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November 1, 2001

EMS/AMTC Review: Compassion Under Fire

The September 11 terrorist attacks in New York City, Washington, DC, and Pennsylvania underscore the need for helicopter emergency medical services.

by Mark Forror

AS AMERICA RECOVERS from the shock of the extraordinary events of September 11, the carnage of that day brings into sharp focus the importance of the countryís helicopter-based medevac services.

The air medical community itself has been hard hit by the fallout of the terrorist acts. During the week following the attacks, the FAA shut down all general aviation flights, leaving traditionally underfunded emergency medical services (EMS) strapped for cash.

Dawn Mancuso, executive director of the Association of Air Medical Services (AAMS), Alexandria, Virginia, an organization representing EMS operators and crewmembers, says: "Many of our members have faced severe cash flow problems. The losses for that one week alone were one to two million dollars [per operator].

"In addition, some insurance companies have notified their customers that the war riders on their policies have been canceled. Our risk pool is the same as the airlines, so weíre facing liability insurance premium increases as well."

Military call-ups also have left a few AAMS members shorthanded, while others report problems getting takeoff clearances. "Some of our members have reported waiting as long as 45 minutes for clearances," she says.

AAMS members foresaw the terrorist threat early and focused on the logistics of handling large numbers of injured, but many were not prepared for the collateral damage to their businesses.

"There has always been ongoing training and discussion on what to do with mass casualties. What the programs didnít expect is the aftermath of the management problems related to insurance issues and lost revenues," Mancuso says.

In the long run, however, the attacks will force hospitals and insurance companies to re-evaluate the importance of EMS in facing a looming terrorist threat. That re-evaluation is likely to work in the rotorcraft industryís favor.

The show must go on

Less than two weeks after the attacks, the 2001 Air Medical Transport Conference (AMTC) began as scheduled, September 24-26, at the Orange County Convention Center in Orlando, Florida. Six associations, including AAMS, sponsored the conference.

The September 11 attacks failed to derail AMTC, as they did many trade shows. However, the growing sophistication of terrorist cells means that all government agencies and private associations are rethinking the logistics of caring for mass casualties in the context of a well-coordinated attack.

An unsigned statement posted on the AAMS web site soon after the attacks noted that it was "premature" to cancel the conference and vowed that the show would go on. The statement also praised those who canceled their attendance after being called to active duty, and offered refunds to any attendee who sent AAMS written notice of cancellation.

Despite the events of September 11, attendance was strong. About 1,500 visitors went to the show, with five or six exhibitors and about 300 attendees backing out.

Those who visited the conference found a total of 112 educational seminars, a majority of them focusing on helicopter EMS. Many of the seminars carried over themes from years past: insurance coverage for helicopter services; creating effective safety programs; avoiding accidents; human factors for flight crews; and certification standards for medical personnel, to name just a few.

AAMS is now in the process of learning the lessons of September 11, according to Mancuso. In that vein, AMTC quickly lined up two unscheduled sessions on the World Trade Center attacks.

Matt Caudill, a fireman-paramedic with the Plain Township Fire Department, New Albany, Ohio, presented "Urban SAR Response to Terrorist Acts." As a rescue specialist for Ohio Task Force 1, the stateís search-and-rescue contribution to the Federal Emergency Management Agency (FEMA), Caudill reviewed his unitís participation in relief efforts at the World Trade Center in New York.

Diane Fojt, president of MECA, an air medical training company based in Tampa, Florida, conducted a "Review of World Trade Center Critical Incident Stress Management." The session focused on coping mechanisms for medical personnel responding to the World Trade Center tragedy.

In addition to these seminars, three sessions scheduled before September 11 proved chillingly prescient.

Perhaps most on-target was Michael Coxís "Chemical and Bacteriological Terrorist Attacks: The Coming Threat." An emergency medical technician-paramedic and registered nurse, Cox flies with Florida Flight 1 in Orlando.

His presentation began with a historical overview of the use of blood, nerve and blistering agents, as well as bacteriological agents such as anthrax, to infect urban populations. He also discussed the availability of materials that could be used to construct a chemical or bacteriological weapon and presented several scenarios illustrating how a chemical attack by terrorists would affect prehospital, transport and in-hospital management of victims.

