Photo by Robert Burroughs

Now that a second Life Flight helicopter has been activated to serve the county’s new trauma center system, new questions have arisen.

At 6:33 p.m. the radio in the Life Flight operations center at UCSD Medical Center in Mission Hills crackles: two accidents have occurred in the East County. In Alpine, a young boy has fallen off a bicycle; in Tecate, a woman has collapsed in a federal building used by the border patrol at the border entry station.

August 5 Bonita horse accident

Photo by Robert Burroughs

The crew of the Life Flight helicopter is put on standby for both accidents. Emergency medical technicians -are now rushing to the two locations in ambulances and fire engines, and if they deem the injuries serious enough they will call for Life Flight to pick up the victims.

Landing

Photo by Robert Burroughs

During standby, the flight nurse who is on duty often goes up to the hospital s rooftop hel ipad to make certain all the needed medical supplies are on board the helicopter, and to prepare for a quick takeoff.

Randy Mains

Photo by Robert Burroughs

But today, a Sunday, has been a slow day; this is the sixth time the Life Flight’s crew members have been put on standby since ten o’clock this morning, and they have not left the ground yet. The flight nurse, Pat Terry, knows the helicopter is ready to go, so she heads over to the hospital cafeteria for a bagel with cream cheese. If Life Flight is needed she will be notified on her electronic beeper, and it will take only seconds to get to the roof through the hospital’s quiet, empty hallways.

Bill Baxt

Photo by Robert Burroughs

Across the street, in an apartment the hospital maintains for on-duty pilots of Life Flight, chief pilot Randy Mains acknowledges the standby notification on his portable radio. The radio dispatcher at the operations center informs Mains of the map coordinates of the two locations, but Mains has been to both Alpine and Tecate many times and doesn’t bother to check his map.

Marti Bennett

Photo by Robert Burroughs

He is more concerned about the low gray clouds that have blanketed the sky since morning. If the clouds are too low. Life Flight may not be able to make it to either Tecate or Alpine, because the German-made Boikow 105 helicopter is not equipped for instrument flying and Mains cannot legally fly without being able to see for at least one mile.

Mary Cunanan

Photo by Robert Burroughs

On the hospital’s third floor. Dr. Paul Phillips also hears the notification to stand by, but keeps reading through research data he is compiling on ultrasound tests on pregnant women. As the minutes tick by, the standby for the Alpine bicycle accident is canceled, and it begins to look as if the standby for the woman who collapsed in Tecate will also be canceled.

Pat Terry

Photo by Robert Burroughs

Phillips is new to Life Flight and is looking forward to his first flight on the helicopter, but his twelve-hour shift at the hospital ends at seven o’clock and he is looking forward to going home for the evening, too.

Paul Phillips

Photo by Robert Burroughs

At 6:56, though, all three crew members are notified that Life Flight has been asked to pick up the woman in Tecate, who is now reported to be unconscious. Moments later they are in an elevator heading up to the helipad on the roof. Someone asks Phillips what time it is, and he replies, “Three minutes until the end of my shift.” He flashes a good-natured smile.

At 7:02 Phillips, Terry, and Mains are seated in the helicopter’s cramped cabin. The aircraft vibrates as the big blades whirl overhead, and the acrid smell of fuel exhaust drifts in through the windows. Mains radios the control tower at Lindbergh Field for clearance to take off — Life Flight is given priority over every other aircraft in San Diego’s skies, although actual conflicts are few because the helicopter usually flies less than 1000 feet above the ground — and seconds later the Bolkow climbs smoothly into the air. Soon Mains banks the helicopter sharply to the right over Highway 163 and then heads eastward some 800 feet above El Cajon Boulevard.

The summer evening is just beginning to grow old; the city basks in muted gray light. A few cars on the streets below have their headlights on. Above the helicopter, clouds stretch like a ceiling to the horizon, and in the distance, mountains can be seen faintly through haze. Pat Terry, glad to be on a call after spending most of the day busying herself with paperwork and bantering with her colleagues, is the most lively crew member on this flight. She is a short, attractive woman with blond hair and a quick laugh, and over the headphones that all crew members wear, she kids Phillips about having almost made it to the end of his shift. “Three more minutes and you could’ve been home,’’ she says.

Phillips grins. “That would have been a shame,” he tells her.

A moment later Terry turns to Mains and says, “Nice weather, huh? In Seattle this would have been a great day.”

