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Evaluating the decision to suspend STARS’ services

January 13, 2014  By The Winnipeg Free Press

Jan. 13, 2014, Winnipeg - Manitoba's Shock Trauma Air Rescue Society (STARS) helicopter air ambulance service is the only one of its kind in North America known to have been temporarily suspended because of concerns over patient safety.

And one U.S. expert says if the province imposes further dispatch
restrictions on STARS following its review, it could essentially neuter
the helicopter emergency medical service and create a potential barrier
to patient care.

Tom Judge, executive director of
LifeFlight of Maine, a non-profit hospital critical-care system that
serves more than 40 hospitals in Maine and New England and provides
helicopter response to accidents and medical emergencies in remote and
island communities, said while the province was correct to suspend
STARS, it must also accept that in emergency medicine, things go wrong
— especially in the confines of a helicopter.

"It's a tremendous amount of courage by
the health authority and the provider to open the books when they have
something that doesn't go as planned," Judge said. "Obviously, from the
public's perspective, transparency is good.


"Not all that happens in medicine goes
right, even with the best of intentions, and sometimes even with the
best of care, patients do not do well. There's lots of preventable
medical error, but there are some things where bad things just happen."

Judge, who's worked with STARS over the
years, has also advised the U.S. National Transportation Safety Board
(NSTB) on pre-hospital emergency medical services and is a member of the
Federal Department of Transportation's national EMS advisory council.
He was named the 2011 Program Director of the Year by the International
Association of Air Medical Services.

In its review, the province must balance patient safety with the inherently unpredictable nature of emergency medicine, he said.

"In a time-critical world, time in the
patients that we deal with is often as much an enemy as the actual
disease process. Yes, sometimes we want more controls in the system, but
how do we put those into the system without having more time get taken
off? That becomes a problem for patients."

Manitoba Health Minister Erin Selby
suspended the operations of STARS Dec. 2 after three critical incidents
in less than a year, including the death of a female patient suffering
from cardiac arrest three days earlier. Each of the incidents involved
issues with intubation and proper delivery of oxygen.

The first occurred last February and
involved an adult — no details have been released. It resulted in six
dispatch restrictions being placed by the province on STARS, including
the type of patient the service could fly and the distance it could
transport patients.

The second critical incident was last
May, and involved two-year-old Morgan Moar-Campbell, who was being flown
from Brandon on a STARS helicopter for tests following a seizure. The
boy was in an induced coma and could not breathe on his own. When he
landed in Winnipeg, it was discovered his breathing tube had become
dislodged, depriving him of oxygen and leaving him severely brain
damaged. His case is now the subject of a lawsuit.

The provincial review, which includes an
external audit of 15 other cases involving STARS, continues, Selby said
this week. Originally, officials said the expectation was STARS would
resume emergency flights this month. In the meantime, the service
conducts regular training flights.

Judge said those reviewing STARS must be
mindful that to restrict the service further — on top of the six
dispatch restrictions already placed on STARS — will impact patient

"There's risk in both directions," he
said. "There are certainly some patients, I would guess — with this
suspension now more than 30 days — that probably could have benefited,
or also had bad outcomes, and that's not being captured."

He also said there are "bad patient outcomes" in ground ambulances the public never hears about.

"There's an issue of opacity in medicine
in general, I think, all over the world. There are ground ambulance
accidents and there is lots of care that goes south… and no one even
knows about. And that's a problem."

Vancouver writer Paul Dixon, who's
written extensively on Canadian helicopter air ambulance systems for
Helicopters magazine , said despite Manitoba's experience with STARS, the
overall Canadian experience with helicopter emergency medical services
is far superior to the experience south of the border.

"The short story is that Canadian
operations in one word are safer," Dixon said. "With the exception of
Quebec, all the helicopters used are large helicopters, or in the
business they would be 'medium' helicopters. Twin-engine, they fly two
pilots and almost universally the pilots are instrument-rated so they
are capable at flying at night and in conditions that would ground a
light helicopter."

Judge agreed.

"Canada has a much better record when it comes to the safety of medical helicopters," he said.

