During my time as a rural midwife in New Zealand, I spent a short time providing care to families in Taupō, a community located in the middle of the North Island. A helicopter base and rural ‘midwifery-led’ primary maternity care unit were based here, which served the surrounding communities.
I happened to be at the maternity unit one day when a pregnant woman arrived in pre-mature labour with a cord prolapse (when the umbilical cord has fallen below the baby’s head). In this situation, when the woman has contractions, the baby’s head puts pressure on the cord, blocking the supply of blood and oxygen through the cord.
This incident reflects one of the few rare obstetrical emergencies that you train for and manage as best you can in a low resource setting, until you can transfer care to a facility with specialist services. Fortunately, in this instance we were able to arrange a local helicopter within 20 minutes.
This incident has made me appreciate that having a helicopter available on short notice for emergencies saves lives. Yet, the future of that same Taupō helicopter base was placed in jeopardy last year under a newly proposed plan for the reorganization of New Zealand air ambulance services.
I was reminded of this experience during a recent presentation by Paul Carolan, the director of fundraising for HALO, a dedicated medevac helicopter service serving southern Alberta and southwest Saskatchewan. Carolan’s presentation sparked my interest in the status of helicopter emergency medical services across rural Alberta.
In terms of helicopter emergency medical services, I wanted to know if Alberta can benefit from the experiences of other jurisdictions with similar geography challenges and rural population size—like New Zealand. How can we design more effective, sustainable, coordinated services that provide equitable access to all rural Alberta patients and communities?
Case Study: New Zealand
In 2018, the New Zealand Government proposed a re–design of their national air ambulance service (the National Ambulance Sector Office or NASO). The aim of their ten-year national air ambulance services’ modernization program (2017-2027) is to build a national integrated network of services that covers New Zealand and ensures these services are well connected with other emergency services, available around the clock, and are safer and more appropriately clinically resourced.
As part of the re-design, NASO released a tender for the purchasing of air ambulance helicopter services across the country, splitting the country into three geographical areas.
There are many Helicopter emergency medical services trusts (non-for-profit organizations) operating in each of the three identified geographical areas. Several operators came together to form joint ventures to provide tenders for either the South Island or two North Island areas.
South Island: How do non-for-profit trusts collaborate and provide services under the new design?
Helicopter Emergency Medical Services New Zealand was created through a joint venture between two helicopter non-for-profit providers. After a formal agreement with the National Ambulance Sector Office near the end of 2018, these providers now provide helicopter emergency medical services for all of the South Island, Stewart Island, and the Chatham Islands.
The ratio of public to government funding varies across the country, but the restructuring has meant that air ambulance providers do not have to rely on public fundraising and sponsorship to make up budget shortfalls to the same degree that they had to previously, because a lot of the standard costs are paid for by the government.
North Island: Re-designing helicopter base locations under the national service re-design
In 2018, the Taupō helicopter base (where I was located) was under threat of being removed from the proposed national service re-design. The local medevac trust/non-profit was a joint venture, so the mayors of Taupō, Rotorua, and the Ruapehu Districts lobbied the health minister to keep services. Celebrities such as model, Rachael Hunter, and avid hiker and past Health Minister and Prime Minister, Helen Clark, joined in the chorus calling for services to be retained. One local champion, Simon O’Neill, wrote scores of emails to MPs, asked questions, and gained 48,000 signatures on a change.org petition to keep the base.
In April 2018, more than 1,000 people marched in Taupō to protest the potential removal of its helicopter base. Although the area population was low, surrounding parks bring over a million visitors into the region in the summertime. Following much public outcry, the Minister of Health announced the helicopter base would remain. Moving forward, Taupō will be serviced by a larger twin-engine helicopter, crewed 24/7, with a response time goal of getting off the ground in between ten and 20 minutes.