“Right,” says Mains. “In Seattle they put on their bathing suits when they have a day like this.” He sounds distracted, though. He swings the Bolkow southeastward over Lemon Grove, then steers a course over Sweetwater Reservoir. Most of Life Flight’s six pilots would simply follow Highway 94 to Tecate, but Mains intends to save time by flying a more direct route, straight over the mountains. The danger, however, is that the low clouds could reduce his visibility to zero. Meanwhile, in an upstairs room inside the old wooden federal building in Tecate, a woman sits against a wall, her eyes half closed, her breathing labored, her blood pressure pushing dangerous limits, unaware of the flying emergency room coming to her aid at 130 miles per hour.

Since its inception in 1980, the UCSD Medical Center’s Life Flight program has never been far from controversy. When the university first announced its intention to start an emergency medical helicopter service, critics said that normal old ground ambulances were adequate.

They pointed out that transporting patients via helicopter would be considerably more expensive, too, driving up the cost of medical care. There were also complaints that UCSD Medical Center would be “stealing” patients with its helicopter, patients who, if they had been picked up by ambulances, would be transported to other area hospitals. More recently, some critics have even suggested that such helicopters are little more than elaborate public relations gimmicks, high-tech, high-visibility vehicles that grab headlines as well as patients, impressing people who might soon be making a choice about which hospital to enter.

To a large extent many of these criticisms still persist. And now that a second Life Flight helicopter has been activated to serve the county’s new trauma center system, new questions have arisen about how much hospitals and their patients can afford to pay for such service. But Bill Baxt, Life Flight’s medical director, feels that at least one of the early criticisms of the program has been laid to rest. Baxt points to data he compiled last year on 300 patients, 150 of them transported by Life Flight and 150 transported by ambulances. Baxt used a scoring system to rate the seriousness of the injuries, and calculated that 14.7 of the patients transported by ambulance were statistically expected to die. Nineteen actually did. Of those transported by Life Flight’s crew, 20.6 were expected to die, but only ten actually did. The lower mortality rate for patients treated by helicopter has also held true in a similar study done recently on more than 1000 patients from seven different medical centers around the country, according to Baxt. “There is a class of patients who basically are going to have a [high] mortality rate unless they have access to a program like this,” said Baxt. “For example, the guy with major multisystem injuries in Jacumba, seventy-five miles from the nearest hospital. Or the patient who is pinned in a vehicle and needs major interventions [by a physician) right there before he’s extricated, because [otherwise] by the time he’s extricated he’s going to be dead.”

Life Flight is Baxt’s brain child. Although there are now some seventy such emergency medical helicopter programs in the United States, Life Right is one of the few in which a physician always rides in the helicopter; and while roughly eighty percent of the calls most medical helicopters go on involve transferring patients from one hospital to another, eighty percent of Life Flight’s calls are “scene” calls — emergencies in the field. At forty-three Baxt is a tall, thin man with a square jaw and wiry black hair that is turning gray on the fringes. While doing research in molecular biology as a faculty member of UCSD’s School of Medicine in 1975, he took a second job as a pol ice officer. (“I think physicians tend to go through an incredibly sheltered educational experience and end up in a very sheltered life,” he says. The police work “exposed me to things I never would have been exposed to . . . crime, people in trouble.”) Baxt left the police department three years later when he suffered a compression fracture of one of his vertebrae during a scuffle with a man he was trying to arrest, and not long after that he was named director of Life Flight. He noted that the helicopter is not intended to replace ambulances but to augment them, going out after the critically sick or injured patients who make up only about two percent of all patients admitted to hospitals. It isn’t that Life Flight gets these patients back to the hospital more quickly than an ambulance would; Baxt says that because the doctor and nurse begin administering emergency treatment on the scene (they don’t simply throw the patient on board the helicopter and speed back to a hospital), the patients probably arrive at a hospital equally fast by helicopter or ambulance. But medical experts and a vast array of equipment and supplies reach the patient more quickly via helicopter, and that, Baxt believes, is the secret to the program’s success in saving lives. “What we do is, get them . . . care faster, and stabilize them faster and more extensively” than paramedics in ambulances could, he said. “And we can have a team of surgeons waiting for them when they arrive.”

Each time the helicopter flies there is a physician and a specially trained nurse on board, along with what is for all practical purposes a fully stocked hospital emergency room. Life Right carries pacemakers and safety pins, oxygen and adhesive tape, syringes, forceps, and sponges. There is Lidocaine for treating an irregular heartbeat, Mannitol for reducing swelling in the brain. Narcotics such as morphine are also on board, but they are almost never used; most of Life Right’s patients are unconscious or too far gone to be concerned about pain. A portable electrocardiograph rides on the helicopter, and patients can also be hooked up to equipment that will automatically provide a digital readout of their blood pressure and pulse rate on a small screen mounted in the helicopter’s rear panel. A complete list of the equipment carried by Life Right runs to seven full pages, and it can be explained more readily by noting what is not on board: an x-ray machine and laboratory facilities. Life Flight’s doctor and nurse can cut open your trachea and insert a breathing tube into your lungs. They can deliver a baby via Caesarean section, although in four and a half years and some 2500 flights that is one operation that has never been performed. They can split open your chest and massage your heart, or put a clamp on your aorta to prevent you from bleeding to death. No one at Life Right keeps tally of how many lives have been saved by the emergency medical helicopter, but Baxt sums up by saying simply, “A lot.” One of them is Glenn Chancer’s.

