EMS helicopter operators build a case for their service

 - March 26, 2007, 12:29 PM

Jeff Hensel leaves the same voicemail every July 23. “Today is the anniversary of my accident,” the 25-year-old Northern Illinois resident reminds people, as if those listening might actually forget that day in 1999 when his car slammed into a tree. “If it weren’t for Flight For Life and a lot of people who took care of me, I would not be here today.”

In late January, Scott Gordon, COO at Arkansas Children’s Hospital in Little Rock, proudly announced a record-setting 100th Extracorporeal Membrane Oxygenation (ECMO) transport flight. ECMO machines act as temporary mechanical alternatives for children whose hearts will no longer beat without external help.

The glue that holds these events together is an emergency medical services (EMS) helicopter and the improved level of immediate patient care it brings anywhere it operates.

To an EMS physician, paramedic or nurse, the word “critical” barely explains the life-and-death nature of the “Golden Hour,” a concept that evolved from Korean War-era M.A.S.H. units. If a surgeon treats a severe trauma patient within an hour of the injury, that patient’s chances of survival improve dramatically, often by as much as 90 percent. The trick is bringing a surgeon and patient together so the work can begin.

Few dispute the life-saving role of an on-scene helicopter. According to Association of Air Medical Services (AAMS) statistics, some 800 EMS helicopters transported more than 450,000 patients in the U.S. last year. AAMS members also operate 168 fixed-wing aircraft that transport another 110,000 patients each year.

However, EMS helicopter operations provide critics with more than a small amount of ammunition. First, helicopters have high operating expenses. In addition, running a flight department is far removed from most hospitals’ core business competencies, blinding many executives to its possibilities. The costs and time drain of an EMS operation often incur regular losses or, at best, break-even numbers that can translate into bad PR for healthcare institutions.

Finally, the safety record of EMS helicopters has attracted a good deal of negative attention, as the sector consistently amasses one of the worst accident rates in aviation. With that significant a list of cons pulling on the pros, why would a hospital bother?

Gordon said the drive to open an EMS operation at Arkansas Children’s Hospital was partially the result of its being the only children’s hospital in the state, but also because there was no other helicopter EMS service in Arkansas. From the beginning, he said, “We simply were not as driven by profit as much as by the need to deliver
a quality service. It was essential that the EMS operation aligned with our corporate values and delivered the same level of quality service found in other parts of the hospital.” Arkansas Children’s Hospital’s EMS unit flies each of its two Sikorsky S-76C+s between 1,000 and 1,100 hours annually and employs 12 pilots and a half dozen helicopter technicians.

Operationally, the hospital is bucking an emerging sub-contracting trend in EMS programs by running the entire operation itself. It owns the helicopters, deals with maintenance and pilot hiring and dispatching and is responsible for the capital investments required to jumpstart such a program.

Taking on the responsibility of running a flight department was actually an evolutionary step for the hospital. When it first launched its EMS service 22 years ago, it subcontracted through a local FBO and later with PHI and Keystone Helicopters before it decided to undertake the project itself. Gordon said the decision to go it alone was based in part on some of the “conflicts between the goals of the hospital and those of the contractors, such as overall responsiveness and the need to minimize down time.”

Gordon’s group did not wander into flight department operations blindly. “We knew the learning curve would be steep, and honestly, the last thing we wanted to do was run a Part 135 service.” The hospital’s business plan detailed the need for setting up 24 clinics around the state, so staff looked at all the options the helicopters might support before deciding to bring the operation in house.

The business plan included competitive bidding for the helicopters, which helped bring the Sikorskys on site. “These were not the cheapest helicopters, but they were the best fit for our operation. The key was the realization that transport would be the gateway to our service.”

A Revenue-generating Operation
The University of Chicago Hospital Aeromedical Network’s (UCAN) bright orange Eurocopter Dauphin is an EMS icon familiar to regular viewers of NBC’s long-running ER series when it lands on the Chicago hospital’s rooftop helipad.

Dr. Ira Blumen, an emergency room physician, is UCAN’s program director. “Our program has been in existence for 23 years to extend the arm of critical care
to the out-of-hospital environment. That has translated into a stepped-up number
of inter-hospital transports and on-scene recoveries,” by ensuring that the choice
of EMS helicopter or ground ambulance gives patients the care they need appropriate to the situation.

“We see tremendous growth coming in EMS helicopters,” Blumen said. “But I think more hospitals are getting out of [running] the helicopter business themselves. UCAN runs the medical side of the EMS program, but hired CJ Systems to handle the management of pilots, technicians and all maintenance issues for UCAN’s 1,300 to 1,400 annual transports.

