Part One: A Rural Air Ambulance Service Sprouts Wings

Near the end of the Viet Nam War, I had the good fortune of experiencing military service as a newly minted physician at Brooke Army Medical Center (BAMC) a service hospital in Fort Sam Houston, Texas. That war was the coming of age of the helicopter as a reliable means of the rapid transport for seriously wounded soldiers, and other medical emergencies not related to combat. At BAMC, I saw many examples of how just the minutes saved in air transport to advanced medical treatment made the critical difference between life and death. Time saved over conventional ground transport was also a very important variable in setting the course for success in achieving an improved prognosis and ultimate recovery in serious trauma of all types. 

This fact was forever burned into my memory on the night when an Army Ranger, who was conducting night maneuvers at nearby Camp Bullis Military Training Reservation, was brought in to BAMC’s emergency department (ED) by air. That rescue would have been treacherously longer and more difficult if the patient had been transported using conventional ground transport.  Since the incident occurred in the remote areas of the reservation I am sure the outcome would have been very grim.   

Our patient had repelled out of a helicopter in total darkness and landed on top of a hungry 10-foot Diamondback rattlesnake, which promptly returned the favor by administering a full load of a very potent, well-aged venom into his right leg, just below the knee. A very alert pilot quickly landed the helicopter and loaded the stricken Ranger on board.  In the brief time it took to land and reload the stricken soldier, he began showing the signs of serious envenomation.  He was quickly flown back to our ED, and on arrival the affected leg had swollen to nearly two times its normal size, and our examination quickly established that his limb was quickly losing the battle to the devastating effects of an acute compartment syndrome that mandated immediate action. This was the first time, and thankfully the last time, that I would perform such extensive fasciotomies to save a leg while simultaneously and expeditiously administering anti-venom to save a life. 

After what seemed like a never-ending administration of anti-venom and fluids, our patient finally stabilized. He went on to survive this horrific event bearing those long telltale scars from fasciotomies to prove it. There was little doubt that, had air transport been unavailable that night and conventional means of evacuation had been used instead he surely would have died enroute.

Rescue successes similar to this, along with the thousands of severely injured soldiers who cheated death in Viet Nam thanks to “dust off” helicopter crews, inspired the St Anthony Central Hospital in Denver, Colorado to purchase a single Alouette III helicopter in 1972. They would become the first civilian hospital-based medical helicopter program in the U.S. 

I left the Army Medical Corps and entered rural practice in Craig, Colorado on July 10, 1974, just two years after the launch of that air service in Denver. Immediately, I began to utilize St. Anthony’s Flight for Life services when we could. However, I quickly learned that, while the helicopter was well suited for the Hill Country of East Texas and the jungles of Viet Nam, the Alouette III faced challenges with transports over Colorado’s Continental Divide. Even in good weather, the back and forth trips from Denver to Craig and over the Rocky Mountains took great skill to navigate. The craft also guzzled fuel, forcing the crew to stop and refuel on each side of the mountain, also burning valuable time before finally landing in Craig.

Sudden storms and high winds would often blow up out of nowhere and the whirlybird would have to abort the transport and turn back. Response times were frequently long and many times exceeded the time it would have taken to go by ground ambulance to that same medical center.   Relying on an air service from the other side of a mountain range in which the flight crews traversed the high peaks twice during the course of a single transport was too often fraught with failure. Time and aeronautic technology eventually solved these issues, but we knew instinctively that it would take years before that would happen and in reality, that was what happened.

In our relative isolation, we needed a more immediate solution.   The best answer at that time was to develop our own rural air ambulance service using local fixed wing aircraft as our primary carriers. Fixed wing flight over long distances and high mountain peaks seemed to be safer and more reliable.  It clearly was a much faster solution than rotary wing aircraft which were still in development (more powerful models with larger blades for higher altitude work were still being perfected).