Just after midnight on July 11, Life Right received a typical call to come to the scene of a traffic accident on Mission Center Road, just north of the San Diego River. Chancer, twenty-eight, had been driving a sports car when he was hit head-on by a pickup truck. Firemen on the scene had been on the verge of pronouncing Chancer dead when someone noticed he was still breathing, if only barely. Because they knew it would take some time to extricate Chancer from the wreckage of his car, the firemen called Life Flight. At thirteen minutes after midnight Life Right’s helicopter lifted off the helipad at UCSD Medical Center, and two minutes later landed on Mission Center Road. “Patient very cold, clammy. Appeared dead!” reads the report written by the Life Flight nurse on duty that night, Mary Anne Bockman. On a sixteen-point trauma scale that Life Flight doctors use to evaluate their patients, Chancer scored a four — meaning that his chances of surviving were less than one percent. (On the scale, which takes into account such things as blood pressure, respiration rate, and level of consciousness, a sixteen means the patient has a ninety-nine percent chance of survival; a zero means he is dead.) While firemen labored to cut through the mass of twisted steel and chrome, Bockman and the Life Flight physician that night, Tom Neuman, crawled into the passenger side of the car. After a quick check of the patient they inserted a plastic tube into Chancer’s nose and down into his lungs to protect his breathing passages. Chancer’s blue lips, pale skin, and almost total lack of blood pressure told Bockman that the accident victim had major bleeding somewhere — she guessed that the major artery carrying blood from his heart, the aorta, was torn. She stuck intravenous tubes into both of Chancer's arms and began to feed saline solution into his veins to boost his critically low blood pressure. Minutes later, when Chancer was finally freed from the wreckage of his car, Neuman and Bockman attached an oxygen bottle to the breathing tube in Chancer’s nose in order to force him to breathe more deeply. Then they fitted him with trauma pants, tightly fitting pants with an inflatable “balloon” in each leg. The pants can aid victims suffering from profound shock by forcing blood to stay in the upper part of the body, particularly in the vital brain. At twenty minutes to one the Life Flight helicopter lifted off, and, because Mercy Hospital’s and UCSD Medical Center’s operating rooms were full, flew quickly to Scripps Memorial Hospital. Doctors there had time to analyze the full extent of Chancer’s injuries. In addition to having a tear in his liver big enough for the operating surgeon to put his hand into, Chancer had had his aorta cut in two. His left hip was fractured, and he had several broken ribs. Today, after three major operations. Chancer is still in Scripps Memorial Hospital, but he will live to return to his job as a salesman for Gencom, a manufacturer of electronic equipment. When a patient is revived after a bad injury it is referred to as a “resuscitation” in medical jargon, but a few days after the incident one of Scripps ’ doctors called Neuman on the phone and told him, “That was no resuscitation — it was a resurrection!”

Nearly all of the requests for Life Flight come from “first responders” — the paramedics, firemen, law enforcement officers, and park rangers who get to an accident scene first. If a first responder calls for the helicopter, no questions are asked — Life Flight simply takes off immediately — but through an extensive series of lectures and slide presentations, members of Life Flight have explained to such agencies what types of emergencies the helicopter should and should not be called for. (The average person cannot call Life Flight; the program’s emergency phone number is unlisted, and the citizen who does occasionally call the emergency number is referred to a first responder.) Baxt said the number of inappropriate calls for the helicopter has dwindled since the early days of the program; when such calls are made, they are followed up by a letter from Life Flight crew members explaining why an ambulance or some other agency could have taken care of the situation. “We don’t want to fly sixty miles out into the wilderness to pick up some guy who’s been in a traffic accident, but his only problem is that he’s drunk, or he’s got a broken arm,” Baxt explained. Utilizing the helicopter for such patients is simply too expensive.

