PITTSBURGH (AP) — After a horse kicked her in the head in 2015, the unconscious woman took a 16-minute ride on a LifeFlight helicopter that saved her life.
In a race against the clock, Christine Holt, 54, arrived at Allegheny General Hospital in Pittsburgh with only minutes to spare to undergo surgery to relieve dangerous levels of pressure against her brain due to bleeding.
Her case exemplifies the sophistication of equipment and treatment inside modern medical helicopters, all while studies are focused on assuring that helicopters are used only when necessary due to the cost per trip that can reach $50,000 and higher.
But research is clear that for patients with serious injuries, trauma or medical situations, when survival clearly is in question, helicopters can save lives.
That was the case with Holt.
That Oct. 17, the Chicora, Butler County, resident was atop a Morgan horse and ready for a second test ride to determine if she wanted to buy the gelding. Another woman planning to ride with her checked Holt's saddle and then went inside the stable to prepare her own horse.
That's when the woman heard Holt cry out, "Whoa, whoa!" and then go silent.
The mother of two teenagers had been thrown off the horse and kicked in the head on her way to the ground, causing head injuries and bleeding that put life-threatening pressure on her brain.
Inside a LifeFlight helicopter, the crew stabilized her and prepared to take her immediately into surgery at Allegheny General. She was told by medical staff afterward that she likely wouldn't have survived had she arrived five minutes later.
"I was banged up with a head injury in the shape of a horseshoe," she said.
Unconscious for 11 days, she then underwent a month of rehabilitation and has fully recovered.
She didn't buy the horse.
Modern airborne medicine
Allegheny Health Network's LifeFlight is 41 years old this month, and UPMC's STAT MedEvac is celebrating its 35th anniversary this year. These services have expanded significantly over the past four decades, with so many helicopters twirling overhead — especially for Pittsburgh neighborhoods that host hospitals — that unsuspecting residents might think military operations are underway.
What once were flying ambulances — hurrying people to hospital intensive care units as fast as possible — have been transformed into flying ICUs, keeping patients alive and stable with blood transfusions, portable pharmacies, and modern equipment, protocols and treatments. That means crews upon landing can roll the patient straight into surgery or a heart catheterization lab, where a thin tube is inserted in an artery or vein in the groin, neck or arm and threaded through blood vessels to evaluate the heart.
"What we've seen is that some people think flying a helicopter becomes a faster way to move a patient to the hospital. But the reality is it's a faster way to get critical care to the patient," said STAT MedEvac President and CEO Douglas Garretson.
"What we can do now you couldn't do five, 10, 20 years ago," he said.
LifeFlight's James Palafoutas, director of AHN's Prehospital Care Operations, said what medical crews accomplish in the back of a helicopter is "quite impressive."
"We've had multiple cases where crews went right into the operating room with a patient."
"Medically speaking," said Dr. Matthew Poremba, medical director of Allegheny Health Network's LifeFlight, "we take care of patients as if they are in an ICU in a tertiary care hospital — the Allegheny Generals or (UPMC) Presbyterians — and transport the sickest of the sick and put people on heart-lung bypass if their heart is failing."
UPMC's STAT MedEvac owns 23 helicopters situated at 18 bases concentrated in Western Pennsylvania, but it has expanded to Central Pennsylvania, Eastern Ohio, Jamestown, N.Y., Washington, D.C., and Baltimore, where Johns Hopkins University sought UPMC's assistance in establishing a medical helicopter service, Garretson said.
STAT Medevac's staff of more than 300 includes pilots and helicopter maintenance crews.
LifeFlight, operated by the Allegheny Health Network, has five bases in Western Pennsylvania serving a 150-mile area around Pittsburgh. Metro Aviation from Shreveport, La., provides the pilots and six LifeFlight helicopters, along with maintenance.
Both operate independently as not-for-profit organizations.
"The operation covers its costs and is able to maintain equipment and invest in future expenditures," Garretson noted of STAT MedEvac. "It is not subsidized. We have not had any accidents. We have a robust safety culture, invest in the best equipment and have a proficient training program."
"It's chaotic at times"
The patient can choose the destination hospital, as long as it can handle that patient's medical issues, he said.
The number of flights each year has remained steady in recent years — about 12,500 combined, including 462 flights into UPMC Children's Hospital of Pittsburgh. STAT MedEvac also has four ambulances dispatched 2,000 times a year when weather conditions prevent helicopter service.
Some rural hospitals have closed, making helicopter flights even more necessary. In other cases, rural hospitals have expanded their facilities to include heart catheterization labs and improved care for stroke victims, which results in fewer helicopter transports.
STAT MedEvac dispatchers at the Allegheny County Airport in West Mifflin and LifeFlight's at Allegheny General Hospital on the North Side cooperate rather than compete. Generally, the closest helicopter available gets the call.
That means LifeFlight might transport a patient to UPMC Presbyterian, and STAT MedEvac might take one to Allegheny General Hospital.
"Both programs are highly regarded, and there is enough need in the Western Pennsylvania region for both to operate," Garretson said.
Despite the frequent trips, crews do strive to "fly neighbor friendly" in Pittsburgh skies, choosing routes to each hospital to avoid homes.
"However, safety of the patient, flight crew and aircraft supersedes that, and if (rerouting of a helicopter over homes) does occur, it is 99.9% justifiable due to strong winds, other aircraft in the area or other conditions," Palafoutas said.