The U.S. has been plagued with fatal helicopter air ambulance crashes for the past decade.

The U.S. Federal Aviation Administration says from 1992 through 2009, 135 helicopter air ambulance accidents claimed 126 lives.

Since then, there have been an additional 39 deaths and 19 injuries resulting from helicopter emergency medical services.

"They are almost universally operating
single-engine aircraft (like a Bell 206) with a single pilot," Dixon
said of U.S. helicopter air ambulances. "You've got one pilot, one nurse
or paramedic and one stretcher patient and you're loaded to the brim."

They are also flying under the pressure of getting to an emergency scene quickly.

"The hero mentality, they call it," Dixon said.

The NSTB is pushing for better training
of pilots, since many accidents happen at night. Crashes are also due to
helicopters colliding with wires and flying in extreme weather. The
NTSB has also recommended national guidelines be created for the
selection of appropriate emergency transportation (ground or air) for
urgent-care cases. Draft guidelines have been published in the journal
Prehospital Emergency Care.

There have been crashes in Canada. Last
May 31, an Ontario Ornge helicopter air ambulance, a Sikorsky S-76A on a
night flight, crashed near Moosonee, killing two paramedics and both
pilots shortly after takeoff. The crash may have occurred because in the
darkness, the crew lost visual reference with the ground.

In March 2011, a B.C. helicopter air
ambulance taking off from a road near Pitt Meadows almost crashed when
its rotor blades cut into a telephone line. The pilot landed safely. No
one was injured and the patient was loaded into an ambulance to be
driven to hospital.

The main difference between the two
countries is U.S. helicopter air ambulance services — there are more
than 600 — are mostly private, for-profit companies. In Canada, all
operators except for Quebec are in varying degrees publicly funded.

What's needed in both countries is to
continuously push up the standards of care, but in a reasonable way, be
it how patients are ventilated — manual "bagging" versus monitored
intubation — to how each emergency flight is reviewed to prevent error
and reduce risk, Judge said.

"But there's a cost to that. Every time
we put a new standard of care in, there is a cost associated with it.
We're always trying to balance the cost of getting it wrong with putting
the standard in."

Dixon also said what's often overlooked is the vast majority of helicopter air ambulance flights are extremely stressful.

"The people they are generally flying are
critically ill — these aren't pleasure flights. And the conditions
they are flying in are often marginal.

"People don't realize this. They just get fixated on the helicopter."

Comparison of helicopter ambulance services across Canada


Operations were suspended Dec. 2 after
three critical incidents — including the death of a woman three days
earlier — in less than a year. Each of the incidents involved issues
with intubation and proper delivery of oxygen.

FUNDING: The province and Shock Trauma
Air Rescue Society (STARS) signed a 10-year agreement, worth $10 million
per year, in February 2012 for the non-profit, Alberta-based
organization to provide helicopter air ambulance services in southern
Manitoba. STARS is also funded through corporate, community and
individual donations. In Manitoba, fundraising, including a lottery, is
expected to raise 25 to 30 per cent of the service's $10-million annual

ON BOARD: Each crew comprises two pilots,
a critical-care nurse and a critical-care paramedic. An emergency
physician trained in pre-hospital care and transportation is also
available by telephone for every emergency response and travels in the
helicopter when medically necessary.

AHEAD: The province said two years ago it
would build a helicopter landing pad atop the new seven-storey,
$39-million diagnostic imaging centre being built at the Health Sciences
Centre. A value-for-money audit on the STARS agreement by Manitoba's
auditor general, Carol Bellringer, is to be released early this year.

Here's what's happening in other jurisdictions:


The BC Ambulance Service contracts
helicopter services with two private companies, Helijet International
and CC Helicopters Ltd., as part of its provincewide critical-care
transport program. Two helicopters are based in Vancouver and there is
one each in Prince Rupert and Kamloops.

There have been no critical incident reviews.

ON BOARD: Each base is staffed with
dedicated critical-care paramedics with the exception of Prince Rupert,
which is staffed with on-call primary-care paramedics.

