Air Transport for Island Medical Emergencies-History and Possible Future  

by Joseph Moore

Introduction

Beaver Island Emergency Medical Service (BIEMS) is a governmental agency functioning under and funded by the two Beaver Island Townships, Peaine and St. James.  The funding for BIEMS from the two townships is not based upon population or land area.  It is a 50/50 equal contribution by each township.

BIEMS has been providing emergency medical services (EMS) for the residents of Beaver Island (BI) and the visitors to BI for twenty-five years.  The numbers of emergency transports and responses without transport have ranged from under ten to close to one hundred in the twenty-five years of existence with a median being forty-eight (48) in the last ten years.

BIEMS has not charged for any air transports in the last 25 years because it was not licensed by the State of Michigan for air transports.  It is believed that the air transport portion of the EMS transport for emergently ill or injured patients can break even or be very close to breaking even if the only transports are from BI to the mainland.  If other islands are included in the operations of this air transport license, it might be possible to add a little to the BIEMS budget to purchase replacement and updated equipment.

Project:  License an emergency air transport operation for the purpose of:

1.        Transporting emergently ill or injured patients from Great Lakes islands, with emphasis on Beaver Island, to an appropriate medical facility for the patient’s illness or injury.

2.       Contracting with an FAA Part 135 Certified Twin Engine, Fixed-Wing Air Ambulance for the purposes of providing transportation of patients mentioned in (1) and contract with the air transport operation to provide a qualified pilot for operations.

3.       Holding the air transport provider harmless for the medical treatment provided prior to loading the patient in the aircraft as well as during the air transport.

4.       Requiring the air transport provider to hold BIEMS harmless from the aviation aspects of the flight.

5.       Nothing in this project would suggest or require the air transport operator to fly when the weather or other conditions were outside the FAA operating rules and procedures for that operator.

History

Beaver Island EMS has been transporting ill and injured patients from the location of their injury, from their homes, and from the local medical center, now a rural health center, for twenty-five (25) years.  The three methods commonly used for this transportation include use of a local flight service as a charter, use of a fixed wing air transport aircraft from Traverse City owned by Northflight Air Division, and use of a United States Coast Guard (USCG) medical evacuation (medivac) helicopter.

In 1986, the first emergency medical technician course graduated, and this group used a ground ambulance and provided the ground transport to one of the island’s two airports.  This EMS was licensed by the State of Michigan as a basic ambulance service, and any method mentioned above was used to move the ill or injured emergent patient off Beaver Island to the mainland.  Throughout the last 25 years, BIEMS has continued to advance in medical care procedures, available medical equipment, and education opportunities in emergency medical education.

In 2011, BIEMS is an advanced life support agency licensed by the State of Michigan.  BIEMS has two year-round resident paramedics, nine basic EMTs; and nine Medical First Responders (MFR), all licensed by the State of Michigan,.  BIEMS is also an approved education sponsor and an approved continuing education sponsor.  BIEMS has two AHA certified ACLS and PALS instructors; four AHA certified BLS instructors, two International Trauma Life Support (ITLS) instructors, one PEPP instructor, and one ASLS instructor for year round education and continuing education.

So, BIEMS has grown and continued to improve patient care over the last 25 years.  From one used, high-mileage ambulance, licensed for basic life support, BIEMS has grown to one emergency response advanced life support non-transporting vehicle, one advanced life support ambulance, and one basic life support ambulance.  Over the 25-year period of BIEMS existence, the agency has never licensed an air transport operation.

In 2003 and 2004, BIEMS attempted to start the process of licensing an air transport operation.  A grant of $25,000 was received to purchase an FAA approved cot for the purposes of getting a local flight service to complete the FAA requirements.  It should be mentioned that the FAA calls ALL aircraft certified for medical patient transport, an air ambulance.  The State of Michigan does not call a fixed wing aircraft an air ambulance.  A fixed wing aircraft is called an air transport vehicle.  This is an important difference.  An air ambulance in Michigan requires a certificate of need and a multiple page application that requires a very complex application procedure.  An air transport vehicle does not require a certificate of need or this complex application procedure.

In 2004, the only local flight service decided not to seek FAA air ambulance certification.  The grant money was required to be used for emergency patient treatment and transport and had to be spent within the one year grant cycle.  This money was used to purchase and outfit the non-transporting emergency response vehicle instead of purchasing the FAA approved cot.

