September 13, 2004
Lifting off | LifeFlight of Maine brings the state's air-medical infrastructure into the 21st century
By Taylor Smith
In November 1993, a Bell 206-L-1 helicopter en route from Ellsworth to the Portland Jetport plunged into the storm-whipped water of Casco Bay. Bad weather and poor decisions were blamed for the crash. Headwinds of 40 to 60 knots drained the helicopter's fuel reserves, stalling the engine seven miles from the airport.
To compound the tragedy, the helicopter ˆ owned by Portland-based Airmed Skycare and operated by its parent company, Echo Helicopter ˆ was an air ambulance, and carried a paramedic, a nurse and a 70-year-old burn victim being transported to Maine Medical Center's Special Care Unit. All three were killed in the crash. The pilot, John G. "Sean" Rafter, survived but was seriously injured. Rafter ultimately accepted responsibility for the accident, and the Federal Aviation Administration revoked the operating license of Rafter's company, Airmed Skycare.
It's a sobering story, and one that Tom Judge, president of the Association of Air Medical Services, an industry group based in Alexandria, Va., says routinely comes up in national discussions about air-medical safety. "Without question, it was a very tragic event," says Judge, who also is the executive director of LifeFlight of Maine, a statewide critical response medical helicopter service. "But it was also a very big setback to the concept of air medicine in Maine."
That setback lasted until 1998, when LifeFlight of Maine was established as a joint venture between Eastern Maine Healthcare in Bangor and Central Maine Healthcare in Lewiston. In early 1998, Maine was the only state in the nation without medical helicopter service. The state relied on a handful of fixed-wing air ambulance providers and occasional helicopter support from the Maine National Guard's 112th Medical Company based in Bangor, as well as medical helicopter services in Boston and New Hampshire.
But the state's health care officials that year decided Maine needed its own medical helicopter service. After all, they figured, Maine is one of the most rural states in the country, and many residents are far removed from health care facilities that offer the kind of care required by a critically injured patient, since most hospitals in Maine can't afford to keep a staff filled with specialists such as gastroenterologists, cardiologists or neonatologists. "The state's geography is a barrier preventing people from getting care," says Judge. "If you live in Jackman or Calais, Fort Kent or Rumford, we should do everything from a policy standpoint so you have every access to services that other towns have."
Since LifeFlight's inception, the state's air medical infrastructure has grown rapidly. The board of directors of EMH and CMH recently voted to purchase two specially outfitted $4.2 million AgustaWestland helicopters to replace LifeFlight's two current aircraft, which are each leased for $350,000 a year. What's more, voters last November overwhelmingly approved a $63.5 million transportation bond that earmarked $3 million for improvements to LifeFlight and Maine's air medical system. That money will start being disbursed in October, and will go toward new helipads at regional hospitals and fuel storage and communications improvements at regional airports across the state.
The profit effect
Judge was well aware of the consequences of the Airmed Skycare accident on Maine's health care system, as he was a board member of Maine Emergency Medical Services in 1993 when Rafter's helicopter crashed into Casco Bay. For one, Rafter owned Airmed Skycare, which operated as a private, for-profit air ambulance service. Though his ownership of the company wasn't discussed beyond a brief mention in the National Transportation Safety Board report of the accident, a number of people in Maine's health care community saw a serious conflict of interest with Rafter operating both as owner and chief pilot of the company. "There was little doubt that he shouldn't have taken off in the conditions that he did, and I think there's little doubt that there was financial incentive behind [his decision]," says Jay Bradshaw, director of Maine Emergency Medical Services. "It was an example of what happens when a for-profit ambulance service is struggling to get going."
In the 1990s, air medical service was a polarizing topic in the national health care community. Opponents felt that the risk involved in such flights ˆ from both helicopters and fixed-wing aircraft ˆ didn't outweigh the benefits of rapid transport for critically injured or ill patients. Supporters simply said that air medical services saved lives.
