24 hours with Care Flight
Our writer catches a ride with northern Nevada’s leading helicopter ambulance service
10:05 p.m.
North of Wadsworth, three women—mother, daughter and cousin—travel a silent highway. The pickup climbs over a rise. Patchwork ghosts pop into the night, a group of cattle. Four cows die in a tumble of steel and bone.
A state trooper calls the Care Flight air ambulance stationed at Washoe Medical Center. Within minutes, a crew of three—pilot, critical-care nurse and paramedic—are in the air traveling at 170 miles per hour toward the wreck. In less than 15 minutes, the pilot lands beside the highway where flares signal in the dark. The helicopter’s blazing halogen spotlight stutters over sage and asphalt. The nurse and paramedic help spot the clear hundred square feet needed to land at night. Visibility is always a problem. They bump down in a cloud of dust. The flashing lights reveal cow parts and blood, most of which, fortunately, is not human.
12 midnight
Two family members have been transported by ground to an outlying hospital. The mother went with Care Flight to Washoe Med. The crew spends the better part of an hour wiping cow blood from the interior of the MD900 Explorer chopper. They change blood-splattered uniforms and restock supplies before another call comes in. In five minutes, they are at the end of Vista Boulevard in Sparks, where a teenager has run her car off the road. The cause of the accident isn’t clear. The injuries are serious.
“She’ll probably be an organ donor,” the flight nurse later informs her colleagues.
It’s not something she says with sadness or enthusiasm. Her speculation has the simple tone of factuality.
7:20 a.m.
Chief flight nurse Karen Johnson, 37, comes onto duty along with “newbie” paramedic Laura Brown, 34, and helicopter pilot Chris Cattell, 42. Johnson and Brown check the medical supplies and review pre-flight procedures.
Cattell consults with mechanic Katy Rael, who checks fluids atop the aircraft. The chopper’s transmission recently has been replaced, and safety is always a concern.
Aviation in the Sierra has inherent risks. Care Flight has suffered losses over the years. In 1987, a Care Flight airplane went down while banking over the Bridgeport Reservoir, killing the pilot and flight nurse. On a snowy November evening in 1991, another devastating accident took the lives of three helicopter crew members and a patient south of Reno when the main rotor blade apparently detached from the body of the aircraft. During winter 1994, a helicopter skittered into a small ravine at Heavenly Valley, resulting in minor injuries to the crew and severe damages to the aircraft. In 2001, a helicopter was caught in a cloud of dust during takeoff and made a “hard landing” near Hallelujah Junction with a patient on board. There were no injuries in the rollover, which was eventually attributed to pilot error.
Karen Johnson was the flight nurse on board. “I walked away,” she says. “I have no complaints.”
Her blue eyes stare intently. It’s a dangerous business.
In 1986, the frequency of air ambulance crashes became so alarming that the Federal Aviation Administration performed safety audits of air ambulance operators, including Rocky Mountain Helicopters, which maintains aircraft for Care Flight. 60 Minutes reported that 85 percent of 15 crashes were attributed to pilot error. Fallon internist Gary Ridenour charged that companies like Care Flight were forced to overuse air ambulances in order to break even financially due to massive operating costs.
Care Flight’s director of critical-care services, John Morrison, says safety has improved significantly.
“The industry looked at its practices and made changes,” Morrison says. “We have no flight pay, for example. We don’t push crews into flight.” Care Flight policy favors a conservative course.
Working with severe injuries in an environment of inherent risk foments caution and requires courage, but it doesn’t prevent the crews from loving the job.
8 a.m.
Even though Brown has emergency medical experience with the Truckee Fire Department, this is her first shift as a Care Flight medic. Over the course of the day, Johnson checks her out on drugs, procedures and equipment. It’s one thing to speed around in a red truck, but this is Care Flight.
There’s a touch of fly-boy swagger to all of them, nurses, paramedics and pilots alike.
“You have to have a certain amount of confidence to be effective in this job,” says Johnson. “And that comes from experience.” Nurses enjoy relative autonomy in the field, making critical decisions that are often left to doctors within a hospital setting. The paramedics likewise take to the adventure, although the reality isn’t as romantic as imagination frames it.
Medic Steve Alcorn, also an Incline Village fire captain, sums it up: “I like being a medic, and I love aviation.”
As for the pilots, what can be said? They are pilots. They wear cool sunglasses.
