Neighbor Isle medical transport system lacking
| • | Military may help in emergency situations |
| • | Maryland boasts nation's best medical evacuation system |
By Beverly Creamer
Advertiser Staff Writer
When a medical emergency strikes on the Neighbor Islands, a patient is supposed to be transported to the state trauma center within five hours. But, on average, it takes nearly eight hours for patients to reach treatment, according to the most recent statistics.
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"It's not as fast as we would like," said Donna Maiava, manager of the State Department of Health's Medical Services System. "We're hoping to improve it."
A patient is removed from a Hawai'i Air Ambulance Cessna 414 after a flight from Kaua'i to Honolulu. HAA, with five airplanes, has served the state since 1980.
Maiava, who oversees a patchwork system of aging, privately operated air ambulances augmented when possible by Coast Guard and Army helicopters, vowed that she won't retire until the response time is cut to five hours — her goal, and also the recommendation of the American College of Surgeons.
That requires addressing the many obstacles to prompt delivery of trauma patients:
- The state's population is thin and scattered everywhere but on O'ahu, and hospitals can't afford to set up sophisticated emergency treatment centers on each Neighbor Island.
- Those whose injuries are too serious to be handled at Neighbor Island hospitals must be evacuated to Queen's Medical Center in Honolulu in one of five small, fixed-wing planes operated by Hawai'i Air Ambulance. HAA's planes can be airborne in eight minutes but travel and link-up time between islands can stretch into hours.
- Helicopters are better suited for Hawai'i, where mountains and powerful winds pose problems for pilots of fixed-wing planes. But it would cost $8 million to $10 million to buy and operate a state-of-the-art system with three emergency helicopters providing point-to-point patient delivery, compared with $3 million to operate the fixed-wing fleet. And medical insurance reimbursement won't cover the increased costs of helicopter evacuation.
- Hawai'i lacks a state police force that, in other states, coordinates emergency transportation.
No one is more aware of the problems with air evacuation than Andy Kluger, chief operating officer of the air ambulance service.
Kluger has invested $4 million in the company since he rescued it from near-bankruptcy in 1997.
"The state couldn't afford what we do," he said. "If we weren't there, nobody would be there."
Hawai'i Air Ambulance has served the state since 1980 and its pilots typically fly between 1,000 and 2,000 missions a year from bases on O'ahu, Maui and the Big Island. Last year, its pilots flew 2,047 missions.
Timeliness an issue
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Hawai'i Air Ambulance recently earned accreditation from the Commission on Accreditation of Medical Transport Systems, which certifies air and ground emergency evacuation companies nationwide. But timeliness remains inconsistent — and it's something the accreditation commission doesn't measure.
Dispatcher Judy Opunui assigns medical missions from the Hawai'i Air Ambulance terminal at Honolulu International Airport. In other states, emergency transportation is coordinated by state police.
When the company's five planes are in use, or when some are down for repairs, patients wait.
"We can get a call that a patient is ready to be discharged (but) they may not get the patient to the airfield for an hour, and that can hurt everyone waiting for a flight," Kluger said.
The company must rank patients according to severity of injury, just as a hospital emergency room operates by triage, said Kluger.
"It's not just the time of injury until they reach the hospital, but the time they're stabilized even before the air medical transport is activated," Maiava said. "Then ... getting them from the hospital to the airport, flying them, then getting to the facility — that's a lot of components to make sure they're all operating efficiently."
When aging HAA aircraft are grounded for maintenance or its pilots have exhausted their flight allowances, the Coast Guard or Army may be approached. But Coast Guard and Army Military Assistance to Safety and Traffic, or MAST, helicopters are generally reserved for patients who are too large for HAA's airplanes — and even these aircraft aren't always available.
Further frustrating the air ambulance service's efforts to improve emergency services are government health-insurance programs that reimburse only a fraction of each flight's $2,800 cost.
Private insurance carriers such as Hawai'i Medical Services Association reimburse the full amount of emergency flights, Kluger said. But 45 percent of his clients are covered by Medicare, which pays $1,235, and Medicaid, which pays $738.
Alaska two years ago won a 300 percent increase in its Medicare reimbursements because of the unique challenges of serving its trauma patients, Kluger said.
Congress was poised to increase payments to carriers for rural Medicare patients in other states, but President Bush froze that expenditure upon taking office.
"Reimbursement is certainly a big issue," agreed Eileen Frazer, executive director of the accreditation commission. "Typically the helicopter programs were started by hospitals years ago and hospitals would underwrite the program. But without that help from the hospital, it's very difficult for a program to see black and survive."
Maryland system works
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A few states, especially the most populous, have found extra money or raised taxes to pay for emergency air services.
Mike Yamamoto, a chief flight paramedic, left, and flight nurse Carolyn Allen inspect medical equipment, while medic Bobby Thurston prepares a bag with IV equipment and trauma pack. HAA is accredited by the Commission on Accreditation of Medical Transport Systems.
Maryland legislators found creative ways to underwrite what is said to be the country's best air ambulance system. With eight bases for 12 helicopters statewide, a chopper can be airborne in five minutes and reach an accident site within 10 minutes, even with four helicopters out of service for maintenance.
Patients then are flown directly to the nearest of nine state trauma centers.
"A lot of people think it's the best insurance they can get," said Dr. Robert Bass, executive director of the Maryland Emergency Medical System. "And it's about a penny a day per person."