Health care officials in Maine ˆ including Tom Judge ˆ kept close watch on a medical helicopter program developed in 1994 at the Dartmouth-Hitchcock Medical Center in Hanover, N.H., which sits on the eastern border of Vermont. The Dartmouth-Hitchcock Advanced Response Team was told by Vermont officials that the program couldn't operate in the state because it wasn't properly certified. A compromise was reached in 1996 when Vermont officials agreed to vet the program, with an expert panel of physicians closely examining the circumstances of more than 100 flights to determine if awarding DHART certification would amount to a good policy. "At the end of period, they said yes, it does make sense," says Judge.
The DHART review also yielded a set of guidelines illustrating the types of patients and scenarios that should be served by air ambulance helicopters. For example, it found the service appropriate for patients whose clinical conditions would worsen the longer they were kept from a treatment center, and for patients who needed specialized critical care life support during transport that typical ground transportation couldn't offer.
Those guidelines were adopted by LifeFlight of Maine in 1998, as the service was in its early stages of formation in Bangor and Lewiston. In addition to these guidelines, Judge worked with officials from EMH and CMH to craft a well-defined mission for LifeFlight. One area Judge felt strongly about was streamlining the decision-making process ˆ for everyone from pilots to flight nurses and paramedics. "We have to marry the clinical and the aeronautical realities" of LifeFlight, says Judge, "but the first requirement is to never do anything where safety is compromised."
That agenda has earned accolades from members of Maine's health care industry, including Maine EMS's Jay Bradshaw, and has helped further LifeFlight's somewhat unique status as a nonprofit organization that has become a critical piece of infrastructure in the state.
LifeFlight's two helicopter crews fly more than 800 times a year combined, and while the majority of the program's flights are in response to emergency calls, Judge says LifeFlight often is called upon for the good of Maine's medical community. Whether it's flying to an American Red Cross blood bank in Dedham, Mass., to replenish the state's blood supply or delivering a cup of medical leeches to physicians in Fort Kent, Judge says the flights occur because it's LifeFlight's job to serve the public. "The business of medicine is not business," he says. "First and foremost, it's based on a medical imperative."
The cost of doing business
But LifeFlight's role carries serious financial implications. The average cost for a LifeFlight flight is roughly $5,500, and the program generates more than 90% of its $5 million annual operating budget through patient services, which are billed to patients' insurance companies. That said, much of LifeFlight's operating costs ˆ such as fuel and personnel expenses ˆ aren't recouped when providing additional services such as flying supplies of blood and cups of leeches. LifeFlight also isn't reimbursed for the hundreds of thousands of dollars a year spent operating injury prevention programs for school children or clinical education seminars for local emergency medical service personnel. Judge says that LifeFlight operates "right around the break-even point."
Fresh Air, a Caribou firm started by Bill Belanger in 2000, is a for-profit fixed-wing operator that provides air service for the Aroostook Medical Center's Crown Ambulance in Presque Isle and Caribou Fire and Ambulance. Belanger ˆ who is one of three Fresh Air pilots ˆ says his company also is at the break-even point, but that financial considerations don't factor into flight decisions. "We follow FAA regulations," he says. "If we can go, we go."
For Belanger, who also operates an optical retailer in Caribou called Optix, profit isn't a big consideration. In 1995, his daughter was involved in an accident and was flown by the now-defunct Pine State Airlines to Maine Medical Center in Portland. "It pretty much saved her life," says Belanger, who has decades of flight experience. "When Pine State went out of business, there were no air ambulances. Somebody had to do it."
Crown Ambulance called Fresh Air 93 times last year for flights, the majority of which were emergency calls to transport trauma or cardiac patients to tertiary care centers in Bangor and Portland. Dennis Cornelio, assistant manager of Crown, says Fresh Air's service provides a welcome change from the days when charter aviation companies would try to fit emergency flights into their schedules of mail drops, scenic tours and charter flights. "We struggled miserably," he says. "I can't express how valuable it is to have a dedicated plane waiting for us."