FUNDING: In 2012-13, the
publicly funded BCAS spent $55.1 million for the aircraft, ambulances,
personnel, training and fuel in support of the transport program. The
annual cost of the four helicopters is estimated at about $15 million.

AHEAD: B.C. auditor general John Doyle
said in a report last year the province's air ambulance service was weak
in measuring the quality, timeliness and safety of its patient care. He
also said staffing shortages mean lesser-skilled paramedics were sent
to emergencies in pairs because higher-skilled responders were
unavailable. Doyle's report recommended the service had to better manage
performance, to periodically review distribution of staff and aircraft
and to regularly review a sample of air ambulance dispatch decisions to
ensure resources are allocated with due consideration for patient needs.


Shock Trauma Air Rescue Society (STARS)
has operated in Alberta since 1985. During that time, it has transported
thousands of patients with no critical incident reviews.

FUNDING: The Alberta government provides
only 20 per cent of the cost, with the non-profit agency making up the
rest through sponsorships and fundraising.

In an 2010 agreement, Alberta Health
Services agreed to support STARS and provide funding through to the year
2020. In 2010-11, Alberta Health Services provided $6.34 million. Total
AHS funding in 2011-12 was $6.88 million.

Total operating expenses per base is
approximately $10 million a year. STARS currently operates a fleet of
seven Eurocopter BK117 and one AgustaWestland AW139 helicopters from
bases on Calgary, Edmonton and Grande Prairie.

ON BOARD: Two pilots, a nurse experienced
in emergency/ICU care, an advanced-life-support paramedic and a
referral emergency physician.


STARS began service in 2012. There have been no critical incidents.

FUNDING: The Saskatchewan government
funded $5 million for STARS in 2011-12, with approximately $10 million
annually moving forward. The remainder of the funds will come from STARS
fundraising efforts, including contributions from the community and
corporate sector. Corporate partners to date are:

Crescent Point Energy, lead and founding donor, $5 million.

Mosaic Potash, $5.5 million toward a hangar, engineering and crew quarters and a helicopter for the Regina base.

PotashCorp supports STARS by making
available a helicopter and hangar at the Saskatoon base. The estimated
value of these assets is $27 million.

Enbridge — $500,000.

Enerplus — $300,000.

Husky Energy — $250,000.

Rawlco Radio — $100,000.

Graham Construction — $25,000.

AHEAD: Recently, STARS started landing at
Regina General Hospital with Transport Canada's certification of a new,
provincially funded $3.4-million rooftop heliport for use. A similar
helipad is planned for the new Children's Hospital in Saskatoon.


Ornge is the publicly funded ambulance
service, which includes helicopter ambulance locations across the
province. Ornge is responsible for all aspects of the province's air
ambulance system, including performing inter-facility transfers, scene
calls and non-urgent transfers.

FUNDING: The entire
service receives about $150 million annually from the province. Ornge
has also been under fire for more than a year over executive salaries
and alleged spending irregularities. It fell under public scrutiny after
the release of the auditor general's report in March 2011 and is
currently the subject of a legislative committee review and an Ontario
Provincial Police criminal investigation.

ON BOARD: Two pilots and two paramedics;
the level of care required for a given patient determines the level of
paramedic assigned to the transport: primary-care paramedics,
advanced-care paramedics and critical-care paramedics.

AHEAD: Ornge's service has never been
suspended. Ornge reports critical incidents or adverse events to the
ministry of health, which has the authority to conduct investigations
through its Emergency Health Services Branch.

As a result of a number of these
investigations, the Office of the Chief Coroner undertook a review of
air ambulance transport-related deaths in Ontario in 2012 under its
Patient Safety Review Committee.

It looked at 40 cases and whether
operational issues related to the air ambulance transport may have
caused or contributed to any deaths between Jan. 1, 2006 and June 30,

The review found in five cases there was a
possible impact; in one there was probable impact; and in two cases
there was a direct impact.

The focus of the review was on systemic
issues rather than the medical care provided by paramedics. However,
there were three cases it said blurred the distinction between systemic
and individual issues. These cases related to oxygen and ventilation
equipment and management of oxygen reserves.