“I’m still blown away at the level of care this staff provides,” says Cattell. “It’s been mind-boggling to see what’s on the other end of the 911 call.” He has seven years and 5,000 hours of flight experience, but this is his first medical services job. Before, he worked logging jobs from Alaska to Arizona, spending eight hours hovering over tree tops watching crazy, stoned “hookers” pulling logs nearly on top of themselves. Medical flights are definitely less stressful than logging.
The crew follows routines so that everything becomes habit. They don’t “rush” to scenes. They pace themselves to put safety first. Cattell doesn’t mind calling it superstition. He buckles his five-point harness the same way each time, left side first. He radios to dispatch as the blades swing overhead. Care Flight Three is “coming hot” from Edison Way to work a 12-hour shift from Washoe. The big blue MD900 Explorer that Cattell pilots will fly to the new operations base at the Truckee airport.
The chopper lurches forward and left as it leaves the ground, a normal tendency. In 30 seconds, the Explorer reaches 1,100 feet and cruises at 118 knots (about 136 mph) on a bright, warm morning. The dark ribbon of the Truckee River oxbows past Verdi. Johnson tells Brown over the helmet mike to keep eyes out for small aircraft. On weekend mornings, experimental aircraft tear over the uncontrolled Truckee air space at speeds approaching 250 miles per hour. Cattell spots one of these homemade jobs zipping away from the airport.
Reno to Truckee takes 12 minutes. The Explorer is a strange craft with a system of air intake and expulsion instead of the normal tail rotor to prevent the chopper from spinning in circles. The $3.25 million MD900 was purchased on a 10-year deal in 1995. Care Flight helicopters need power to handle thin mountain air and hot summer swells, potentially dangerous conditions. The company is in the process of standardizing its fleet, having finalized a purchase agreement for three Eurocopter A-Stars, craft designed for mountain rescue.
Two of the new single-engine aircraft will arrive at the end of May. Care Flight will phase out the quirky Explorer along with its entire current fleet. Standardization entails obvious benefits—only a single aircraft system to learn and maintain. Increasingly, it has become difficult to obtain parts for the MD900. One employee—maybe simply invoking a figure of speech—says that a less experienced pilot would “kill himself in this aircraft,” although another pilot disagrees, saying all helicopters fly the same. In any case, Care Flight hires only experienced pilots with a minimum of 2,000 flight hours and mountain night flight experience.
9:15 a.m.
Cattell stretches his lanky frame into a cushy chair, flips on the Science channel. A fireman eyes him with suspicion. The firefighters aren’t allowed to use the cushy chairs until 5 p.m. A feature on moon exploration makes Cattell think of his science fiction novel, the one he’s written in his head—uranium isotopes, encoded information traveling at light speed, secrets of a lost civilization.
“Here we go,” he sits up, hearing a special series of tones on his handheld radio.
Grass Valley dispatch directs Care Flight to Squaw Valley. A complicated dispatch web gets ambulances to ski mountains. Each resort has its own protocol, and each fire department has a preferred ambulance service.
As part of the Regional Emergency Medical Services Authority (REMSA), Care Flight, a nonprofit corporation, generates revenue through fees for service, billing insurance companies an average $3,500 initial fee plus $79 per mile. In 1999, the allowable average rate rose from $2,900 to $4,600 and has subsequently increased to $5,000. Care Flight fees are “well below other helicopter services in the region,” according to spokeswoman Tanya McLain. The program is self-sufficient, with no hospital or government subsidies, and collects about 60 percent of its bills. REMSA was cited by the Washington Post in 1991 as having the best service per dollar in the nation, but the corporation hesitates to conflate “revenue” and “community service.”
Care Flight’s move to Truckee is a business decision as well as a community service decision, however. REMSA wants to snag back ski resort traffic it lost when competitor CALSTAR opened in South Lake Tahoe in 2001. CALSTAR chief flight nurse Bob Griffith thinks Care Flight’s Truckee expansion “was a business move to get the ski resorts.” His company was invited by the community and never wanted to compete head-to-head with REMSA, he says. He acknowledges that CALSTAR has already been hurt by Care Flight’s Truckee base. “It has definitely impacted volume to our detriment.”
A few incidents in the past 18 months have stirred mistrust between the air ambulance services. The issue of “poaching” calls—in other words, of improperly rushing to beat another chopper to a scene—is a sensitive one. Griffith admits that “poaching” exists but says that two helicopters flying to the same scene is usually the result of a miscommunication caused by the complicated dispatch web in the region.
“There’s a mutual respect for service areas,” Johnson says diplomatically. Poaching doesn’t happen very often, she says. Even so, Care Flight won’t announce flight destinations on open bands.