At LifeFlight, its Lewiston and Bangor locations are each staffed with crews of four pilots and 20 flight nurses and paramedics. The pilots are contracted through Keystone Helicopter, a West Chester, Penn.-based service company that also leases LifeFlight its two helicopters. Keystone is paid a set fee of roughly $1 million a year for its services, which includes pilot and mechanic training, upkeep of the helicopters and administrative services.
LifeFlight's communications center does double-duty as an ambulance dispatcher, and medical crews are leased by the hour from the hospitals where LifeFlight is based. LifeFlight nurses and paramedics work in the intensive-care units of Eastern Maine Medical Center and Central Maine Medical Center between LifeFlight calls, and are expected to be in the air 12 minutes after the phone rings at the LifeFlight communications center.
Though much of LifeFlight's operating budget comes from patient flights, a fundraising and public relations organization called the LifeFlight Foundation was established in 2003 to provide additional financial support to LifeFlight of Maine. The foundation, headquartered in Union, is governed by a board of trustees separate from the LifeFlight board and has set a three-year fundraising goal of $4.7 million. Judge, who is on the foundation's board, says the organization hasn't yet begun a widespread capital campaign, but that it expects to do so in the next year or so.
Meanwhile, much of the fundraising activity has been centered around receptions ˆ from Cape Elizabeth to Tenants Harbor ˆ where past LifeFlight patients recount their experiences with the program. "You need to friendraise before you can fundraise," says Judge. "The blueberry farmers that have been in accidents or loggers who had emergencies spoke far more eloquently than I could ever speak about the effects of LifeFlight."
Patients aren't the only ones to ready to back LifeFlight; hospital administrators and state health care officials also testify to the organization's importance in Maine. Rumford Hospital CEO John Welsh was among the dozen or so Maine health care administrators who spoke in support of increased LifeFlight funding through the transportation bond. Welsh remembers when his hospital wasn't equipped to handle LifeFlight helicopters, and patients arrived to the hospital in ambulances over treacherous snow-covered roads. "When we didn't have a helipad, we didn't use that service," he says. "Now that we do, I can't imagine being without it."
To compound the tragedy, the helicopter ˆ owned by Portland-based Airmed Skycare and operated by its parent company, Echo Helicopter ˆ was an air ambulance, and carried a paramedic, a nurse and a 70-year-old burn victim being transported to Maine Medical Center's Special Care Unit. All three were killed in the crash. The pilot, John G. "Sean" Rafter, survived but was seriously injured. Rafter ultimately accepted responsibility for the accident, and the Federal Aviation Administration revoked the operating license of Rafter's company, Airmed Skycare.
It's a sobering story, and one that Tom Judge, president of the Association of Air Medical Services, an industry group based in Alexandria, Va., says routinely comes up in national discussions about air-medical safety. "Without question, it was a very tragic event," says Judge, who also is the executive director of LifeFlight of Maine, a statewide critical response medical helicopter service. "But it was also a very big setback to the concept of air medicine in Maine."
That setback lasted until 1998, when LifeFlight of Maine was established as a joint venture between Eastern Maine Healthcare in Bangor and Central Maine Healthcare in Lewiston. In early 1998, Maine was the only state in the nation without medical helicopter service. The state relied on a handful of fixed-wing air ambulance providers and occasional helicopter support from the Maine National Guard's 112th Medical Company based in Bangor, as well as medical helicopter services in Boston and New Hampshire.
But the state's health care officials that year decided Maine needed its own medical helicopter service. After all, they figured, Maine is one of the most rural states in the country, and many residents are far removed from health care facilities that offer the kind of care required by a critically injured patient, since most hospitals in Maine can't afford to keep a staff filled with specialists such as gastroenterologists, cardiologists or neonatologists. "The state's geography is a barrier preventing people from getting care," says Judge. "If you live in Jackman or Calais, Fort Kent or Rumford, we should do everything from a policy standpoint so you have every access to services that other towns have."