As we looked into our local resources to implement this plan, I was surprised learn that the air transport of patients was not a new concept for our sparsely populated, rural Northwest Colorado county. Transport of patients by private plane had been happening sporadically for years. Our little town had a number of veteran military pilots who had logged thousands of hours during WW II and the Korean War and they continued flying in the mountains under all kinds of conditions. If a medical issue surfaced in the past that was severe enough for a community physician to request an air transport, the word went out to the aviation community, and they would readily volunteer to fly the patient in their private plane to a larger hospital for care. 

The only limiting factor was that patients were compelled to occupy a seat in the plane, rather than being placed in a stretcher like with ground transport. In addition, a nurse or family member would need to be in attendance to lend some support, but there were no provisions on the aircraft to do anything more than comfort measures during the trip. In one case, a child with a serious head injury was flown in the right front seat of the aircraft in her father’s arms. Sadly, before the trip was completed, pressure mounted on her brain past critical levels and she passed away.

In another remarkable case a patient and a nurse were being flown to Denver with an unknown emergent condition when the plane encountered a bad thunderstorm.  Unable to continue or turn back safely, the pilot dropped out of the clouds, landed on the highway, and pulled off onto a wide spot in the road to wait out the storm. When the storm sufficiently cleared, the pilot, nurse, and patient took off again and arrived in Denver, though later than anticipated but with a story to tell. The incident luckily escaped the notice of the news and the FAA, but it became part of our folklore in the county.  

I had the opportunity to fly with that pilot many times as we developed and refined a safe and reliable way to transport urgent and emergent patients to the larger regional hospitals for specialized care. He was the only member of our community who had large enough aircraft with the collective muscle to handle the weight of a patient, two support medical personnel, the oxygen delivery system, and the vital signs monitoring equipment for the flights.

He preferred his single engine Cessna T210 Turbo aircraft because the position of the passenger cabin was below the wings; this made loading a patient much easier and faster than his twin engine Piper Seneca II. While the twin engine aircraft seemed to be a better choice for the extra power a second engine provided, the fuselage was positioned above the wings requiring the patient to be hoisted to a greater height to move up and along the wing to enter the cabin’s relatively small door. In flight, that twin engine aircraft also tended to sway gently back and forth so upon arrival all the passengers if not already air sick, felt as if they had been riding on a swing for the entire trip.

The pilot also temporarily took off the Cessna T210 Turbo’s passenger side door, which allowed for the patient to be easily loaded feet first and left their head positioned forward into the open area of the right front seat. The physician and nurse would occupy the remaining open seats next to the patient’s head and torso to monitor their patients overall condition, and take appropriate action if that patient’s condition began to deteriorate. Transport time from Craig to Denver Stapleton Airport was a little over an hour in either the single engine or twin engine aircraft, and having a ready aircraft sitting on the tarmac when we made the call would increase time and efficiency of the transport.   

There were several other issues with our rural service that needed to be solved. Most notable was the fact that none of our aircraft had pressurized cabins, and in some cases our flight path took us high above the mountain peaks and over and around rough weather. We tried to keep our time at higher altitudes as short as possible and took great care in assuring that we had adequate oxygen monitoring equipment and a generous supply of oxygen on board at all times. Maintaining a high standard of vigilance during transport meant using electronic monitors to record vital signs and the electrical activity of the heart. It also meant using pumps to more accurately deliver intravenous fluids and other needed medications at a higher altitude.

All of these technologies were available at our hospital, but they were also far from being as small and compact as they are today. There was no long lasting battery technology at this time, and all of the monitors utilized “plug in the wall” Alternating Current (or AC), whereas all the power on the airplane was Direct Current (DC).  We solved this issue by installing an Inverter box into the plane’s electrical system to convert the DC from the engine’s generator into AC that powered the monitors, IV pumps, and suction machines servicing the patient in the cabin of the airplane. 

