Medic’s-Eye-View of Manitoba Air Ambulance System (Part 1)

Editor’s Note: The Spectator is going a little further afield than usual this week, with a report on Manitoba’s private air ambulance serviceThis article is the first of two based on the experiences of a number of medics who work (or have worked) regularly with the service. The Spectator has agreed not to identify them, as some are still employed in the Manitoba system.

Pisew Falls Provincial Park, Northern Manitoba (via Reddit https://www.reddit.com/r/canada/comments/2mlt5l/pisew_falls_provincial_park_northern_manitoba/)

Pisew Falls Provincial Park, Northern Manitoba (via Reddit )

I became a flight medic in Northern Manitoba with romantic notions of adventure and excitement in my head: the adrenaline rush of priority transports; the chance to experience the far north; the opportunity to meet people and see places few ever lay eyes on.

Like most romances, the imperfections and minor annoyances that I first found cute and funny, I later came to resent.

Let me state up front that this article is about Manitoba’s air ambulance system, not the people it serves or employs: Northern Manitobans deserve quality healthcare and those on the front lines (medics, pilots, nurses) are doing all they can to provide it, often under trying circumstances. I also acknowledge the challenge of providing healthcare in a region as large – and as sparsely populated – as Northern Manitoba.

What follows is based on personal experience and work adventures shared with me by colleagues, over years in the industry.

 

Commercial service

Manitoba provides both airplane (fixed wing) and helicopter air ambulance services in the region via a mix of providers.

Lifeflight air ambulances, based out of Winnipeg, provide “rapid inter-facility ambulance transport for critically ill or injured Manitobans outside a 200-km radius of Winnipeg.” Lifeflight teams usually consist of two registered nurses (RNs) or an RN and a medic.

Merlin aircraft

Merlin aircraft, one of two types of aircraft flown by Manitoba’s private air ambulance services. (Photo by
YSSYguy,  GFDL, via Wikimedia Commons)

The province also licenses several commercial service providers, like the one I worked for, to provide “inter-facility ambulance transport from Northern communities.” Our flight teams consisted of one medic or nurse and two pilots, one of who might have standard first aid training. Provincial policies and company medical protocols determine the type of patient each service can transport: some commercial service providers, for example, are not equipped to handle patients requiring intubation.

A typical private service call-out looks like this:

  • Northern nursing station calls the Manitoba Medical Transportation Coordination Centre (MTCC) to request a patient pick up;
  • MTCC calls the private company’s dispatcher to request the company’s service. (Dispatchers have no medical training so can make no judgment as to the appropriateness of the call at this stage of the process);
  • Private company dispatcher calls the flight-team medic;
  • Medic calls the original nursing station for a patient report;
  • If necessary, medic then calls online medical control (OLMC) and speaks to a doctor. (This is not an automatic part of the process; it happens only when we need to discuss a patient’s condition.)

At this point, medic and doctor discuss the patient’s condition, the medic’s comfort level with transporting the patient, the availability of appropriate medical equipment and the applicable protocols.

As the medic, you make a recommendation whether or not to transport. Sometimes the doc agrees with you, other times, s/he encourages you to take the patient despite your belief that a Lifeflight would be more appropriate.

One of the complicating factors in the decision is that Manitoba Lifeflight services travel in fixed-wing planes that are often too big to land at the northern community airports. In these cases, the private service must decide whether to take the transport (hoping the patient’s condition won’t worsen, requiring tools they do not have at their disposal on the flight) or refuse the transport, requiring that alternate arrangements be made. (These alternate arrangements might include one of the minority of private services that have a plane staffed with more than one medical provider.)

 

Never say no

My first indication that the air ambulance service might not be my dream relationship came during orientation when I was told that I should never turn down a transport without showing up to the nurses’ station in person to assess the patient because “we get paid even if we don’t transport.” The obvious issue with this policy? A patient in need of Lifeflight transport must wait for treatment while we fly in to assess.

King Air 200 air ambulance interior. (Photo Public Domain via Wikimedia Commons)

King Air 200 air ambulance interior.  (Public Domain via Wikimedia Commons)

I knew, from my own experience and conversations with others in the industry, that we would regularly fly in and assess patients only to decide we couldn’t take them, but I didn’t realize how frequently it happened until I read a 2013 Manitoba EMS System Review:

MTCC began dispatching Basic Air Ambulance calls in March of 2012. They have gathered dispatch data since the go live date on March 19, 2012 up to July 19, 2012. During this four-month period there were 2005 Basic Air incidents created. Of these 2005 incidents, 1907 incidents were assigned and dispatched to a fixed-wing aircraft. These 1907 incidents had 2572 air resources assigned to the incidents. This number reflects the fact that some transports may have had multiple resources assigned. During the four month reporting period, MTCC received a total of 2447 patient transport requests from facilities and Nursing Stations.