The two direct-impact cases are:

Case No. 1 — A 17-year-old male with a
history of depression was found by his mother with a self-inflicted
shotgun wound to his face. He was stabilized at a community hospital in
northern Ontario and transported to a community hospital in another
province via air ambulance. Prior to transport, he was intubated, though
with difficulty, due to the shotgun injuries to the face. During the
transfer, the patient became agitated and removed his medical
therapeutic airway. This self-extubation was followed by a failure to
re-intubate, profound lack of oxygen and a cardiac arrest that lasted 25
minutes with ongoing resuscitation efforts. The patient was
resuscitated with return of pulse, but he subsequently died. The review
found a delay in co-ordinating the patient's transfer and a lack of
effective sedation led to a circumstance where the extubation could
occur, which ultimately had a definite impact on the death.

Case No. 2 — A 22-year-old male had a
history of drug and alcohol misuse, diabetes, and acute alcoholic
pancreatitis. After bloody vomiting followed a two-day drinking binge,
he arrived at the local First Nations nursing station. He was treated
and sent home. He returned the next day with worsening symptoms. He was
transported via air ambulance to a community hospital in northern

The patient required more extensive care
than could be provided there, and arrangements were made to transfer him
by air to a centre in eastern Ontario. Staffing configuration for the
flight was non-standard because of the sudden illness of a critical-care
paramedic during the call. A nurse from the intensive-care unit of the
sending hospital had to step in. During the transport, the oxygen flow
rate was set at 25 litres per minute (L/min) instead of the typical
15L/min. This resulted in the medical oxygen supply running out before
landing, at which time vital signs were absent. Resuscitation, including
CPR, was initiated, and oxygen from the ground ambulance was provided.
Resuscitation efforts continued, but the patient was pronounced dead
shortly after arrival in hospital. The review found the non-standard
staffing configuration and the accompanying registered nurse's lack of
familiarity with the equipment and aircraft may have contributed to the
potential for the error in oxygen flow rate setting.


AirMédic Air Ambulance is a private,
membership-based company independent from the public health-care system.
It was formed in May 2012 and operates from seven bases in Quebec to
airlift members in need of rapid hospital care. It also operates two
fixed-winged Pilatus aircraft. AirMédic has never been the subject of a
critical incident review.

ON BOARD: Crew includes a pilot, a nurse
and a flight paramedic. Aircraft crews assigned to inter-hospital
transfers include a pilot, a co-pilot and two flight nurses.

FUNDING: AirMédic is not funded by the
Quebec government. Annual individual coverage starts at $120 and family
memberships are $250. Members also include remote lodges, the Quebec
Major Junior Hockey League and La Capitale General Insurance, which
provides its clients with coverage. Services are free of charge for its
members. Its structure is similar to Swiss Air-Rescue Rega in
Switzerland, which has operated since 1952.

AHEAD: AirMédic plans to open an eighth
base shortly. It's currently based in Saguenay, Quebec City,
Mont-Tremblant, Saint-Hubert, Chibougamau, Sherbrooke and Radisson.


Emergency Health Services LifeFlight is
the smallest helicopter air ambulance service in Canada for emergency
patient and intra-hospital transport. Canadian Helicopters is contracted
by the province to operate a single helicopter base. The service has
operated since 1996 and serves more than one million Nova Scotians.
Prince Edward Island and New Brunswick also contract this service. At
one time, Nova Scotia had a contract with the STARS service, but
terminated it in 2001 over discomfort with the fundraising model and the
desire to bring the air-ambulance service under the province's
umbrella. EHS LifeFlight has never been subject to a critical incident
review or suspended because of a death or review.

ON BOARD: A critical-care registered nurse and a critical-care paramedic and two pilots.

FUNDING: The program is fully funded by
the province's Department of Health and Wellness. The department's total
budget for 2011-12 was $3.76 billion of which the EHS budget was 2.9
per cent or $108 million. Approximately 80 per cent is for paramedic,
nurse, physician and other health professionals salaries. The remaining
20 per cent covers operational costs.


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