The new choppers were bought with money from Maryland's general fund. Operational costs are underwritten by an $8 annual surcharge on vehicle registration.
In recent weeks Bass has been testifying before the Maryland General Assembly hoping to increase the surcharge by $3 to cover costs for the next decade.
While the Legislature has praised Kluger for a service that costs the state nothing, medical professionals and the families of patients wonder why government isn't doing more to speed up or subsidize the system.
When it took 17 hours to transport a critically ill infant from Hilo to O'ahu last year, Hilo pediatrician Dr. Mark Cohen was outraged. The only plane flying had broken down and the flight was postponed until it could be repaired, he said.
Cohen wrote former State Sen. Andrew Levin calling for the Legislature or a state regulatory agency to investigate "before a patient dies as a result of this inadequate service."
Nothing has changed since, said Cohen, and the state still can't afford to subsidize the service.
"The system is good when it works," said the pediatrician, "but it doesn't work often enough."
HAA's Kluger has appealed to Hawai'i's congressional delegation to ask for an increase in Medicare reimbursement rates for Hawai'i and the Legislature is moving a similar resolution.
Maui Memorial Medical Center medical director Dr. Jonathan Weisul emphasizes how crucial it is to have immediate access to critical services.
"The state should be able to guarantee its citizens access to that care in a timely fashion," said Weisul. "The more resources we can dedicate in this direction, the more lives will be saved."
Second-class care?
The family of Erin O'Connor is in the first stage of filing a lawsuit over delays in evacuating the 19-year-old Irish teen from the Big Island after a Sept. 17 car accident that tore O'Connor's aorta and interrupted blood flow to her extremities. Doctors at Queen's saved O'Connor's life but were forced to amputate her legs four days after the accident.
The severity of the circulation loss may have been exacerbated by the 10 hours that elapsed between the accident and O'Connor's arrival at Queen's.
Though O'Connor reached Kona Community Hospital by county helicopter soon after the 2 p.m. accident, Erin's uncle, Big Island resident Darryl Johnson, said it took four hours for doctors to summon a plane to O'ahu and another six hours for O'Connor to arrive at Queen's.
"If there were just a chopper available ... " fumed Johnson, who reached O'ahu by commercial carrier three hours before his niece.
"I can't understand it. Maybe the people on the outer islands are considered second-class citizens. If they wanted to do something about it, they could."
The O'Connor family has retained Honolulu attorney Richard L. Fried Jr., and Fried has already filed a request for a medical claims conciliation panel, which precedes a lawsuit. "This is the same injury that June Jones had," said Fried, referring to the UH football coach who veered off the H-1 freeway Feb. 22 and crashed into a concrete pillar. "It does well almost always, if repaired early. He got to the hospital quickly, but Erin didn't."
Though he chafes at the idea that the Neighbor Islands receive "second-class" care, former Big Island Rep. David Tarnas said lawmakers can't squeeze that much from the budget to meet Maiava's request for three state-of-the-art ambulance helicopters to airlift patients from the Neighbor Islands to O'ahu.
"There's not that much flex," he said. "There just isn't $8 million there."
Not that Tarnas isn't sympathetic. He waited with a close friend whose arm was torn in half when a drunken driver sliced into the side of his car.
Though it took about five hours for the flight to Queen's in the middle of the night, his friend was fortunate. A tourniquet and immediate assistance at North Kohala Community Hospital prevented him from bleeding to death.
"Everybody is touched by accidents," said Tarnas, "and this transport can make a difference. It can save peoples' lives, and my friend is one of those. We have to make sure everyone has that chance."
Already, said Tarnas, the counties struggle just to keep on-island coverage. Every year, just pushing through funding for the Big Island's county chopper operated by the Fire Department — but which cannot transport patients between islands — takes determined lobbying, said Dr. Patricia Arthur, a member of an advisory committee on Emergency Medical Services under former Mayor Steven Yamashiro.
Last year, the chopper's medical officer was eliminated by budget cuts. As a result, each time the chopper leaves on a call, it has to stop first at the nearest fire station to pick up a paramedic, which slows response time.
"It was the most unfair thing," Arthur said.
It all comes down to money
Maui, meanwhile, has been without a county helicopter since 1997, when Maui-based Mercy Air shut down its Hawai'i operations. Two hundred flights a year were too few to make the service profitable, said David Dolstein, president of Mercy Air Service Inc. of California. And with nine Army choppers available to help with critically injured people on O'ahu, Dolstein saw little chance of expanding to the state's most populated island.
But Dolstein said two helicopters backed by fixed-wing aircraft would be a good system for Hawai'i.
"You should have no less than 30 flights a month to make it a viable system, with whatever mix. Anything less than that and there's no logical reason that someone would do it," he said.
His business averaged about half that number when they operated here.
Dr. Fred Holschuh, an emergency physician for 30 years in Hawai'i, said equality of care between rural areas and urban Honolulu has been controversial for years. And while he has been a relentless advocate for improvements in the system, he is aware of budget demands.
"Unless there's a specific incidence where you need a chopper to save a life right now, it doesn't get the public's attention," said Holschuh.
"I've told my wife many times that if I keel over in the front yard, cradle my head and tell me you love me," he said, "because it's going to take a half hour (for help) to get here."