Griffith and Johnson agree that the nearest helicopter should always get the call. When CALSTAR opened, it became the nearest chopper for much of the Tahoe area. That situation changed when Care Flight expanded to Truckee.
The crew crosses a wide tarmac; it’s six minutes to the top of Squaw. Cattell and Johnson discuss the landing zone, their voices crackling back and forth. The awesome western expanse of the Sierra recedes as if in a pretty postcard. Cattell spots patrollers with the victim in a stretcher near the bungee tower at High Camp. A 16-year-old broke a femur. Then the ski patrol radios to say the patient wants to be skied out. She’ll use ground transportation. The Explorer swings back to the airport.
“That’s the cost of doing business,” Johnson says. There will be no billing for this flight.
Care Flight will soon expand the Truckee operation from a 12- to a 24-hour service base. When this happens, most of the north shore of Lake Tahoe and all of Donner Summit will be within the company’s service area around the clock.
REMSA’s business tactics have been aggressive since losing a bid for the South Lake Tahoe contract to CALSTAR. One month after CALSTAR opened, Care Flight expanded its Gardnerville service from 12 to 24 hours. The company is experiencing what might be considered its first real competition. REMSA was granted an exclusive franchise for ambulance services in 1987. Gary Brenner, owner of Reno-based Medic Air, sued central dispatch in 1985 for mismanagement, claiming that Care Flight unfairly received all calls. Critics like Brenner believe that local competition was squelched in favor of a monopoly. Medic Air now focuses on long-distance air flights with a fleet of three fixed-wing aircraft.
12:20 p.m.
Few employees have been around long enough to remember the embattled history. Cattell acknowledges reality as he returns from lunch at a deli near the airstrip.
“If it weren’t for snowboards, people not wearing seatbelts and alcohol, we’d be out of business,” says the grinning, youthful-looking pilot. “Sad but true.”
Soon Care Flight is heading to Quincy for an inter-hospital transport, and the details of the accident leak in. A teenager on a dirt bike for the first time wasn’t wearing a helmet when he slammed into a tree. He walked into the Quincy hospital, but the attending physician wants to send him to Washoe Med. A two-hour, one-way ground ride will take Care Flight 25 minutes.
As the Explorer rises over the Truckee airport, Cattell announces the departure.
“They don’t need to know where we’re going,” Johnson says.
Care Flight’s policy of not announcing flight destinations causes CALSTAR’s Griffith some concern. He believes that, for safety reasons, all helicopters should be made aware of traffic.
Last year’s Martis Peak fire damage is visible south of Interstate 80, and the 1994 Cottonwood fire has scarred the mountains north of the interstate. As the aircraft passes the dramatic Sierra Butte, Mt. Shasta is barely visible beyond Mt. Lassen. The crew chats amicably.
“Look at those ski tracks!”
“Snowmobiles get way out here.”
Everyone spots for power lines and low-flying aircraft when the tiny town of Quincy comes in sight. Probably the most bizarre accident in company history occurred when a Turbo Commander airplane snagged an 8-year-old’s kite and carried the girl 10 feet off the ground for 200 feet. The incident, which reads like fiction, was reported in the Reno Gazette-Journal on March 23, 1988. Care Flight no longer operates any fixed-wing crafts.
Pilot and crew wear latex gloves as they wheel the gurney toward the helicopter. Johnson opts not to restrain the patient’s neck. She always has some concern whether hospital staff will question her transport decisions. No one does.
She requests that Cattell fly low in case an air bubble should pressure the patient’s brain at high altitude. The low-flight path makes for a bumpy ride. Attending the patient, Brown takes a deep breath. Under Johnson’s supervision, she administers a morphine drip. She asks the teen if he needs medication for nausea. Her expression shows that motion sickness affects the entire crew (although a smiling Cattell seems OK). It’s sweltering inside the chopper, and the air conditioning is on the fritz.
Later, Johnson notes, “It’s one of the misperceptions that it’s all guts and glory. We are skilled rapid transport.”
It’s been a rough ride. After hospital staff takes control of the patient, Brown runs a slender hand through her brunette hair. The ride made her nauseated. The taller, blonder Johnson finally admits that one time she got sick inside a helicopter. It’s one more element to overcome, along with weather and decision-making under pressure. Johnson wears an imposing frown as she shakes off the queasiness.
4:45 p.m.
A middle-aged man approaches Mt. Rose’s guest services desk and informs the clerk that he can’t remember where he parked his car. Could somebody help him? He might have banged his head out on the hard pack, he thinks.
The Truckee base responds within minutes. A REMSA ground crew that happens to be in south Reno also rushes to the scene.