Since LifeFlight's inception, the state's air medical infrastructure has grown rapidly. The board of directors of EMH and CMH recently voted to purchase two specially outfitted $4.2 million AgustaWestland helicopters to replace LifeFlight's two current aircraft, which are each leased for $350,000 a year. What's more, voters last November overwhelmingly approved a $63.5 million transportation bond that earmarked $3 million for improvements to LifeFlight and Maine's air medical system. That money will start being disbursed in October, and will go toward new helipads at regional hospitals and fuel storage and communications improvements at regional airports across the state.
The profit effect
Judge was well aware of the consequences of the Airmed Skycare accident on Maine's health care system, as he was a board member of Maine Emergency Medical Services in 1993 when Rafter's helicopter crashed into Casco Bay. For one, Rafter owned Airmed Skycare, which operated as a private, for-profit air ambulance service. Though his ownership of the company wasn't discussed beyond a brief mention in the National Transportation Safety Board report of the accident, a number of people in Maine's health care community saw a serious conflict of interest with Rafter operating both as owner and chief pilot of the company. "There was little doubt that he shouldn't have taken off in the conditions that he did, and I think there's little doubt that there was financial incentive behind [his decision]," says Jay Bradshaw, director of Maine Emergency Medical Services. "It was an example of what happens when a for-profit ambulance service is struggling to get going."
In the 1990s, air medical service was a polarizing topic in the national health care community. Opponents felt that the risk involved in such flights ˆ from both helicopters and fixed-wing aircraft ˆ didn't outweigh the benefits of rapid transport for critically injured or ill patients. Supporters simply said that air medical services saved lives.
Health care officials in Maine ˆ including Tom Judge ˆ kept close watch on a medical helicopter program developed in 1994 at the Dartmouth-Hitchcock Medical Center in Hanover, N.H., which sits on the eastern border of Vermont. The Dartmouth-Hitchcock Advanced Response Team was told by Vermont officials that the program couldn't operate in the state because it wasn't properly certified. A compromise was reached in 1996 when Vermont officials agreed to vet the program, with an expert panel of physicians closely examining the circumstances of more than 100 flights to determine if awarding DHART certification would amount to a good policy. "At the end of period, they said yes, it does make sense," says Judge.
The DHART review also yielded a set of guidelines illustrating the types of patients and scenarios that should be served by air ambulance helicopters. For example, it found the service appropriate for patients whose clinical conditions would worsen the longer they were kept from a treatment center, and for patients who needed specialized critical care life support during transport that typical ground transportation couldn't offer.
Those guidelines were adopted by LifeFlight of Maine in 1998, as the service was in its early stages of formation in Bangor and Lewiston. In addition to these guidelines, Judge worked with officials from EMH and CMH to craft a well-defined mission for LifeFlight. One area Judge felt strongly about was streamlining the decision-making process ˆ for everyone from pilots to flight nurses and paramedics. "We have to marry the clinical and the aeronautical realities" of LifeFlight, says Judge, "but the first requirement is to never do anything where safety is compromised."
That agenda has earned accolades from members of Maine's health care industry, including Maine EMS's Jay Bradshaw, and has helped further LifeFlight's somewhat unique status as a nonprofit organization that has become a critical piece of infrastructure in the state.
LifeFlight's two helicopter crews fly more than 800 times a year combined, and while the majority of the program's flights are in response to emergency calls, Judge says LifeFlight often is called upon for the good of Maine's medical community. Whether it's flying to an American Red Cross blood bank in Dedham, Mass., to replenish the state's blood supply or delivering a cup of medical leeches to physicians in Fort Kent, Judge says the flights occur because it's LifeFlight's job to serve the public. "The business of medicine is not business," he says. "First and foremost, it's based on a medical imperative."