This had never been tried before by anyone in our community, but being a pragmatic group of folks they were willing to try it anyway. While our electrical system modification worked well during ground tests, the question unanswered was would work in flight with real patients and not interfere with the operation of the airplane’s navigation system. We also didn’t know if our medical equipment would function as efficiently on converted DC to AC power compared to the 120-volt AC power from the plugs in the hospital and ER.

To answer this question decisively, I did what any other rural physician would do when faced with a similar dilemma. I asked my sons to volunteer as “patients” to test our new patient monitoring system in flight. They were naturally delighted to do so, because it meant a free plane ride and a chance to help their Dad solve a real dilemma. I knew it would also be winning proposition in the minds of these pre-adolescent boys?

We planned the flight for the coming weekend when my sons were out of school, and set the time for the early morning when the air was smooth and cool and winds were at their calmest.  One of my sons was connected to a monitor and we took flight with the data screen up and running. All systems in the airplane worked normally and the quality of the data on the screen remained steady and without static interference.

We switched monitors and equipment on the boys in flight to see if that made a difference and started the IV pump, allowing it to deliver its maximum volume into a small catch basin. Once again, all systems on the aircraft and monitors continued to function normally. A check of all the gages in the airplane showed that the planes electrical system didn’t seem to be taxed at all. Finally, we started the suction pump, and with everything running we could detect no change in performance of the plane or our pumps and monitoring equipment.    

Working together as a community, we had created a portable system that could quickly transform a regular private airplane into a useful medical air transport platform when we needed it.  

The final piece to put in operation involved selecting and training several nurses on our nursing staff to serve as flight nurses, and for them to agree to be on call for transports when they occurred. There was no shortage of volunteers for the task of being an inaugural flight nurse. Those selected were among the best of our nursing staff with strong medical skills and a dedication to making the system work.

The flight nurses were trained on inflight procedures and the effects of altitude on patients and crew. They also designed and helped facilitate the development of protocols for working in the cramped spaces of the Cessna T210 Turbo while in flight. We all learned the rules of flight preparation and flight safety including evacuation of patients and crew in the event of an emergency. Above all there was a tremendous sense of pride and accomplishment as we launched The Memorial Hospital – Craig’s first official air ambulance service. 

Epilogue 

As a community, Craig and Moffat County were on the ground floor in the development of medical air services in our region at that time. I am grateful that everyone from our medical staff, hospital administration, and even those in the seat of county government saw the vision I had experienced that night at Brooke Army Medical Center when I witnessed the tremendous value of medical air transport in blunting the effects of time on trauma patients. I was equally proud of our aviation community who were there to supply the most vital component of our success; providing well maintained and reliable aircraft and experienced pilots.  

We had not developed this service to make money or expand our service beyond our region;  we had quickly learned that those in need of our service could not afford it.  We did it because it was the right thing to do for our citizens at the time when there were no other reliable medical air services in our region.  It would not be long before St. Anthony’s vision took hold throughout the nation, and other air ambulance services entered the field and easily eclipsed our efforts with larger and faster fixed wing aircraft. The Flight for Life program also expanded with more powerful and reliable rotary wing aircraft that could easily traverse the Continental Divide, or work among our high mountain valleys and snow covered slopes. We were proud that we had blazed a very small trail for larger services to move in and, well, render us obsolete. Our community had started our humble little rural air ambulance service as a bridge until a better solution could come online, and looking back we accomplished that goal very well.

Note to the Reader

This has been the first in a two-part series chronicling how physicians, nurses, and a rural hospital teamed up with community members to fill the gap in the rapid transport of seriously ill and injured patients by air to higher levels care.  You have seen how innovation and ingenuity successfully bridged the gap in providing lifesaving medical air transport for our citizens until larger and more well-funded services like Air Methods and Flight for Life Colorado stepped in to fill that void. In the second part of this series, I will recount some of our most notable emergency transports and the lessons learned during the short life of The Memorial Hospital-Craig Air Ambulance Service.