By Amy Jeter
The Virginian-Pilot
SUFFOLK, Va. — As green fields and gray waters unfolded far below, the nurse eyed the clear liquid in a hanging IV bag and the numbers on a monitor over the stretcher. Her patient was calm and stable.
So far, so good.
On a blazing late July afternoon, the 14-year-old girl had grown dizzy and toppled off a horse at a riding camp in Suffolk.
Worried about head and neck injuries, medics called the Nightingale Regional Air Ambulance Service. It would carry the girl over car-jammed tunnels to Sentara Norfolk General Hospital, the region’s only Level I trauma center.
Flight paramedic Larry Breneman radioed information ahead and scanned the skies for planes and helicopters, as McKay counted the girl’s breaths. She stroked her patient’s strawberry-blonde hair.
There’s going to be some vibration in the helicopter, McKay told her. We’re getting ready to land.
Over nearly three decades and more than 16,000 missions, Nightingale has delivered the most seriously ill and injured patients in southeastern Virginia and eastern North Carolina into the hands of doctors — all without an accident.
The changing business
But the air ambulance business has changed since 1982.
After a spate of crashes, federal agencies started encouraging expensive technology for better navigation. Demand for speedy transport of heart and stroke patients has increased. And at least two other helicopters equipped for medical transport now dip into Nightingale’s air space.
Health care also is different.
Hospitals are nervously anticipating the fallout of the national overhaul, while they try to make up for government insurance payments that don’t cover their costs.
To keep up, Sentara Healthcare plans to trade in its 24-year-old bird for a new, state-of-the-art Nightingale - price tag, $7.4 million. It’s a hefty order for a program that loses as much as $1 million a year.
For the first time, Sentara is soliciting donations to help pay the bill - at the same time the company continues to pursue new projects worth millions.
“We are really talking about the fact that this is here to support the community, and we want you to be a part of that,” said Mary Blunt, corporate vice president and administrator of Sentara Norfolk General Hospital. “The people that we met with and we talked to, no one has come to us and said, ‘You’ve been giving us this service free, and now you’re going to make us pay for it.’”
Ten minutes after collecting the patient in Suffolk, Nightingale touched down on the helipad outside Norfolk General.
A security officer helped ease the yellow stretcher out of the helicopter and wheel it past parked ambulances through the sliding doors of the emergency department. Doctors and nurses waited in a cleared trauma bay.
“Hello, everybody,” Breneman said. He launched into the patient’s history as they moved her and surrounded her bed. “Can you wiggle your toes for me?” someone asked.
McKay slipped away to disinfect the stretcher and restock medication. The next call crackled over her radio while she was still in the equipment room: A cardiac patient in North Carolina needed a flight to Norfolk General.
634 transports
Nightingale transported 634 patients last year.
A little fewer than half came from the scene of an accident or other injury. The rest were transferred between facilities.
Most often, Nightingale flies to eastern North Carolina or Western Tidewater. Missions also take the crew to the Peninsula, Eastern Shore, Chesapeake and Virginia Beach.
Usually, first responders determine whether to call the helicopter.
The Tidewater EMS Council directs members to request an air ambulance if a patient requires time-critical care; the closest hospital cannot provide needed care; or transportation by ground would leave an area without an ambulance.
Patients who are unconscious, unresponsive or unable to breathe are candidates for a medical helicopter. So are those with critical burns, uncontrolled bleeding or injuries from blunt trauma.
Nightingale offers speed, the expertise of a critical-care nurse and some advanced treatments.
Sometimes the helicopter leaves a patient behind - the cabin is too small for CPR , and speedy transport is useless if a patient dies before Nightingale arrives.
Some patients don’t survive their hospital stay. Others walk out the door within hours.
Caitlin Hankins was one of the lucky ones.
The ninth-grader suffered only a mild concussion from her fall off the horse, and she was ready for a pizza dinner later that night.
Before, she’d associated Nightingale only with bad injuries.
“It was nothing like I thought it would be,” Caitlin said. “It was pretty cool.”
While McKay and Breneman readied equipment, pilot Cameron Ebel scanned two computer screens at Nightingale’s headquarters, a windowless four-room suite on Norfolk General’s fifth floor.
He didn’t like what he saw.
Six missions in 12-hour shift
Both weather maps and numerical readings predicted thunderstorms rolling in from the west within hours. Ebel decides whether to fly, though his employer, Texas-based Omniflight Helicopters, can intercede.
Nightingale has flown as many as six missions in a 12-hour shift. That day, crew members had waited more than seven hours before flying to a patient’s aid. Then, after arriving from Suffolk at 3:17 p.m., they received three requests in quick succession: two to North Carolina and a transfer from Children’s Hospital of The King’s Daughters to the University of Virginia Health System.
Ebel turned them all down.
Last year, Nightingale declined 265 flights because of bad weather, maintenance or other reasons.
When that happens, officials have three options: wait, use ground transportation or call another air ambulance.
“Nightingale base, Nightingale,” McKay radioed to dispatch. “We will be unable to accept because of weather.”
When Nightingale took its first flight, it was one of two specialized air ambulances in Virginia.
Today there are 21.
That doesn’t count Virginia Beach police’s new helicopter, which as a backup medical transport has ferried seven patients since late 2009.