Until now, UCSD Medical Center has covered the vast majority of Life Flight’s annual cost of one million dollars, which includes a lease agreement with Evergreen Helicopters Inc. for helicopters, maintenance, mechanics, and pilots. Each time Life Flight goes out to pick up a patient such as Chancer it has cost the center about $2000. Last year Tri-City, Scripps Memorial, and Grossmont District hospitals agreed to contribute to Life Flight’s budget, but the total amount from the three hospitals was less than $50,000, leaving UCSD to make up the balance. Even so, Mary Cunanan, the administrative director of Life Flight, noted recently that the average bill to patients who are carried in the helicopter is only about $560 (which compares to an average bill of $138 to patients carried in the ambulances contracted for by the City of San Diego). Like other emergency helicopter programs throughout the country, said Cunanan, ‘*Wc felt we should stay competitive with ambulances in terms of cost, even though our services — the doctor, the nurse, the mini-intensive-care unit — are more sophisticated than an ambulance’s. Frankly, if we charged what the helicopter truly costs us, no one would ever use it.” Overall the helicopter program operates in the red, using revenues from the hospital's other patients to make up the shortfall. Life Flight does sometimes bring in patients who, because of the seriousness of their injuries, are lucrative for the hospital; large sums are billed to the patients (or their insurance companies) for such things as surgery, medication, and other care. But patients who have little money and are not covered by insurance must also be picked up, contributing to the helicopter program’s deficit.

One reason Life Flight has survived even though it doesn’t pay for itself is, of course, the enormous amount of attention and exposure it gains for UCSD Medical Center. The competition for patients is intense among the many hospitals in the greater San Diego area, and the highly visible helicopter, mentioned along with the hospital's name so frequently in the local media, is bound to impress on potential patients, employees, and wealthy donors that UCSD Medical Center is a leading state-of-the-art institution. Cunanan insisted that Life Flight would be funded even if it had no such public relations advantages; after all, she pointed out, the helicopter literally brings quite a few patients into the hospital, many of whom provide not only revenue but teaching value. As a teaching hospital, UCSD Medical Center relics on using patients with severe or unusual injuries in the instruction of its young, aspiring doctors, and Cunanan said that nearly all of the emergency medical helicopter programs in the United States are based in large teaching hospitals similar to UCSD’s. Nevertheless, the center recently spent months negotiating an agreement with five local hospitals to contribute to the cost of Life Flight. Under the tentative agreement each of five hospitals (Mercy, Scripps, Sharp, Tri-City, and Children’s) will pay UCSD $1075 each time it receives a patient from one of the helicopters. A UCSD administrator noted that similar agreements with other local hospitals with helipads may be forthcoming; meanwhile, UCSD, which will separately bill patients transported by Life Flight, has raised the average amount it will bill those patients to $800. “You can only go for so long on deficit spending just to prove that an emergency medical helicopter is needed,” Cunanan said wryly.

Beyond Sweetwater Reservoir the houses give way abruptly to barren brown hills. The helicopter sweeps over them with breathtaking rapidity — at an altitude of only a few hundred feet, there is a sensation of speed that passengers in jet airliners experience only while landing or taking off — and churns on toward Tecate. To the south, Otay Lakes come into view, and above, the gray clouds seem to press closer. Mains radios UCSD Medical Center: “UCSD, this is Life Flight One, we’re going behind the mountains in a minute and will probably lose radio contact. ...” A moment later he radios Tecate, trying to get updated information on the woman who collapsed at the border station. Unexpectedly, there is no answer.

The Bolkow hits a pocket of turbulence and swerves and pitches before continuing on smoothly. Suddenly an unidentified voice blares over the radio: “Life Flight, patient is a fifty-year-old female, blood pressure of 160 over 90. pulse of 100, respiration [rate] unknown because of sobbing. ...” The latter information hits the inside of the helicopter like a bucket of ice water. Mains turns to Terry with his eyebrows arched; she makes a face. The unspoken question: If the woman is sobbing, how seriously injured can she be? The medical crew in the helicopter wants a call they are truly needed on; they do not want to fly to Tecate simply to treat someone who is hysterical. But a moment later the voice on the radio says cryptically, “Make sure Life Flight gets here.” The message creates a sense of urgency. “We’re on our way,” Mains responds. “One minute out.” Twisting Highway 94 is beneath the helicopter now, and ahead loom rock-studded mountains. Mains steers toward a gap in the mountains and a few seconds later the houses of Tecate appear below.

Slowing the helicopter. Mains looks out first one side of the helicopter and then the other. He is not looking for other aircraft but for the place he is supposed to land. In most cases the first responders will guide the helicopter down via radio, but on this call no one on the ground is being particularly communicative. Mains spots a green fire truck and points to it. Phillips leans forward to look, then nods. Mains swings the Bolkow sharply left and descends to a point perhaps 200 feet off the ground. He hovers there for a few seconds, surveying the fire truck and a small asphalt parking lot below. Then, as if it is being drawn down by a magnet, the helicopter descends rapidly into the parking lot. Dust kicks up around the Bolkow as it touches down, fourteen minutes after lifting off from UCSD Medical Center. Not far away a small crowd of onlookers has gathered to take in the spectacle. Terry opens the glass door next to her and again the smell of fuel exhaust drifts into the cabin. She and Phillips grab bags full of medical equipment and rush out, crouching low to avoid the whirling blades.