These extra “air resources” also represent flights undertaken by private air services but aborted due to weather conditions – that’s because the pressure to accept calls, even when we suspect we can’t transport, applies to pilots as well as medics. The medics I know have all been on flights that left northern airports in heavy snow or rain or fog. These are conditions in which taking off is not normally a problem (although it can be) but landing safely can be difficult, due to visibility and cloud cover or “ceiling,” as it’s known in the industry. I remember, during one of my winter seasons, an incident where weather prevented us from landing but despite the blizzard-like conditions and low ceiling levels, four other flights were dispatched for the same patient — not one crew managed to land.

Medevac pilots have been asked to fly to locations where they will be unlikely to be able to land because the company gets paid for the attempt. To be fair, the landing is sometimes attempted because a patient is seriously ill and needs to get to a hospital, but often the patient’s illness or injury does not warrant the risk.

Of course, weather is known to move quickly over the flat lands of the Canadian prairies, so should an aircraft fail to land, the dispatch system will then ask another company to attempt to collect the patient. These repeated attempts will happen until they run out of companies to call or someone actually finds a break in the weather and can land. As I said, sometimes the patient’s condition justifies these attempts but sometimes, it doesn’t.

I have heard of cases where one medic/pilot team from a company turns down a trip for medical protocol or weather reasons and the same company asks another of its teams to attempt the transport.

And here’s the kicker: each of these attempts costs money. According to a spokesperson for the government of Manitoba:

Tariff rates vary between companies and aircraft types, but typically average between $10 and $11/statute mile flown (inclusive of any fuel surcharges, landing fees, etc).

It is possible, then, to spend thousands of dollars attempting to transport a patient who ultimately can’t be taken because of poor weather conditions or restricted protocols:

Of the 2,572 air resource assignments, 1867 of these assignments completed a patient transport to the prescribed destination — Manitoba EMS System Review 2013

That means that in the four-month monitored period, roughly one in four assignments was not completed.

 

Solutions

Complaints about the online medical directors, who are employed directly by the private air ambulance companies, are widespread throughout the industry where it is widely believed they will encourage teams to disregard transport protocols in accepting calls because the company earns money for the attempt.

The bottom line is that the private air ambulance service is a private business paid for with public monies and as such, must be properly regulated.

I will reiterate that the people of the northern communities need and deserve medical services, but I question if this is indeed the best system for meeting their needs. Would it not make more sense to better equip the nursing stations so they can complete, on site, the routine testing for which many patients are transported?

Rather than spending thousands of dollars on a failed transport attempt, would it not be better to provide bedside troponin tests (to determine if someone is having a heart attack), lactate monitors (to help determine the chance of sepsis in a patient) or even x-ray machines (to determine if a patient has a fracture or a sprain)?

In 2010/11 Manitoba Health provided an estimated $6m in funding for Basic Air Ambulance services. These costs are funded out of the Northern Patient Transportation Program but are not tracked separately. In the case of the transport of a First Nation member the carrier bills the appropriate Nursing Station/Hospital and those charges are forwarded to the Federal government First Nation Inuit Health Branch for payment —  Manitoba EMS System Review 2013

The province seems to have no standard set for the clinics so they all end up having limited, but different capacities, with good people wanting to provide the best medical care possible. The items I listed, which only scratch the surface, would prevent transports that go out simply because the diagnosis can’t be obtained on site in the north. A redistribution of the money seems an obvious solution to provide the best care possible within the communities, saving the flight transports for the patients needing higher acuity treatments.

Next week: A vital concern is the condition of the planes themselves, which are flown on a regular basis with maintenance issues put off or avoided.

Addendum: The Spectator shared some of the medics’ concerns with the Manitoba Department of Health and received the following statement in reply:

The Manitoba Air Ambulance system consists of Lifeflight, which is operated as a partnership with Manitoba Government Air Services, which provides aviation support while clinical care and the oversight of the medical portion of the program is managed within the health care system.  This program receives baseline program funding and is not dependent on call volume to produce revenues.  Medical direction is provided through provincially-contracted physician medical directors.

A significantly larger portion of the Manitoba air ambulance service (intended to transport lesser acuity patients than Lifeflight) is operated by five private sector companies which operate on a tariff fee per mile flown. These companies provide both aviation services and paramedic or nurse patient escorts as well as engaging physicians to oversee protocol and clinical quality assurance.

All Manitoba companies are expected to adhere to provincial legislation and regulations related to aircraft and personnel standards and are inspected annually to ensure adherence.  All air ambulance companies are dispatched through a central dispatch system which takes into account patient needs, the location of aircraft in relation to the patient, and assuring that the most appropriate aircraft is dispatched for the patient needs.

The Medics involved with this article have a combined 60 years’ professional experience in ground service and industrial environments as well as with the Manitoba air ambulance system. Their concerns, they say, are the same as everyone’s when it comes to healthcare: they want safe, effective systems that put the patient first.

 

 

 

 

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