On April 5, 1976, a Learjet entered Texas airspace from Mexico. One of America's aviation pioneers was strapped to the stretcher aboard the "lifeguard" air ambulance flight. Howard Hughes, the reclusive billionaire, former air racer, and airline owner, would die before the Lear touched down in Houston.
Once the purview only of the wealthy, air ambulances now shuttle aging baby boomers, transplant patients, and others in need of urgent care to "medically necessary" locations around the globe. Insurance companies and other third-party payers are increasingly footing the bill for this complicated and expedient transport.
The entry of third-party payers into the market created an explosion of overcapacity. Virtually every FBO with a twin on its Part 135 charter certificate envisioned a new profit center, bought a stretcher, and put the phone number of its local paramedic on the speed dial. The results were predictable: Price competition became keen and a savvy network of international medical flight brokers sprung up to take maximum advantage of the situation.
"We are providing the service too cheap," says Don Jones, former vice president of Global Air Response, the largest full-time medical charter firm in the United States. "Marginal operators are lowballing the market."
Against the odds, several full-time medical charter companies such as Global Air Response have learned to thrive in this environment. From its headquarters at Centennial Airport just outside Denver in Englewood, Colorado, and bases in Schenectady, New York, and St. Petersburg, Florida, Global Air Response operates a fleet of 11 Learjet 25, 35, and 36 models worldwide, flying each airplane more than 1,000 hours a year.
Global Air Response's Centennial sales and dispatch center is the guts of the operation. Staffed 24/7, during the day it is home to three sales coordinators and three flight coordinators. Several of them are multilingual. Charts and aircraft/crew status boards adorn the walls and The Weather Channel hums from a television hanging from the ceiling. Specialized software programs keep crew schedules, price flights, and track them in real time, allowing the flight coordinators to notify hospitals and ground ambulance companies of any change in arrival times. Golf clubs, foam baseball bats, and other stress relievers lean against the cubicles. This is as much a "Type A" personality zone as the trading floor of the Chicago Mercantile Exchange.
Everyone in here must know chapter and verse the particulars of the federal aviation regulations governing Part 135 charter operations and air ambulance flights; international regulations governing the movements of people and airplanes; reimbursement policies of insurance companies; the special equipment needs of various medical conditions, from congestive heart failure to third-degree burns; and the maintenance schedules of the aircraft in the field and the duty times of their crews. Then there is the knowledge that only comes with years of experience: Who do you call in Antigua to open the airport at 2 a.m.? Which pilot needs to come home and see his girlfriend?
This is the domain of Flight Coordinator Daren Speck, a self-described adrenaline junkie. Speck has arranged flights for members of international royalty and a former president of the United States. For Speck, the "question is not whether you get it done, but how you get it done."
Speck grew up below the approach pattern of Offutt Air Force Base in Omaha, Nebraska, home of the Strategic Air Command and B-52 bombers, a place where urgency was a way of life. He received his aviation degree from the University of Nebraska and is a private pilot. Being a pilot helps Speck understand the impact of weather and other variables on flights. Speck must sort out often-conflicting patient information received from family members and hospitals, and balance the maintenance schedule needs of aging aircraft with the very human stresses of flight and medical crews who "tour" away from base with aircraft for up to two weeks at a time, remain domiciled at motels with numbers in their names, and typically eat at restaurants with drive-up windows. "Lots of times we play psychologists to the crews," says Speck.
When wearing the "lifeguard" designation, the Lear 25s, and their notoriously loud and fuel-hungry (270 gallons an hour at cruise) General Electric CJ-610 engines, can bust curfews and stringent antinoise regulations at places such as Naples Municipal Airport in Florida, Teterboro Airport in New Jersey, and Orange County Airport in California. But Speck and his fellow flight coordinators must deal with the blizzard of noise justification paperwork these flights create. They do most of the legwork for weather planning and routing on transatlantic flights in house, but they rely on international handling firms for these services to politically trickier places such as Africa and South America.
There is not a big price spread between medical transport and straight Part 135 passenger charter. It is typically less than 10 percent. And the air ambulance companies earn every penny of it. Speck provides a recent example. On a Sunday night, an insurance company called to move a patient from Mexico to Miami. No problem, except the patient was a German national without a U.S. visa and there was no accepting physician in Florida. Speck got on the phone with the U.S. Embassy in Mexico City and arranged for an emergency visa waiver. Then he got the German insurance company to issue a letter of financial responsibility. Finally, he reached an on-call doctor in Florida who agreed to accept the patient. These gymnastics completed, Speck was free to actually begin arranging the flight. Neither the insurance company nor the patient is charged anything extra for this urgent diplomacy — it's all part of the service.
On this March morning, many of the nation's retirees are beginning their spring migration. Some will be coming home sick. In the past two hours Speck has changed two airports and two departure times, generating seven phone calls. Ambulance companies, hospitals, relatives of the patients, and airports must be contacted. Runway lengths must be verified. The crews, out there somewhere just waking up — the industry's tight margins mandate that aircraft and crew only return to base for scheduled maintenance and crew changes — often not knowing the day's agenda, must be notified by digital pagers and cell phones. International flights carry satellite phones. "Nothing's ever set in stone here," says Speck. "Sometimes I'm changing four flights at a time. You can't think linear here."