The discussion took on a new sense of urgency when, just one day before Cox made his presentation, news reports revealed that some of the terrorists had approached aerial application operations with detailed questions about the payload capacity of crop dusting aircraft.

This new information led the FBI and other authorities to speculate that such interest was a prelude to a terrorist plan to deliver a chemical or bacteriological agent in another wave of attacks. A 1993 report by the U.S. Congressional Office of Technology Assessment estimated that between 130,000 and 3 million deaths could follow the release of 100 kg. of anthrax spores upwind of the Washington, DC, area.

Andrew Swartzell, a registered nurse with CALSTAR in Hayward, California, reviewed the concept of the Disaster Medical Assistance Team (DMAT) as part of the National Disaster Medical System (NDMS) in his presentation, "NDMS: Catastrophic Care for the Nation." DMATs are groups of professional and paraprofessional medical personnel that provide emergency medical care during a disaster. In mass casualty incidents, their responsibilities include triage, providing austere medical care, and preparing patients for evacuation.

The teams are organized under the NDMS, a partnership between the Department of Health and Human Services; the Department of Defense; the Department of Veterans Affairs; FEMA; and state and local governments.

Another session applicable to the terrorist attacks was Dr. Michael Humphreyís presentation on aeromedical support during a mass casualty incident. A flight doctor for LifeFlight in Toledo, Ohio, Humphrey used as a case study an incident that occurred last year at the Lonz Winery, Put-in-Bay, Ohio, in which one person was killed and 75 were injured when a 25-foot section of a terrace collapsed.

Assistance from industry

Sikorsky Aircraft was among the airframe manufacturers represented at the conference. As a corporation based in nearby Connecticut, Sikorsky aided in the World Trade Center relief effort. On September 11, Sikorsky sent its S-76 chase aircraft to Teterboro Airport in New Jersey at the request of the Port Authority of New York and New Jersey.

Sikorsky also transported trauma teams via a fleet of seven Army Black Hawks flown by U.S. Navy and Sikorsky pilots. Based at the Wall Street Heliport, the helicopters were the cityís only medevac units that day, according to Sikorsky spokesman Bill Tuttle.

Despite the emergency, the company managed to make the Orlando conference. The Palm Beach County (Florida) Health Care Districtís S-76C+ "Trauma Hawk" gave rides to conference visitors from the Orlando airport. On static display at the Sikorsky booth was LifeFlight-Miamiís S-76A+.

MD Helicopters, Inc., Mesa, Arizona, also was highly visible at the conference. EMS is a huge market segment for the company: 35% of all MD Explorer deliveries are to air medical operators.

To underscore the importance of that market, the company celebrated at AMTC the Explorerís 15,000 hours in EMS service. Allegheny General Hospital in Pittsburgh flew 10,000 of those hours, while the Regional Emergency Medical Services Authority (REMSA) of Reno, Nevada, accounted for 5,000 hours.

Allegheny operates four of the light twins; REMSAís single Explorer averages 1,500 flights and 1,000 patients per year, according to John Morrison, director of critical care services for REMSA-Care Flight.

This month, REMSA-Care Flight will upgrade the engines on its Explorer to Pratt & Whitney Canadaís PW207E powerplant, which increases the aircraftís available power by nearly 11%.

"With the current engines, we have issues with the high-desert terrain and the heat, so the upgraded engines will give us much better performance in our [operating] environment," says Herb Brady, vice president of operations for REMSA.

The helicopterís certification for Category A single-pilot IFR (SPIFR) operations gives it more flexibility to operate in visibility conditions that would ground most helicopters.

Cathy Fackovec, administrative director of Allegheny Hospitalís Department of Emergency Medicine, which includes LifeFlight, says the Explorerís quiet NOTAR anti-torque system helps their operation meet the requirements of their noise abatement agreement with the local community. The lack of a tailrotor also means that, in her words, "We donít have to worry about someone walking into the tailrotor anymore."

The Explorerís 172.5 cubic feet of cabin space is especially popular with the male nurses in the program. Although many of the female nurses prefer the old bench seats from LifeFlightís earlier BK-117s, that is no longer an option, Fackovec says, due to new crash attenuation standards.

Rounding out the list of major airframe manufacturers represented at the show were Agusta Aerospace, American Eurocopter and Bell Helicopter Textron.