Hot weather, which adversely affects helicopter aerodynamics, requires more energy to fly and the need to land while facing the wind, if possible. That could require the helicopter to alter its approach to the hospital.
Medical helicopter trips are expensive and with some risk, including the occasional crash. A 2008 helicopter crash in a Maryland suburb of Washington, D.C., during bad weather killed four of the five people aboard. It prompted Maryland's statewide helicopter ambulance system to improve overall safety by adding a second pilot on all flights and establishing protocols to determine when helicopter service is necessary.
Dr. Samuel Galvagno, a University of Maryland School of Medicine professor, has served as a flight physician and also has done research analysis showing that medical helicopters should be used prudently.
The key, he said, is to be able to identify the patients best suited for the transport.
UPMC research — establishing criteria for dispatching helicopters based on more than 260,000 patients transported by ambulance and helicopter — did "a very good job in attacking this problem that's plaguing helicopter emergency medical services," he said.
As a result of that research, first responders, including paramedics and EMTs, use a checklist, based on respiration levels, injury patterns, collapsed chest, paralysis and other impacts, to establish a score. "When the severity score is high enough, there is a clear benefit in using a helicopter," Dr. Galvagno said.
Years ago, based on established protocol at that time, he said he called for a helicopter for a person who was hit in the head by a Frisbee and lost consciousness for 30 seconds. The transport was unnecessary, costly and of risk to patient and crew. "It was not life-threatening," he said.
Adventures in saving lives
Medical helicopter crews typically include one or two nurses and a paramedic.
Helicopters need only a flat space to land — an interstate highway, a hay or ball field, the top of a building, or residential cul-de-sac — and that explains why most pilots are Army, Marine or Navy veterans, with some still active in the Army Reserves, officials say.
Pilot Scott Jackson of Leet prepares a STAT MedEvac helicopter before taking off in Cranberry on Thursday, Aug. 22, 2019. (Steve Mellon/Post-Gazette)
Scott Jackson, 54, from Leet, has been a STAT MedEvac pilot for 17 years. Jackson, a former Navy helicopter pilot during the Gulf Wars, Desert Storm and Desert Shield, is stationed with a new helicopter parked behind UPMC Passavant in Cranberry.
Pilots work 12-hour shifts, he said. Joyce Fee, 62, a nurse from Franklin, Venango County, and paramedic Brian Greenawalt, 32, of Jackson Township, Butler County, work two 24-hour shifts a week. Pilots and medical crew members are assigned to a base but may be assigned to other bases for scheduling reasons.
When the emergency tone goes off in the building, Jackson checks to see if there's a threat of dangerous weather. If so, a helicopter from another base may be dispatched, weather permitting.
Jackson said the helicopter he pilots can carry up to 187 gallons of fuel but usually has 100 gallons on board, ready to go, due to uncertainty about the weight of the patient. He adds fuel if it must go greater distances.
Takeoff times from a dispatcher call to liftoff can vary, but the goal is six minutes.
Jackson took the Post-Gazette for a test flight to experience flight conditions and see limited quarters for the patient and crew. All supplies and equipment are in backpacks organized in standard ways for ready access and easy transport.
Some days there are no calls for an entire shift, so they cook, sleep, watch television, read or do training. Other times, there are multiple trips. Once, Fee said she did seven in a 24-hour shift.
Being a crew member is "a more physical job than working in a hospital," said Fee, who has served 22 years as a helicopter nurse.
"We go through cornfields, ditches and around hay bales and stumps. You might be pushing a 200-pound guy while you're carrying a 38-pound backpack," she said.
They also cross muddy fields and in one case landed in a field of 18-inch-high clover that made it difficult to walk, let alone maneuver the wheeled stretcher that must be carried on occasion.
"On any given day we are seeing a patient or family members having the worst day of their lives, and we hope to make it a better day than it might have been," Fee said.
"There are easier jobs that pay better," she said, "But this is the best job in the world."
Heroes: LifeFlight and wife
At 10 p.m. on Jan. 28, 2018, Alison Michaels' husband, Lee, was making unusual noises in his sleep, but she couldn't wake him. She called 911. Dispatchers coached her on providing CPR until two ambulance crews arrived and used a defibrillator to restart his heart.
His survival was in doubt, given that only 10% survive cardiac arrest occurring outside a hospital.
He was rushed by ambulance from his home in Allegheny Township in Westmoreland County to Allegheny Valley Hospital in Natrona Heights and a LifeFlight helicopter was dispatched.
Once he was again stabilized, the LifeFlight trip to Allegheny General Hospital took only minutes, and once there he immediately underwent cardiac catheterization. One heart artery was blocked completely and another had 95% closure, leading to cardiac arrest.
In all, Mr. Michaels said he received cardiac defibrillation six times, with emergency room doctors able to regain a pulse "after an unprecedented 45 minutes of resuscitation without a pulse."
"Yep, it's a miracle," said Mr. Michaels, 56.
Unconscious for 11 days, he said, he had little chance of survival. But with six arterial stents and 21 days in the hospital, he was able to undergo extensive cognitive and physical rehabilitation and is now fully recovered. He returned to work in recent months as a marketing consultant.
"It really was a great save — the best of medical care every step of the way, starting with my wife," Mr. Michaels said. "Obviously, as my daughter said, all of these people are near and dear to our hearts and true heroes, and I consider my wife to be the first hero."