With the sun westering and Tahoe’s broad expanse suddenly appearing over Brockway Summit, Johnson says ironically, “I hate this job.” Cattell riffs back with a comment about the size of their office.
Passing over Incline Village, Brown spots some outrageous snowboard tracks S-ing from the ridges. She smiles in admiration.
The ground unit arrives at the same moment Cattell touches down alongside the parking lot. Because the ground ambulance has first contact, and because there is no necessity for air transport, Johnson lets the ground crew handle it. It’s another flight for which Care Flight will receive no compensation.
In 1994, REMSA generated net revenues of $7.2 million and claimed expenses of $6.6 million. In 2002, revenues were $16.6 million and expenses were $15.8 million. Long ago, there was talk of grounding Care Flight due to revenue losses, but the company now seems well beyond solvent.
While competitor CALSTAR averages 20 to 30 flights per month from its Tahoe base, Care Flight averages five times that volume from its three eastern-Sierra bases—Reno, Gardnerville and Truckee—with an average of 1,500 flights per year (about 125 per month). CALSTAR has six other bases in California. Unsubstantiated rumors claim Mountain Life Flight from Susanville might try to gain a foothold in northern Nevada.
Given the competitive atmosphere, critics have cited the temptation to load patients unnecessarily into a helicopter, but Care Flight administration says several things prevent this.
“Most insurance companies don’t reimburse unless they believe [the flight] is justified,” Morrison says. “Utilization reviews” monitor flight necessity and deter employees from taking patients on unnecessary flights. Moreover, if a patient doesn’t want an air ambulance, no one forces it. (Care Flight was sued in 1992 for attempting to revive and transporting a dead patient who had a “no resuscitation” order. Crew members said they were following protocol.)
Proponents have claimed that 12 percent of flight patients would die without Care Flight’s “flying emergency rooms.” Doctors put the figure at 5 to 10 percent but add that 35 percent of patients wouldn’t recover as well without rapid air transport.
Such care doesn’t come without cost. The 1985 base rate was $175 (now $3,000) plus $7 per mile (now $79). The increase reveals rampant inflation of health care costs (along with other inflationary factors). Every patient that Care Flight brings to a hospital draws in-hospital revenues of $13,500, according to a 1985 figure. There’s little doubt that Care Flight carries millions of dollars to local hospitals, but the company receives no fee or subsidy in return.
8:30 p.m.
The city is an explosion of lights as the Explorer returns from the mountains at the end of its shift.
A call comes in, but FAA regulations prevent Cattell from taking the flight. Care Flight nurses don’t have the same time restrictions. In Gardnerville, they are allowed to take 24-hour shifts and sometimes do.
At the Washoe Med helipad, pilot Andy Peek refuels the craft. Johnson consults with registered nurse David Gore and paramedic Steve Alcorn, then retreats with Brown into the office to fill out shift reports.
Soon the Explorer approaches Sand Mountain near Fallon. The chopper is put on “airborne standby” and circles the sky flashing its halogen lamp as if to search for clues on the ground. A man has overturned a sand rail, a sort of small dune buggy. He is unconscious. Time is critical. No ambulance lights materialize in the dark and dust.
This is what they live for, the adrenaline pumping, a life at stake. A deputy on line-of-sight radio can’t tell them where to land. Each crew member stays calm in what could easily turn into a storm of frustration. A female medic from the first-response unit finally establishes visual contact with the aircraft. She directs Peek to land in a bowl. He realizes there is no escape route. If a brown-out occurs, he could tip the way a Care Flight chopper did less than two years ago in daylight. At night it’s worse. He aborts the landing. The Explorer can’t get near the victim.
The helicopter lands at the north campground. The victim lies on inaccessible terrain on the far side of Sand Mountain.
The crew hail several sand rails and explain the situation. The night riders agree to use their “quads"—nothing more than a steel frame and an engine—to retrieve the victim. One man nods his beard and snubs out a cigarette.
Alcorn and Gore strap their equipment onto tenuous steel frames. Sputtering engines creep out of camp and thrust up the dark mountain of sand, headlamps ablaze. Alcorn and Gore grit their teeth and hang on.
The victim, now conscious, complains of neck and back pain. They secure the man to a backboard and ease the sand rail down the slope where a 4x4 flatbed arrives like a timely taxi and carts patient and crew to the helicopter.By the time the Explorer reaches the Trauma Center, it has only 20 minutes of fuel. The patient has broken his neck in two places. Tonight, when the helicopter touches down at Washoe Med, his chances for full recovery approach 100 percent.