A total of eight helicopters and two full-scale mockups graced the show floor. Bell exhibited a 407 flying for MedTrans in Greenville, South Carolina. Agusta brought an EMS-configured A109 Power mockup and a VIP-configured A119 Koala. Rocky Mountain Helicopters, Provo, Utah, displayed a medical interior concept in an EC-130 B4 cabin mockup to solicit comments from potential customers for Rockyís own EMS interior design. The company signed a purchase order for 10 EC-130 B4s at the Paris Air Show in June.

The Pentagon: A case study

No one knows the significance of EMS better than Sgt. Pilot Ron Galey, a United States Park Police helicopter pilot whose Bell 412, callsign "Eagle 1," was the first medevac helicopter on the scene at the Pentagon.

"I was on the crash phone for National Airport the day of the Pentagon attack," he recalls. "National Airportís tower called and said, ĎWe have a 757 down somewhere in the vicinity of the 14th Street bridge.í We were watching coverage of the World Trade Center attack on television, and when the call came down, we looked at each other, and we just knew it was not an accident."

Within four minutes, Eagle 1 arrived on scene. Eagle 2, the unitís other 412, was two minutes behind them. What Galey found on the Pentagonís quiet, parklike grounds was something akin to a war zone. A hijacked Boeing 757 had dipped its wing into the ground and cartwheeled into the west side of the Pentagon, cutting a six-story notch out of the nationís joint military headquarters.

"I saw a lot of fire, a few people running away from the Pentagon who were on fire, and thick black smoke," he says. "We were told that a 757 hit the Pentagon, but we saw absolutely nothing that looked like an aircraft. There was nothing left."

The first few minutes were spent bringing order to chaos. National Tower told Galey the smoke was so thick they were closing the airport and turning over command and control to Eagle 1. By the time Eagle 2 arrived carrying two Department of Defense paramedics, the unit commander and the assistant commander, Eagle 1 was already downlinking information to other aircraft in the area.

Soon the sky was full of rotorcraft, including a variety of military models, and those from local TV affiliate Fox 5 and the Fairfax County Police.

Sgt. Pilot Ken Burchell, the Eagle 2 co-pilot, says that at first, the Pentagon didnít appear to be extensively damaged.

"We arrived there before the floors began to collapse, and the damage didnít look that bad. It almost looked as though their attack had been unsuccessful," he says. Minutes later, the floors crumbled into a charred heap.

The Arlington County Fire Department reported 20 possible casualties. Galey asked the Maryland State Police to send a helicopter, but the MSP was unable to respond because the military already had clamped a no-fly zone over the area. Calls went out to AirCare at INOVA Fairfax Hospital in Virginia and MedSTAR at Washington Hospital Center. Each dispatched a medevac helicopter to the scene.

At Galeyís request, a DC Metro Police helicopter, callsign Condor, arrived ahead of the EMS ships to take over the command-and-control function. That allowed the Park Police and EMS aircraft to assume a medevac role.

Pete Russett, the Air Methods pilot flying AirCare 1 for Fairfax Hospital, is also executive officer of Marine Light Attack Helicopter Squadron 775, Detachment A, in the Marine Reserves. Even his time in the Corps and EMS service did not prepare him for what he saw. "The destruction and fire in front of me seemed surreal," he says. "I have seen many accidents and victims, but the idea that terrorists had done this to our Pentagon was unbelievable."

Twenty casualties soon became 11, then only three. Eagle 2 already had taken two of the victims, and MedSTARís EC-135 took the third. The victims were transported to Washington Hospital Centerís burn unit.

Burchell says that, given a final death toll of 189 people, the Park Police were prepared to transport many more casualties. "Both of our 412s have mass casualty kits that allow us to take four patients. Our aircraft happened to have those kits already on board," he says.

Reports that another unauthorized radar contact was heading toward them added another dimension to the chaos.

"Even as we launched, we were advised that there was the possibility of another inbound aircraft," Burchell says. "That certainly adds to the pressure of getting people out of there."

At one point, Galey says, they received a report that the unauthorized aircraft was only four miles away. "We looked up, and at about 15,000 feet I saw the glint of an airplane," he says. "I thought, oh sh--, but it turned out to be a military aircraftóthank God."

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