“We considered the choice of CJ systems a sound business decision because it gave us added equity in the program and offered us many more options than we would have had if we’d tried to run everything ourselves. We simply did not want to be in the helicopter business,” he said.

Gordon explained that from a financial perspective EMS operations are not doomed to be money losers. “We realize that often the sickest patients require many more resources, resources that often provide the hospital with the greatest revenues. While the helicopter might carry 1,000 out of 10,000 new patients in a year, the revenue we derive from those 1,000 patients represents much more than 10 percent of the hospital’s overall revenue. It is critical to balance the matrix of direct cost to the overall contribution of a department to the organization as a whole.”

Blumen recalled, “Fifteen years ago, most [EMS operations] lost money. I think more today are at least breaking even thanks to a significant increase in reimbursement four or five years ago from Medicare.”

Ed Marasco, CJ Systems’ senior vice president of air medical services, said, “This is a high-cost business. You have to provide a service that is medically necessary. But if you do it with the right volumes, you can make it all work. There have been many operations we started where the local organization knew they would not make money running an EMS operation, but the benefits to the community made it worth being there.”

Other EMS operators have realized that overall effectiveness translates into basing helicopters where patient need is the greatest, closer to where the research shows the most accidents occur.

Many experts credit Marasco with helping convince Medicare executives that reimbursement needed to be more closely tied to the cost of services delivered. “I represented the medical industry in the government’s two-year negotiated rulemaking process. Now, most EMSs receive payments that more equitably reflect the local differences in the cost of providing service, such as in rural communities where costs can be enormous.”

CJ Systems employs more than 400 pilots and successfully evolved because “this industry is on a pendulum of control and risk,” according to Marasco. “Some hospitals have their own Part 135 certificate. They own everything. Next are hospitals that own the helicopters and employ the medical staff. Then there are those who contract with us for everything, and finally hospitals who partner with us to varying degrees.”

Marty Tompkins is administrative director for AirMedic Flight Service, attached to Doctors Memorial Hospital in Perry, Fla., just over an hour southeast of Tallahassee. AirMedic operates two EC 135s on 45 flights per month through a partnership with CJ Systems. The hospital provides the paramedics and doctors and CJ handles everything else.

Tompkins says the CJ partnership limits the hospital’s exposure to risk “and we see no reason to change something that’s working well. I do wish we’d known more about the details of establishing an EMS operation at first, though, because it took us nearly two years to become operational.

“Before we started our program, I heard horror stories about how expensive it would be,” Tompkins recalled. “We’ve been breaking even on our helicopter service since day one.” AirMedic recently placed a second helicopter in Quincy, Fla., north of Tallahassee, and reports a small profit from the overall program.

Safety Record Raises Concerns

Bob Breiling, president of Robert E. Breiling Associates, said “Twelve percent of turbine-powered helicopters are operating as EMS machines in the United States.” While the accident rate for EMS helicopters is not much worse than for other civil helicopter operations, their fatal accident rate is nearly double that for their more traditional civil counterparts.

EMS helicopters, especially those operating to and from an on-scene accident site, often fly at night and in unfamiliar terrain. Despite guidance from public-service people on the ground, EMS helicopters often fall victim to wires, trees and collisions with terrain. “Twin-engine helicopters fare little better in EMS operations,” Breiling added. In 2005, for example, three single-engine EMS helicopter accidents resulted in a single fatality, said Breiling, while nine twin-engine accidents that same year killed three people. Anecdotally, experts believe the fleet of twin-engine EMS helicopters is larger than the single-engine fleet.

One EMS helicopter pilot who preferred to remain anonymous recalled his flying experiences, as well as a few war stories from comrades. “Although all of our flying is VFR, there are helicopter pilots who push the weather just [as some] fixed-wing pilots [do]. Some pilots are simply adrenaline junkies who do this for the excitement, like ambulance drivers.” In fact, he continued, “Some of my nastiest on-scene responses were to ambulance accidents.”

Comparing EMS helicopter accidents with ground-based ambulance crashes is eye-opening. A study published in the Annals of Emergency Medicine said that as many as 12,000 emergency medical vehicle (ambulance) crashes occur each year in the U.S. and Canada. Dozens have resulted in fatalities to paramedics as well as patients.

Swift advances in technology are also proving challenging to EMS helicopter programs, precipitating choices about the equipment to be carried on board. Arkansas Children’s Hospital’s ECMO machine can be easily removed from the aircraft. Patients retrieved by helicopter can now have an intra-aortic balloon pump inserted on-scene, right after heart failure, by a doctor flown to the scene 10 minutes before. Five years ago, pumps could be inserted only in an operating room.
As CJ Systems’ Marasco explained, other new technologies such as night-vision goggles for pilots will be standard on the 25 new helicopters the company has on order.