The average number of emergency flights over the last eleven years is thirty-nine (39).  The average number of flights that a local air transport provider could fly based upon an eleven year history is thirty-five (35).  The numbers are accurate averages.  The highest number of emergency flights over the eleven year history is fifty (50) in 2007.  Of those fifty flights, only three were handled by the USCG or North Flight. The numbers for the previous years of 2006 and 2005 were forty-six (46) and forty-four (44).  It would seem that the number of emergent flights from Beaver Island would range from 35-50 based upon historical information.   This would indicate that the air taxi service that takes on this challenge could have between thirty-five and fifty emergency charters added to their business each year.

BIEMS personnel have been quite creative in arranging transport over the last twenty-five years.  One patient was placed in the ambulance, the ambulance driven aboard the Beaver Islander ferry, and transported to Charlevoix, taking two hours and twenty minutes for the ferry.  Another patient was taken to the Beaver Island Boat Dock on the island in the middle of a blizzard, loaded aboard a USCG cutter, accompanied by BIEMS personnel, and transported to the BIBCO dock in Charlevoix breaking ice on both ends of the journey.  Another was loaded aboard a private yacht and transported to Charlevoix.  The creativity and need to transport friends and neighbors has been the utmost reason for pursuing this ATIME plan described below.

Motivation for Licensure of Air Transportation of Island Medical Emergencies (ATIME)

Each method of available patient air transport has its advantages and disadvantages. 

USCG

The USCG medivac’s major advantages include lack of a transport fee for the patient and ability to fly in weather conditions not allowed by the other two possible transportation methods.  The major disadvantages of a USCG medivac is that the BIEMS paramedic is required to fly with the patient and is stranded at the transport destination and the dispatch time for the helo can require 45 minutes plus flight time.

Northflight

The major advantages of using Northflight (NF) fixed wing air transport service is that the care of the patient can be turned over to  NF paramedics on Beaver Island after their arrival, and BIEMS personnel do not need to leave Beaver Island.  The two major disadvantages of NF are the dispatch and response time of the aircraft from Traverse City, which is never less than one hour and frequently longer, and the $10,000+ cost to the patient.  For uninsured patients and insured patients with copay and/or deductible, this cost can be exorbitant.

Local Flight Service

The major advantages of using a local flight service are a very short dispatch and response time, the flight service returns BIEMS personnel to the island, the cost to the patient can be more reasonable, and the event is less stressful for the personnel and the patient.  The only disadvantages are the need for the local flight service to have FAA Part 135 Air Ambulance Certification, a lease agreement and/or contract will be necessary with a hold harmless clause, and the need for obtaining $10 million in liability insurance for BIEMS.

It has been determined that two of the above mentioned options for ATIME, excepting the NF option, require $10 million in liability insurance.  At the current time BIEMS is NOT covered by current liability insurance for air transport.  Since BIEMS is a subsidiary under the townships of Peaine and St.  James, much like the Beaver Island Fire Department, the liability insurance for ground ambulance is included in the township liability insurance.  Air transport is not a covered benefit in the township liability insurance.  Excluded specifically from the township liability insurance policy is air transport.

Reasons for Use of Local Flight Service

Patient Care is the primary reason for wanting to use a local flight service for emergent patient transport.  More than 80% of all patient transports by BIEMS are in the general category of medical emergencies including cardiac and neurological emergencies.  It has been demonstrated and research clearly shows that “Time is Muscle” (AHA ACLS) in a cardiac-related event and that “Time is Brain” (AHA -ACLS, ASLS) in a neurological stroke-like event.  BIEMS has demonstrated the ability to have a patient to Charlevoix Airport or Harbor Springs Airport within forty-five minutes of the response to an emergency when using the local flight service.  BIEMS has demonstrated the ability to get a patient to Traverse City airport within a 90 minute time frame from dispatch using the local flight service. 

Both of these periods of time fit the optimal patient care time frames recommended by the AHA for cardiac and stroke events.  However, use of NF or the USCG helicopter are time-devouring methods due to the long dispatch and response period.  In most circumstances, neither NF or the USCG can even arrive and load a patient into the aircraft within this period of time (45-90 minutes).  They both then have further flight time and transfer of care time.  This additional time is detrimental to patient outcomes according to the research results provided by the AHA and the University of Miami research for ASLS.