It does include LifeEvac III, a West Point-based helicopter affiliated with Riverside Health System and operated by Air Methods Corp., a Colorado-based company with a fleet of 300 medical transport aircraft.
The air ambulance business began booming nationwide about a decade ago, driven by an aging population, shrinking rural hospitals, closures of emergency departments and a change in how Medicare pays for patient flights.
Not competition
Despite some overlap, services in Virginia and North Carolina don’t consider themselves competitors.
Yet the number of requests for Nightingale decreased by about 10 percent and the number of transports fell by 15 percent since LifeEvac III appeared on the scene in 2006. LifeEvac III flies about 400 missions a year.
Sentara pays $2.8 million a year to run the service, and it loses as much as $1 million annually, said Robert Broermann, the company’s chief financial officer.
He attributed the loss to the one-third of flight patients who are uninsured or on Medicaid, the government insurance program for low-income people, which generally pays less than the cost of medical services.
On average, a Nightingale mission costs $4,400, of which an average of $3,500 is reimbursed, Broermann said.
Historically, hospital-based air ambulances often lost money because the programs were developed as a community service, said Ed Marasco, a vice president for Quick Med Claims, a Pittsburgh-based medical transport consultant.
Recently, many have tried to at least break even by upgrading to more fuel-efficient aircraft or sharing dispatchers with local emergency services. Others left the business.
A 2002 change to Medicare’s air ambulance rules favored for-profit companies. Hospital-based helicopters no longer were paid on the basis of cost and, instead, were reimbursed on the same fee schedule as other airborne programs.
Programs run by for-profit companies — like LifeEvac III — stay in the black by spreading resources over the entire fleet of aircraft.
When Sentara officials started thinking about a new Nightingale helicopter in 2007, they considered outsourcing the program but decided against it.
They worried that the companies might pressure crews to take risky flights in order to make more money.
Craig Yale, a vice president of Air Methods, LifeEvac’s parent, refutes such claims.
“The pilots know when to say, ‘No,’” he said.
Keeping control
But Sentara preferred to keep control.
“It may be a couple of hundred thousand dollars more a year for us to have the program completely under control,” Broermann said, “but at the end of the day, we concluded that it was well worth it in the interest of being able to maintain the level of the program that we’ve had for the last 28 years.”
The last time Sentara purchased a helicopter for Nightingale was 2003. After eight years of leasing a 1986 BK 117-A4, the company bought the aircraft with $1.6 million from Norfolk General’s capital budget.
This time, officials decided $7.4 million was too much to carve out of that budget, which also was funding two specialized operating rooms.
So they’re looking for help.
Sentara Health Foundation’s helicopter fundraising campaign is trying to raise $3.5 million.
It would help pay for the new bird, a Eurocopter EC-145, which is already being manufactured. It will have many recommended safety features: autopilot, night vision goggles, terrain and traffic avoidance features, satellite weather and tracking. It also will have a bigger cabin, with more room for a second patient and additional equipment as technology advances.
With more power and fuel capacity, the new Nightingale will be able to go farther and faster, said Nightingale manager Christopher Cannon . It should serve the program for two decades.
The foundation has raised more than $2 million so far. But it hasn’t been easy.
Donation requests to local governments, health foundations and private businesses have run to six and seven digits - a lot of money in tight times.
And some of the foundation’s requests have contained incorrect information. Executive Director Meril Amdursky told at least two potential donors that Nightingale flights cost $7,500 to $8,000. The average cost last year actually was $4,400.
Amdursky said she was new at the time and confused the cost of a flight with what Sentara charges. “I made a mistake,” she said.
So far, contributors include TowneBank, SunTrust Bank and more than 1,800 Sentara employees, who together donated more than $500,000.
The Norfolk Economic Development Authority is considering a request for $100,000. Although Nightingale flew just nine patient transfers from Norfolk last year, Sentara officials said in their application it’s “part of the advanced healthcare infrastructure that attracts new business to Norfolk.”
There for the community
Currituck County commissioners asked for a financial audit and an explanation for why Sentara, a company with $1.4 billion in unrestricted net assets, needed $1 million from a locality with a budget of about $44 million. They were told Sentara’s assets were mostly accounted for in facilities, medical equipment and emergency reserves.
The commissioners decided to contribute $200,000.
“They could pay for it tomorrow,” Commissioner Paul O’Neal said. “That’s beside the point. We wanted to participate from the standpoint we felt everyone should participate.”
Sentara, which operates as a nonprofit, is being careful with its money, especially because it faces so much uncertainty from the national health overhaul, said Broermann, Sentara’s CFO. Pending changes could drastically affect Sentara’s finances because so much of its business comes from people with government insurance.
Proposals for new or upgraded facilities will cost the company millions but also generate revenue, he said.
“You can always argue that there’s money laying around somewhere and things could be moved around,” Broermann said. “The question gets to be, how long do you want to continue to make that argument? Until the last dollar of the organization is spent?”
Still, the new helicopter is coming, no matter how much Sentara raises. No one will be penalized for not contributing. And the Nightingale program isn’t going anywhere.
“We always want to make sure it’s there for this community,” Broermann said, “regardless of what happens.”
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