Marasco warned new program entrants to evaluate carefully how an EMS helicopter might fit their business plan, as well as which delivery system will be most effective. “In this business, you must assume you’re going to make transports you won’t get paid for. If you only wanted to make money you wouldn’t be mixing the aviation business with healthcare. You have to recognize the mission comes first.”   

European Helicopter Emergency Medical Service Operations Still Lack Homogeneity

European helicopter emergency medical services (HEMS) operators have to overcome a number of significant hurdles before the segment can become a well oiled machine. First, because operations are provided under various plans in Europe, the various states’ local authorities and hospitals throughout the continent have different responsibilities and thus different arrangements with operators. Moreover, JAR-OPS 3 helicopter operational rules are not implemented uniformly. The structure of HEMS operations in France, Germany and the UK provides a representative outline of the industry’s organization on the continent.

The lack of statistics on HEMS operations at a national level in France prompted the creation of a medical helicopter operation register in April last year. So far, 10,000 flights have been recorded with information submitted by more than 50 hospital EMS organizations. “We will have details on who operates what, where and so on. The Ministry of Health will use this to shape a policy,” Dr. Nicolas Letellier, president of the French association of HEMS-user doctors, told AIN.

Some 38 helicopters are operated in EMS by companies under contracts with hospitals. They are called “white” rotorcraft, as opposed to state-owned rescue helicopters–either red (those operated by the country’s emergency preparedness organization, the Sécurité Civile) or blue (those operated by the police). The consolidation under way in France, with small hospitals losing their surgery capabilities to bigger hospitals, will increase the demand for transportation. Letellier forecasts a need for 50 to 60 “white” helicopters in France.

For tax reasons, operators in France provide “bare” aircraft. Medical personnel are responsible for the material they bring on board, including stretchers, patient monitoring equipment and so on.

A longstanding issue has been the duration of the contracts between a hospital and an operator. According to French law, the hospital must issue a tender at the European level. The contract runs for one year and can be renewed twice. According to Letellier, “Both operators and hospitals would like a longer-term relationship. We are pushing for five- or seven-year contracts.”

Another issue has been the standardization of training. In France a HEMS operator employs pilots but no medical staff. They come from the hospitals, which are local public administrations. Letellier raised the question of how the pilot is expected to have authority over a third party that could be seen as a customer.

A response might come from the European HEMS and air ambulance committee (EHAC), which is creating an aeromedical crew resources management course. It integrates the mandatory aviation crew resource management training with special aspects of the medical crew in HEMS. This integrated training is expected to yield improved safety in HEMS operations. The reciprocal understanding of the needs of all professions on board should lead to better decisions under stressful situations, said EHAC board member Friedrich Rehkopf.

Rehkopf estimated that 20 instructors will be trained by year-end. Early next year, courses will start to have between 300 and 600 people trained by the middle of next year, Rehkopf estimated.

Government Oversight
In Germany, ADAC Luftrettung, a branch of the country’s Automobile Club, is an integrated service provider. Counties or states responsible for EMS regularly assess medical quality, Rehkopf, who is also managing director of ADAC Luftrettung, told AIN.

He complained about red tape in maintenance and training. “The trend looks a bit like trying to ensure flight safety by the completeness of documentation,” he said. For example, ADAC Luftrettung operates 47 helicopters–BK 117s and EC 135s–and is a certified maintenance organization. However, it is required to have 47 individual maintenance programs.

He also reproached German authorities for being slow in implementing JAR-OPS 3 rules. For example, the most recent official JAA Standard for JAR-OPS 3 is dated Dec 1, 2006. Yet the official German JAR OPS 3 (in the German language) was last updated on July 1, 2002.

Letellier and Rehkopf are promoters of low-level IFR flights. “Flying VFR makes night flights very difficult. A number of them get canceled,” Letellier said. He hopes GPS guidance, advanced autopilots and point-in-space approaches will change the situation. An experiment has just started with a low-level IFR route between two hospitals in Nogent-le-Rotrou and Dreux, in northwest France.

In Great Britain, all 16 of England’s and Wales’ air ambulances early last year created the Association of Air Ambulance Charities (AAAC) to advocate on behalf of the industry. AAAC argues that all the lives and money it saves entitle the group to a significant degree of influence in the creation of health policy. In the UK, HEMS is provided by fund-raising charities. The 16 charities operate 22 helicopters.

Association chairman David Philpott told AIN, “We clarified that we do not want money from the government. But we would like the government to help us with infrastructure issues,” he said.