Although the crew members of Life Flight eagerly look forward to using their skills on critically injured or sick patients — and even complain of boredom if there are no calls during a particular shift — once in a while an accident occurs that, years later, can be remembered all too easily. For Randy Mains it was the time he picked up a twenty-nine-year-old man who worked for SDG&E. “He was an aspiring ballet dancer,” Mains remembered. “He was married, and he had just had a little girl. He burned himself somehow on an underground electrical outlet or transformer or something — ninety percent of his body had third and fourth degree burns. We picked him up at Tri-City Hospital I for transfer to UCSD Medical Center’s burn center). When I got to the emergency room he didn’t have a stitch on him. . . .” The man died a few days later, but the sight of his charred body will stay with Mains for the rest of his life.

As a pilot Mains's attention is often concentrated on something other than the patients he picks up. Usually that something is the weather. “There are no heroics in this job,” he is fond of saying. “We [pilots] get paid to say no, we’re not going to do that mission” because conditions are too dangerous to fly. Rain and wind are only minor concerns; what grounds the helicopter are low clouds or fog that reduce visibility. There are other dangers — landing on sloping mountainsides, on crowded freeways, or in tiny parking lots that are surrounded by electrical wires — but the flight Mains remembers mast vividly was a routine flight to Oceanside. “It was one of those situations where you’re awakened out of a deep sleep,’ ’ he said (like all Life Flight pilots. Mains works a twenty-four-hour shift). “Mentally you’re maybe eighty percent there. It was a real piece-of-cake flight, just fly up Interstate 5 to Tri-City Hospital (in Oceanside). We had a neo-natal team on board that we were going to drop off. But it was overcast, there was a bit of a light drizzle . . . and there’s a place in the flight where I have to veer away from the freeway and fly directly over Palomar Airport. I was only about 400 feet above the ground and all of a sudden — boom! — I went into a cloud. I thought I could see the lights down below, and I tried to do a 180-degree turn, and I lost the lights. So I was completely in the soup, 400 feet above the ground, trying to do a 180-degree turn, and I got vertigo so badly that for a good thirty seconds I was not in control of the helicopter. It’s hard to relay the feeling to you — your inner ear starts playing tricks on you. My mind was telling me, ‘Turn left! TUm left!’ but the instruments were telling me, ‘Turn right! Turn right!’ And you’ve got to believe the instruments. I had to talk myself through it, say, ‘Okay, first thing, level the helicopter. . . .’ So I leveled the helicopter. [Then) I talked myself through the turn, and all of a sudden we broke out of the clouds. That’s the closest I ever came to losing it.” Mains is tall, mustachioed, and younger-looking than his thirty-eight years. He is known among Life Flight personnel for his sense of humor, and his official identification badge reads, “Randy Mains — Emergency Medical Vertical Levitation Practitioner.” He learned to fly helicopters in the Army, and ferried troops and supplies to various American military stations in Vietnam. After being discharged in 1971 he moved to Australia, where he found work herding cattle with a helicopter. Mains subsequently moved to Iran, where he trained Iranians in helicopter instruction in the years before the Shah was overthrown. Before becoming a pilot for Life Flight Mains worked for a similar emergency medical helicopter program in Houston, and when the company he worked for there, Evergreen Helicopters Inc., won the original contract for Life Flight in 1980, he moved to San Diego.

Mains claims that the people who work for Life Flight have become especially close, an assessment echoed by many members of the helicopter crew. Flight nurse Pat Terry says that there has been a close bond among the people in every medical unit she has worked in, “but Life Flight feels more like a family than anything I’ve ever experienced before. Maybe it’s the hours we keep, or the fact that you’ve got to trust the others one hundred percent. If you’ve forgotten one thing on the helicopter, a patient might die because of it.” There is also a certain amount of prestige that goes with working on an emergency medical helicopter; members of Life Flight are conspicuous around UCSD Medical Center in their blue jumpsuits with gold trim, and they give slide presentations and interact with the local news media almost constantly. ‘ ‘For all of us who have specialized in emergency room work,’’ said Terry, “this is the top.”