The most efficient method of patient transport from Beaver Island to the mainland is by using a local flight service.  Since every transport from a medical center or rural health center is classified as an emergency transport, that makes every air transport from Beaver Island an emergent air transport whether originating at the patient’s home, accident scene, or the BI Rural Health Center.  NF and the USCG are unable to provide this time-crucial emergent air transport.  This does not mean that NF and the USCG are not appreciated and will not be used if the local flight service is not available.  Both will be used when circumstances require it.

Air Transport Vehicle Licensing Procedure for a Non-Licensed Agency

A business or organization wishing to license at the advanced life support level in Michigan most follow the following procedure according to the Administrative Rules for EMS Agency Licensing:

1.        The agency must gather together and seek approval for all the policies and procedures required by the State of Michigan for developing an EMS agency

2.       The agency must prove the existence of a roster of personnel approved for the advanced life support level of licensure including paramedics and EMTs.  

3.       The agency must demonstrate competence in EMS skills as well as continuing education for the personnel listed in 2.

4.       The agency must license the air transport vehicle, which means demonstrating the proper equipment and the proper personnel are available for a transport and onboard the aircraft during any air transport.

The Most Efficient Method

The most efficient method of patient transport from BI to the mainland is by using a local flight service.  Since every transport from a medical center or rural health center is classified an emergent transport, that makes every air transport from Beaver Island an emergent air transport whether originating at the patient’s home, an accident scene, or the Beaver Island Rural Health Center.  NF and the USCG are unable to provide this time-crucial, time-critical emergent air transport.  That does not mean that NF and the USCG are not appreciated.   It means that NF and the USCG will be used if the local flight service is not available.

The most efficient method of licensing an air transport operation for emergent transport of patients is to make BIEMS the licensed air transport agency.  The reasons for this are:

1.        BIEMS is already a licensed ALS transporting service in the State of Michigan.

2.       BIEMS can add an air transport vehicle to that existing agency license.

3.       BIEMS will have to submit a minimum amount of paperwork to the State of Michigan in order to complete the licensing process.

Literally, once the liability insurance in the amount of $10 million dollars is obtained, once the local flight service has an Air Ambulance certificate, BIEMS will need only to submit one short application to add an air transport vehicle to its existing license along with proof of the liability insurance, and a copy of the Air Ambulance certificate and lease agreement to the State of Michigan, and the inspection of the equipment and the licensing will follow quite quickly.

Resources: 

1.        MCL 368-1978-17-209 found at http://www.legislature.mi.gov/%28S%28o3kyllewjv13mj20ngvw4pq0%29%29/mileg.aspx?page=GetObject&objectname=mcl-368-1978-17-209

2.       Life Support and Medical Control Rules found at

http://www.michigan.gov/documents/FINAL_2001-015__EMS_95428_7.pdf

About the author

Joseph Moore is a paramedic instructor coordinator, licensed by the State of Michigan to be a paramedic provider and instructor up to and including the paramedic level, with a Bachelor’s degree from Grand Valley State University.  He has taught emergency medical services classes to the public and to school students for more than twenty years here on Beaver Island.  He has been providing emergency medical services to the island residents and visitors for slightly more than twenty-four years.  Joe was director of Beaver Island EMS for more than fifteen years.  Joe was the sole paramedic provider for Beaver Island for five years.  Other than the few visiting paramedics who came in the summer time, Joe was on call for twenty-four hours for most of the year for all five years.

 Joe organized, researched, and arranged for both paramedic programs to be taught on Beaver Island for Beaver Island EMTs.  Joe taught classes in both of these paramedic programs and continues to teach classes.  Joe is certified and a certified instructor in Advanced Cardiac Life Support, Pediatric Advanced Life Support, and Basic Life Support, by the American Heart Association.  Joe is certified and a certified instructor for Advanced Stroke Life Support by the University of Miami.  Joe is certified and a certified instructor for Pediatric Emergencies for Prehospital Providers by the American Academy of Pediatrics.  Joe is certified and a certified instructor for International Trauma Life Support, a program endorsed by the American College of Emergency Physicians (ACEP).  Joe continues to provide paramedic care on Beaver Island. 

Joe is on a first name basis with the Manager of the EMS Division and the Education Director of the Michigan Department of Community Health.  Joe is a well-known spokesperson for rural EMS with contacts in rural EMS throughout the State of Michigan including the UPEMS corporation.

Joe is also the editor of Beaver Island News on the ‘Net.