The cost of doing business
But LifeFlight's role carries serious financial implications. The average cost for a LifeFlight flight is roughly $5,500, and the program generates more than 90% of its $5 million annual operating budget through patient services, which are billed to patients' insurance companies. That said, much of LifeFlight's operating costs ˆ such as fuel and personnel expenses ˆ aren't recouped when providing additional services such as flying supplies of blood and cups of leeches. LifeFlight also isn't reimbursed for the hundreds of thousands of dollars a year spent operating injury prevention programs for school children or clinical education seminars for local emergency medical service personnel. Judge says that LifeFlight operates "right around the break-even point."
Fresh Air, a Caribou firm started by Bill Belanger in 2000, is a for-profit fixed-wing operator that provides air service for the Aroostook Medical Center's Crown Ambulance in Presque Isle and Caribou Fire and Ambulance. Belanger ˆ who is one of three Fresh Air pilots ˆ says his company also is at the break-even point, but that financial considerations don't factor into flight decisions. "We follow FAA regulations," he says. "If we can go, we go."
For Belanger, who also operates an optical retailer in Caribou called Optix, profit isn't a big consideration. In 1995, his daughter was involved in an accident and was flown by the now-defunct Pine State Airlines to Maine Medical Center in Portland. "It pretty much saved her life," says Belanger, who has decades of flight experience. "When Pine State went out of business, there were no air ambulances. Somebody had to do it."
Crown Ambulance called Fresh Air 93 times last year for flights, the majority of which were emergency calls to transport trauma or cardiac patients to tertiary care centers in Bangor and Portland. Dennis Cornelio, assistant manager of Crown, says Fresh Air's service provides a welcome change from the days when charter aviation companies would try to fit emergency flights into their schedules of mail drops, scenic tours and charter flights. "We struggled miserably," he says. "I can't express how valuable it is to have a dedicated plane waiting for us."
At LifeFlight, its Lewiston and Bangor locations are each staffed with crews of four pilots and 20 flight nurses and paramedics. The pilots are contracted through Keystone Helicopter, a West Chester, Penn.-based service company that also leases LifeFlight its two helicopters. Keystone is paid a set fee of roughly $1 million a year for its services, which includes pilot and mechanic training, upkeep of the helicopters and administrative services.
LifeFlight's communications center does double-duty as an ambulance dispatcher, and medical crews are leased by the hour from the hospitals where LifeFlight is based. LifeFlight nurses and paramedics work in the intensive-care units of Eastern Maine Medical Center and Central Maine Medical Center between LifeFlight calls, and are expected to be in the air 12 minutes after the phone rings at the LifeFlight communications center.
Though much of LifeFlight's operating budget comes from patient flights, a fundraising and public relations organization called the LifeFlight Foundation was established in 2003 to provide additional financial support to LifeFlight of Maine. The foundation, headquartered in Union, is governed by a board of trustees separate from the LifeFlight board and has set a three-year fundraising goal of $4.7 million. Judge, who is on the foundation's board, says the organization hasn't yet begun a widespread capital campaign, but that it expects to do so in the next year or so.
Meanwhile, much of the fundraising activity has been centered around receptions ˆ from Cape Elizabeth to Tenants Harbor ˆ where past LifeFlight patients recount their experiences with the program. "You need to friendraise before you can fundraise," says Judge. "The blueberry farmers that have been in accidents or loggers who had emergencies spoke far more eloquently than I could ever speak about the effects of LifeFlight."
Patients aren't the only ones to ready to back LifeFlight; hospital administrators and state health care officials also testify to the organization's importance in Maine. Rumford Hospital CEO John Welsh was among the dozen or so Maine health care administrators who spoke in support of increased LifeFlight funding through the transportation bond. Welsh remembers when his hospital wasn't equipped to handle LifeFlight helicopters, and patients arrived to the hospital in ambulances over treacherous snow-covered roads. "When we didn't have a helipad, we didn't use that service," he says. "Now that we do, I can't imagine being without it."
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