“It’s an honor to be associated with it, but it can get you down,’’ added head flight nurse Marti Bennett. “One surgeon here at the hospital calls us all ‘adrenaline junkies.’ A lot of other people say we’re crazy. I like ‘adrenaline junkie’ better.” She laughed, and her laugh, like her words, was colored with a down-home accent she picked up after nearly five years of working in Texas. Bennett has been head nurse of Life Flight since the beginning of the program; before that she worked in a similar emergency helicopter program at Hermann Hospital in Houston. She often works between sixty and eighty hours a week, a schedule that Bennett, who is unmarried. candidly admits has helped end more than one dating relationship in her life. She unwinds by occasionally spending weekends at a cabin near Descanso, where she often helps out with the Descanso volunteer fire department. “People tell me that working for the volunteer firefighters doesn’t sound like relaxing at all,” Bennett acknowledged with a laugh. “But riding on the back of that fire truck is fun!”

Although the Life Flight work is demanding, the turnover rate for employees is low; four of Life Flight’s original six nurses still fly in the helicopter. Bennett thinks it is because of the varied nature of the work. “Working on a (hospital) floor is kind of structured,” she said. “But in emergency department work, you never know what’s going to walk in the door. And the helicopter adds a new dimension to that — you not only don’t know what’s going to happen, but where it’s going to happen. The other aspect I like is that you have to go out there and get control of a situation that could be uncontrollable. In an emergency room, you can keep the family aside once the patient arrives. But if you’re out in someone’s house, you can’t tell them to leave. There might be news media out there, and you can't tell them to leave, either. You have to be creative about how you handle the situation.”

“It’s an entirely different world out there,” agreed Life Flight physician Tom Neuman. “The light isn’t good, the facilities aren’t there, your hearing is not as good because you just got out of a helicopter, you might be climbing over rocks, or inside a car, or ankle deep in a stream. There are too many people or too few people to help you. Nothing is controlled.”

Partly because of such conditions and partly because of the hurried nature of emergency helicopter work, the Life Flight crew is sometimes guilty of oversights. Neuman conceded he has missed detecting such things as broken wrists on patients he has examined in the field, but added, ‘‘When I bring in a patient who has been in shock, it’s been dark, I've been down a cliff, he’s unconscious, his liver is lacerated, and I've missed a broken wrist — so what? . . . Have I ever made a mistake that cost a life? It’s really pretty tough to do that. The critical life-and-death situations are usually pretty straightforward. If a guy isn’t breathing, you stick a [breathing] tube in him. If his heart isn’t beating, you have to pump on his chest to make his heart beat. We always make mistakes, but most of the time they don’t impact on anybody.” Bennett recalled that in the early days of Life Flight, at least one doctor arrived on the scene of an accident in a remote, rugged part of the county wearing a three-piece suit and wingtip shoes. Another time, she and a Life Flight physician performed a complete physical examination of an injured truck driver, “to make certain we hadn't missed, like, a broken toe. Now we’d just do a quick evaluation, put him in the helicopter, and leave. All of our physicians and nurses have been through that kind of learning experience. . . .” Once, when she was helping to lift an unconscious man from the road onto a stretcher in the Laguna Mountains, the patient’s arms slipped off his chest and dangled loosely over the sides of the stretcher. “The guy had a head injury that later proved to be fatal,” said Bennett, “and he was feeling no pain. But both of his arms were fractured, and we hadn't realized it and didn’t strap them down. If that had been me, I wouldn’t have wanted my arms flopping around. It wouldn’t have made [the fractures] any worse, but it wouldn't have made them any better either. It was inexcusable.

“This job is a challenge, but it isn’t always fun,” she continued. “Sometimes you get off the helicopter and the first three or four people you see are dead. You have to take a couple of seconds to say to yourself, ‘You’ve seen dead bodies before, it’s okay. . . .’ Even after all these years [ as a nurse J the blood can come back to haunt you. We can walk into [an accident scene ] that looks awful, but we've got a job to do and the equipment and skills to do it. So you can focus on that for the time being. But later on, when you get back to the hospital, you might sit down and think, ‘Oh God. . . .”’

Upstairs in the old federal building in Tecate, in a room at the end of a long corridor, the woman who has collapsed sits with her back against a wall, breathing heavily. This gray room with its sloping ceiling, its peeling paint, and its heavy, scarred metal desks has become a prison for her; she cannot leave it now. Around her have gathered firefighters from the Potrero Volunteer Fire Department, in fireproof yellow coats; border patrol agents in their army-green uniforms; and Mains, Terry, and Phillips from Life Flight. Phillips and Terry have fitted an oxygen mask over the woman's mouth and nose to aid her breathing, and now Phillips listens to her heart with a stethoscope while Terry takes her blood pressure and attaches a portable electrocardiograph to her chest. The woman’s blood pressure has risen to 230 over 110—almost twice that of a normal person, Terry explains later, and high enough to burst a blood vessel in her brain if it persists, causing a stroke. Through a translator the woman complains to Phillips of pain in her chest as Terry inserts intravenous tubes into the patient’s arms.