Alberta’s Helicopter Emergency Medical Services (HEMS)
As the New Zealand example shows, there is a strong case to support an integrated network of urban and regionally based services with helicopter bases used to maximize reach. Distribution of such bases decreases the need for refueling and shortens travel time from the base to rural service location and on to the receiving hospital. Additionally, funds raised by each regional trust/non-profit (who serve and are a part of the community) continue to support services in their area.
Within Alberta, there are three non-profit helicopter emergency medical service (HEMS) providers with bases in Alberta: HALO based in Medicine Hat; HERO based in Fort McMurray; and STARS in Calgary, Edmonton, and Grande Prairie.
Case Study: HALO
Established in 2007, HALO has a one-hour flight radius covering much of southern Alberta and southwest Saskatchewan from a base in Medicine Hat.
Up until 2018, HALO had a rescue helicopter, which was reliable and affordable ($850,000/year to run), but did not enable effective patient care in the air. With the purchase of a new twin-engine helicopter in 2018, HALO can offer better patient care and land at Calgary Foothills and Children’s Hospitals’ elevated helipads. As part of the upgrade, the new helicopter includes a Stryker stretcher that improves patient safety, loading time, and doesn’t require the patient to be transferred to another stretcher on hospital arrival. It also comes with a sled that lifts it into the ambulance (reducing the potential for lower back injuries for paramedics).
Director of fundraising, Paul Carolan, says the new twin-engine functions well in the challenging weather conditions of the southeast corner.
“[It] doesn’t really care too much about winds, which we get a lot of, and it has a lot of power as far as lift is concerned,” explains Carolan. “HALO’s new twin-engine helicopter is able to accept many more missions due to its ability to fly safely in adverse conditions and to land directly at the Foothills Hospital in Calgary.”
However, a new helicopter with these upgrades costs money, increasing the HALO budget to $2.6 million. To help meet the challenge, the Alberta Government gave a restricted, one-time, one-million-dollar grant in early January 2019 to HALO. The organization still faced a funding gap and, despite the tireless efforts of the dedicated volunteer Board of Directors, HALO was looking at an approximate $750,000 shortfall.
Currently operating without any contractual funding, efforts to acquire sustained funding for HALO continue. The mayors and reeves of southern Alberta recently appealed to the Health Minister in support of ongoing funding for HALO air rescue for southern Alberta. Carolan says conversations have also begun with Alberta Health Services (AHS) about returning to a fee-for-service model which would provide some cost recovery while deployed on approved AHS flights.
“[We] will continue these conversations with our best intentions and trust that a more sustainable agreement can be made,” Carolan explains, assuring us that HALO will continue to serve the rural south.
“HALO is committed to serving our region and with the support of Rangeland Helicopters, we have made arrangements to address the shortfall and continue delivering the same level of service.”
Formed in 2013, HERO covers northeast Alberta and northwest Saskatchewan with a one– to two-hour flight radius around Fort McMurray.
Prior to HERO’s existence, medical evacuation in the Wood Buffalo region was limited to daylight hours and subject to helicopter availability. Now, with a dedicated service, and night vision goggles, HERO can fly 24/7, which greatly improves service during the long dark hours of winter. This level of service requires two pilots and two paramedics to be on standby at all times, ready to provide emergency care related to motor and recreational vehicle collisions, workplace incidents, and medical emergencies.
HERO is currently funded through contributions from local government, the oil sands industry, and the public. Their website indicates that the Regional Municipality of Wood Buffalo is their largest funder, with other major sponsors including Suncor Energy, Cenovus Energy, Husky Energy, and Williams Energy, with the Alberta government providing support on a fee-for-service basis. In 2017, rather than a fee-for-service payment model, AHS committed to providing HERO with $1 million annually for two years to help cover the service.
This funding commitment is appreciated, as fee-for-service models present issues for helicopter emergency medical services in rural areas. HALO’s fundraising manager Paul Carolan notes that HALO is in the same boat as HERO with respect to the fee-for-service model, which “doesn’t work well for a dedicated 24/7 service.” Outside of urban areas where call volumes are lower, having funding based on the number of calls doesn’t recognize that the base operational costs – the most significant costs for air ambulance services – are set regardless of the number of calls.
