have a commercial rating, an instrument rating and a night rating,” he said. “We don’t have a lot of co-pilots, we don’t seek co-pilots. The demands of our missions require that we have as many highly qualified people as possible so we try to recruit captains, unlike a lot of other organizations and airlines that want to split between captains and co-pilots – it saves money. We don’t do that, we look for operational capabilities, not finances. Quite often we fly with two captains, but only one can be PIC. We have that level of expertise in the cockpit, because we have the luxury of putting people first – our patients. We think that is the best model. It’s different for us, in that it costs us money to go flying. Unlike other companies that make money when they fly, it actually costs us money when we fly. It’s not that we don’t want to fly, because that’s what we’re here to do, but if we don’t fly we’re OK.
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In Alberta, STARS receives about 25 per cent of its funding from the provincial government, related directly to aircraft operating costs and maintenance. The rest of STARS’ budget is directly funded by a wide variety of fundraising initiatives from province-wide big-ticket lotteries to small town pancake breakfasts. Corporate donors are significant source of funding. As STARS moves into Saskatchewan and Manitoba, it has taken a large commitment from the provincial governments for the startup costs, but the commitment to the not-for-profit model has been widely accepted by the community at large in both provinces.

STARS flew 1,650 missions from its bases in Calgary, Edmonton and Grande Prairie in 2011, with many of these flights being inter-facility transfers of critically ill patients. Compared to many American operators that may seem low, but as Young said, “our focus is on the most critical injured and sick patients, that’s our only focus. We don’t fly people in for appointments. We don’t fly people in because they have to see a doctor tomorrow. We get called because a patient’s life is in danger NOW.”

STARS flies with a paramedic and a flight nurse in the helicopter. Doctors are a key part of the program, with referral emergency physicians on staff, doctors who work in the hospital system as well. With requests for an inter-facility transfer, the doctor at the sending hospital initiates the process. The doctor talks to the STARS doctor. They look at the patient’s condition is and what assets are available, whether it requires basic life support or could be advanced life support and then they also look and see if there is an aircraft is available. The decision is based on the condition of the patient and what mode of transportation is most appropriate and available. Then they make the call as to whether it’s an ambulance, a helicopter or an airplane.

In B.C, the helicopter ambulance service is integrated directly into the province-wide ambulance system. Helijet operates two S-76C+ aircraft out of Vancouver (YVR) and a third S-76C+ from Prince Rupert on the north coast. In 2011, 2,308 patients were transported by helicopter in B.C. The BC Ambulance Service (BCAS) Critical Care Transport (CCT) Program provides specialized, pre-hospital and inter-facility treatment and transport for critically ill or injured patients across British Columbia in an integrated model that utilizes rotary-wing, fixed wing and ground ambulances.

Additionally, infant transport paramedics are based at BC Children’s Hospital in Vancouver. They have completed advanced training and provide emergency medical care to paediatric, neo-natal and high-risk obstetric patients. The Infant Transport Team is the only neonatal transport team in Canada which operates a dual paramedic team.

Teams from both STARS and BC Ambulance have garnered top honours at international competitions in the past year, underscoring a comment from Cam Heke, media and public relations manager for STARS, “many people see us as a helicopter company, but we’re not. We’re an emergency medical operation.”

A Commitment to Care
The mismanagement of Ontario’s Ornge notwithstanding, Canada’s HEMS is well positioned to effectively serve Canadians from coast-to-coast, transporting them in a safe, efficient “flying hospital” at a time when they are at their most vulnerable. Flying via helicopter continues to be a safe, efficient, expedient form of medical transportation – and Canadians in need should feel confident they are in good hands when medical teams descend from above.