This woman speaks Spanish but little English, and the border patrol agents explain that they had arrested her on the U.S. side of the border with several illegal aliens in her car. They brought her to the federal building that houses their offices, and were fingerprinting her when she suddenly fainted. The agents called the Potrero volunteers, who in turn called for Life Flight when they saw the woman’s condition. There are only two ambulances anywhere near this part of the county, one in Campo and one in Pine Valley, and they are staffed not by paramedics but by emergency medical technicians with limited training. There is little such technicians could do for someone who has apparently suffered a heart attack.

In holding cells down the hallway, other aliens who have been apprehended by the border patrol stare curiously through the wire mesh on their cell doors. In one cell, a woman vomits repeatedly, wailing loudly in between as she tries to get her breath. A boy of about twelve, probably her son, is in the cell with her. There is a look of fear on his face, and tears in his eyes. Mains goes downstairs momentarily to call UCSD Medical Center’s cardiology unit and inform them that Life Flight will soon be bringing in a patient who might have suffered a heart attack; meanwhile, Terry and Phillips give the woman who collapsed nitroglycerine tablets to bring her blood pressure down. After the third tablet it begins to drop, finally leveling off at 160 over 90.

Phillips and Terry stand up now and begin talking with the volunteer firefighters about how to get the woman down to the helicopter. A sharp turn in the narrow stairway that leads down to the first floor renders the use of a stretcher impossible, but after a few minutes someone suggests carrying her downstairs while she is strapped to a desk chair. The plan is accepted, and in a few more minutes the woman is hoisted up by Phillips and three firefighters, and carried out of the room on a chair. The border patrol agents and the rest of the firefighters follow, and the procession makes its way slowly down the corridor, trailed by Terry who is carrying the electrocardiograph that is still attached to the woman’s chest. At the bottom of the stairs Phillips calls a halt; the woman’s blood pressure has again jumped to a dangerous level, and he listens to her heart with his stethoscope for a few minutes before okaying her to be carried outside.

Complaints that Life Flight has “stolen" patients that would have been taken by ambulance to hospitals other than UCSD Medical Center have cropped up consistently since the center first instituted the helicopter program. State law requires ambulances to take patients to the nearest appropriate hospital; Life Flight is bound by the same law but is limited to those hospitals which have helicopter landing facilities. In addition, the “closest appropriate hospital" can, depending on the patient’s condition, be anything from the nearest hospital to the one where his or her medical records are kept. Life Flight’s physician also has the authority to take a patient with a critical injury to the hospital he thinks can take care of that patient fastest and best. At least fifty-five percent of the time Life Flight has been called to emergencies in the field, the physician on board has decided that UCSD was the appropriate hospital to return to. “We know they overfly us once in a while," said Randi Herr Kroesch, director of emergency and ambulatory services for Grossmont District Hospital, which has a helipad and virtually all of the emergency medical facilities available at UCSD. “I don’t know if ‘stealing patients’ is the right term; they felt it was more appropriate to take a patient to their hospital, but other hospitals might not have felt that way. (But] they ’re paying for the helicopter; they’ve got to make money." Added Robert W. Brown, vice president of professional services at Mercy Hospital (which also has a helipad and a wide variety of emergency facilities), “In the past they [UCSD] made no bones about it — [the helicopter] was a way for them to penetrate a particular market."

Mary Cunanan, the administrative director of Life Flight, acknowledged that the hospital still “occasionally" gets complaints that the helicopter has flown past a hospital with a helipad that was actually nearer to a particular accident scene than was UCSD. “We don’t sit in a room and figure out what hospital we can overfly," Cunanan said, “but occasionally there are mistakes, and we do overfly someone."

To a large extent the controversy over Life Flight’s “patient stealing" will be resolved automatically by the county’s new trauma center system, which went into effect August 1. (The word “trauma" refers to a physical injury, as opposed to a medical emergency such as a heart attack.) The six designated trauma centers in the county are UCSD Medical Center, Mercy, Sharp, Children’s, Scripps Memorial, and Grossmont District hospitals, and all have specialized facilities and doctors to take care of people who have suffered major trauma — people like Glenn Chancer. Each trauma center has been assigned a specific “catchment” area within the county, and any patient who suffers a major injury within a particular trauma center’s area must be taken to that center, assuming its trauma facilities and surgeons are not already occupied.