The choreographed cacophony in the dispatch center pales next to what is going on out at the ramp. Lori Bambray, a certified respiratory therapist, is loading a Lear 35-105 with more than 13,000 hours of total time with drugs and equipment. Meanwhile two mechanics have the aircraft's nose pried open and are swapping out an avionics box while the pilots are preflighting. This flight is off to Tucson, Arizona, to transport a patient to Muskegon, Michigan. From there it will reposition to Rochester, New York, and carry another patient to Phoenix. A few feet from the airplane, another team readies a 9,000-hour Lear 25D for a 485-nm hop down to Scottsdale, Arizona, to retrieve an elderly patient with blood clots in his lungs and bring him back to Centennial.
It costs between $50,000 and $80,000 to turn a Lear into an air ambulance. Basically, everything that one would find in a hospital emergency room must be crammed into these little tubes. The list includes the stretcher base unit, which must contain its own power and oxygen supply independent of those that are part of the aircraft's systems; ventilators; monitors; intravenous solution pumps; pulse oximeters; and a half-dozen other drug and equipment bags. "We have all the toys," says Julia Spring, Global Air Response's chief flight nurse. Spring, a flight nurse for 17 years, manages a staff of seven nurses and three respiratory therapists.
Spring will be the flight nurse on today's Scottsdale run. Air transport creates special medical considerations. A patient with blood clots poses unique problems. With clots and respiratory problems, generally a patient's oxygen flow must be increased as air expands with altitude. Blood pressure can fluctuate because of transient G forces, even in stable air. Blood pressure typically drops on takeoff and increases during descent as blood vessels constrict. Both the nurses and the pilots are thoroughly schooled in altitude physiology and how it affects diseases.
A patient's medical condition sometimes dictates that pilots must make shallow climbs and descents or maintain a "sea-level cabin" as opposed to the 7,000-foot cabin the Lear typically produces at cruise altitude, Flight Level 390 and up. This limits the Lear to about FL300 and precludes refueling stops at high-altitude airports, such as Denver. Running at the lower altitudes increases the airplane's already voracious fuel burn and brings down its normal 1,200-mile range. This often means a fuel stop. With a patient on pure medical oxygen, special precautions must be taken when refueling a lifeguard flight. A fire engine must stand at the ready next to the fuel truck.
The reason for this precaution was graphically illustrated at Denver's old Stapleton Airport several years ago when an oxygen fire ripped through an air ambulance during refueling, burning the copilot and exploding the patient's oxygen bottle out of the side of the fuselage.
To be sure, air ambulance crews can experience stressful moments on the ground, but most of the action is still skyward. Cardiac patients in particular have the potential to "go bad in the air," according to Lori Bambray. When that happens, the aircraft lands if it is within 15 minutes of a major city where the patient can receive advanced care not available on the aircraft.
Relatives accompanying patients, often riding in a light jet for the first time and frequently under severe emotional stress, can place greater demands on the medical crews than the patients themselves. Global Air Response tries to mitigate this situation by medically screening the passengers, but sometimes the medical crews end up treating two patients — one they knew about and one who develops when the gear comes up. Often, patients and doctors are taking a calculated risk, moving the ill to a higher level of care even when they are too unstable to fly. Some transports are terminal and tagged "do not resuscitate." Some, like Howard Hughes, die in the air.
The Learjets are ideally suited to the air ambulance role, according to Keith Butler, Global Air Response's director of operations. According to Butler, the Lears, despite their fuel ingestion rates, are cheap to operate, have low acquisition costs (about $1.2 million for a 25D; good 35s start at $2.2 million), and are very durable. "I never cease to be amazed at what old Bill Lear created," says Butler. "More than 10,000 cycles and just look at that little airplane. Just about as responsive as a fighter: 43,000 feet in 11 minutes."
The lure of Lear keeps Global Air Response flooded with 500 new pilot résumés a year and convinces right-seaters to sign on for an apprentice wage of $1,200 a month, says Butler. It also explains a relatively low annual pilot attrition rate of 15 percent. Global Air Response hires virtually all of its captains from within. Starting pay in the left seat runs around $30,000 a year and tops out at $85,000 for check airmen who earn incentives. "The experience they get here is very different to say the least," says Butler. Most of Global Air Response's 40 pilots have flown to every state, every Canadian province, and most of the Central and South American countries.
"This is for people who like adventure," says Global Air Response's Kevin Burkhardt, a 15-year air ambulance pilot. "One day you could be landing in Quito, Ecuador, and the next day you're in the Canadian tundra."
"It makes for a good mix," says Spring. "Pilots and nurses have the same kind of mentality." And they run on the same fuel: adrenaline.
Mark Huber is a marketing executive and an occasional contributor to Pilot. He lives and flies in Michigan's Upper Peninsula.