Perhaps the most well-known air rescue service in Alberta is STARS, short for Shock Trauma Air Rescue Service. Founded in 1985, STARS operates bases 24/7 in Calgary, Edmonton, and Grande Prairie. The organization has a ten-year agreement with AHS extending to 2020 that provides a base amount of funding for mission operations (approximately $6 million per year), plus reimbursement of Alberta mission fuel and landing fees. This amount represents around 20 per cent of the total budget for their Alberta services. STARS relies on industry and philanthropic support to cover the remaining 80 per cent. STARS also has ten-year service agreements with the Saskatchewan and Manitoba Governments.
STARS Air Ambulance crews require additional training and equipment. STARS fly with doctors and nurses with specialty training, and are able to treat patients with special medical needs in-flight. As such, STARS may be asked to fly into areas covered by HERO or HALO even though the transportation time is longer and doing so leaves their response area uncovered.
Helicopter Emergency Medical Services (HEMS): Dispatching, Inter-Facility Transfers, and Helicopter Refueling
During my conversation with Paul Carolan, I asked him some questions about helicopter dispatch, inter-facility transfers, and the logistics involved in refueling. I was curious about what impact these factors had on Helicopter Emergency Medical Services (HEMS), and what kind of coordination occurred between the three Alberta HEMS providers.
911 calls resulting in an EMS response are directed to one of three AHS Communication Centres spread across the province. In the event that one of these centres determines a HEMS response is warranted, they contact the STARS Emergency Link Centre at the Calgary International Airport. STARS plays a central role in coordinating HEMS within the province of Alberta. When a call comes into them, the appropriate air ambulance provider is selected and the crew at the appropriate HEMS base is dispatched. Any bases whose assistance may be required are also alerted. STARS Calgary overlaps with HALO, and STARS Edmonton overlaps with HERO.
“STARS considers HALO a valued regional partner and encourages our use when we are deemed the appropriate asset,” says Carolan.
Inter-Facility Transfers (IFTs)
Transfers between facilities are coordinated by the AHS Central Communications Centre in Red Deer, which coordinates all the fixed-wing (airplane) medevacs throughout the province. If it is determined that a patient needs to be transported by helicopter, that system links into the STARS Emergency Link Centre and requests a helicopter. STARS, through the same evaluation process as a call to the scene of an emergency, determines which provider is most appropriate to send.
“STARS completes the majority of helicopter IFTs in Alberta,” explains Carolan. “HALO had only been on a handful and was unable to complete them prior to the acquisition of the twin-engine helicopter.”
I asked Carolan about the value of regional hubs, and the challenges of re-fueling for all three HEMS providers. According to him, STARS Air Ambulance has established a number of “fuel-drops” around the province during the decades they have been serving Alberta. Working with local EMS, Fire, and industry, they maintain those fuel-drops, and have them available in the event fuel becomes an issue.
“HALO, with our original helicopter, returned to Medicine Hat [on] 99 per cent of our missions and fuel wasn’t an issue, our model was based on flying a maximum distance of half a tank out, leaving a half tank to return,” explains Carolan.
With the addition of their new twin-engine helicopter, their range is drastically increased, with almost 100 per cent of their missions achievable on one full tank, Carolan added.
“HALO has plans to add several fuel-drops within our response area to provide an additional capacity buffer in the event it is needed,” he explained, adding that each is a significant investment, and at the moment they are focused on funding the existing program.
It is my hope that this broader understanding of how Helicopter Emergency Medical Services (HEMS) have been re-designed in other jurisdictions, and how HEMS services are provided in Alberta, will allow rural communities to be better informed about air ambulance services. Hopefully this knowledge will enable communities to better advocate and support initiatives for an integrated and sustainable network of services that reaches all rural Albertans.