As part of the trauma system, two Life Flight helicopters will be stationed in the county. Life Flight One will be at UCSD Medical Center and Life Flight Two will be at Tri-City Hospital in Oceanside. Baxt said that a second helicopter is “unequivocally ” needed because Life Flight One’s current load of sixty to seventy calls a month necessitates extensive maintenance on the helicopter, taking it out of service. “We're working it too hard, so to speak,” he said. “Plus, with that kind of load, you start to miss a significant amount of calls because you’re (already out) on other calls.” Although the protocol for bringing trauma patients via helicopter to specific trauma centers is well defined, no such arrangement exists for non-trauma patients transported by Life Flight, who constitute more than half of the emergency flights. This is an arrangement that is almost certain to lead to future squabbling among hospitals and charges of “patient stealing." Cunanan noted that in the case of some non-trauma emergencies, if the closest appropriate hospital happens to be one that has not agreed to help pay for the cost of Life Flight, the helicopter could simply bypass that hospital in favor of one that had paid up. She insisted that such a policy would not imperil lives because hospitals in the greater San Diego area are only minutes apart by air. But Kroesch of Grossmont District Hospital expressed the fear that such a policy could lead to “air wars — each hospital would want its own helicopter.”

Five local trauma centers are among those hospitals that have tentatively agreed to share in Life Flight’s cost (by paying $1075 on a per patient basis), but so far Grossmont has balked. Kroesch said her hospital is still negotiating with UCSD, but pointed out that as the hospital closest to the vast eastern part of the county (where many of the accidents that activate Life Flight take place), Grossmont gets more patients from Life Flight than any other hospital. That in turn means Grossmont could end up paying $135,000 a year to Life FIight whereas another hospital might pay only $10,000 or $20,(XX) (and receive fewer patients), according to Kroesch. “That could be a financial risk to us,” she said, adding that since Life Flight is considered a community service, not unlike fire and police protection, perhaps city and county homeowners should be assessed a fee to fund the helicopters. Kroesch also raised the question of whether it makes sense to invest money in a second helicopter that will “save some drunk on a motorcycle” at extremely high cost, when the money could be spent on additional ambulances or medical facilities. “Personally, I feel a second helicopter is needed because of the current volume of flights,” she continued. “But if [Life Flight’s funding) is distributed among just a few hospitals, who pays for it |ultimately) but the patients who go to that institution? Then you just have soaring health care costs.” Grossmont supports the idea of two emergency medical helicopters, Kroesch said, “but can the community afford it? That's the bottom line.”

The woman lies on her back in the helicopter, her eyes closed, intravenous tubes attached to each arm. Phillips leans over her, periodically checking his patient’s blood pressure on the digital readout in the Bolkow’s rear panel. The helicopter’s main propeller is already spinning overhead, and Mains’s voice comes over the headphones: “You guys ready?” Terry nods. “All set.” Again the Bolkow rises smoothly into the air.

Mains tries to contact UCSD Medical Center via radio, but because of the intervening mountains he receives no answer. In the hope that dispatchers at the Life Flight operations center can hear him, however, he advises them that the helicopter will be returning in about twelve minutes, and then falls silent. During the half-hour that Life Flight has been on the ground the cloud cover has dropped even farther, and as Mains guides the helicopter westward over a high, rocky ridge, the aircraft enters the bottom of a cloud. The ground is still visible below but only barely, a hazy brown patchwork seen through wisps of cloud. Once past the ridge, however. Mains is able to take the helicopter down to an altitude where the visibility is fine. “I didn’t know if I could get out of there or not,” he says later. “You never really know until you get in the air. In another thirty minutes it would have been darker, we wouldn't have been able to see the horizon, and we would have been obligated to turn back.”

Over the helicopter's headphones Phillips explains that the woman has unstable angina, or pain in her chest that has been increasing over the last several weeks. A few hours later, with the benefit of laboratory tests performed at the hospital, he will revise his diagnosis to a mild heart attack. In either case the person afflicted could experience heart stoppage or sudden death. Paramedics could have gotten the woman to a hospital as safely as Life Flight, Phillips says, but there are no paramedics working in the eastern part of San Diego County.

In a few more minutes Mains reestablishes radio contact with the Life Flight operations center, and Phillips describes the woman’s condition for the benefit of the doctors at the hospital who will soon be examining her. His report ends with the words “Resting comfortably.” Mains adds that Life Flight will be returning to the hospital in five more minutes, and the dispatcher replies, “Roger, Life Flight, thank you.”

“No, thank you!" says Mains, in a joking mood again now that he no longer has to contend with low clouds. The Bolkow recrosses Sweetwater Reservoir and is soon heading west high above El Cajon Boulevard. Lights have come on in the storefronts and shopping centers below, and in the distance a red light atop UCSD Medical Center blinks like a warning signal.