COLUSA COUNTY, Calif. -- When a casino-bound bus rolled over on an isolated Colusa County road in October, rescue workers, ambulances and helicopters from throughout Northern California streamed in to aid dozens of badly injured gamblers.
Some helicopters leaving the scene had troubled transits, including one that hovered over UC Davis Medical Center in Sacramento, low on fuel. The copter was unable to land because the helipad was full.
The crunch in the skies over Sacramento has raised fears about the potential for midair crashes above a densely populated neighborhood.
It is just one of the loose strands in a frayed safety net being studied by emergency officials quietly looking to fix what went wrong during the response to the bus crash that killed 10 people.
Documents, emergency officials and people involved in the casino crash response indicate that areas they are targeting include:
* Why three helicopters that were closer to the crash site stayed on the ground while ones farther away were summoned, apparently because of a computer error.
* Why a system designed to let coordinators know quickly which hospitals could handle more patients didn't work as expected.
* Why some helicopters may have left the crash scene with no specified destination for their patients, potentially leading to overuse of some trauma centers while others were unburdened.
* And, why a helicopter carrying an ailing patient hovered over the UC Davis Medical Center until it could stay no longer, then flew to McClellan airfield to refuel with the patient still on board before returning to the hospital. The fate of that patient remains unclear, shrouded by medical confidentiality laws.
The review comes during a year plagued by so many fatal air medical crashes that the National Transportation Safety Board has scheduled a three-day hearing into medical flight safety, starting Feb. 3. In announcing the hearing, the NTSB said there had been an "alarming" rise in air ambulance accidents, with 35 people killed over 11 months.
One of those crashes occurred in June when two helicopters approaching the same Arizona hospital collided in midair. That collision weighed heavily on the minds of those discussing the helicopter crunch over UC Davis Medical Center.
"All had concerns for safety at the UCDMC helipad," said Steve Russell, a longtime emergency nurse who attended a meeting in November to examine the casino bus crash response.
That meeting was convened by Northern California Emergency Medical Services, known as NorCal EMS, which coordinates and regulates emergency response in 11 counties, including many involved in the Oct. 5 casino bus crash.
The crash killed seven people at the scene and injured 36. Three of the injured died later at hospitals, including two at the medical center.
Publicly, NorCal EMS has stressed the effectiveness of some parts of the medical response to the disastrous bus rollover.
"The people on the ground and in the air really performed admirably," said Dr. Eric Rudnick, medical officer for NorCal EMS. The nearest small hospital, Colusa Regional Medical Center, "had a great turnout," mobilizing most of its staff.
Yet, NorCal EMS has refused to release critical details discussed at the November meeting, and declined to supply flight times for the helicopter that refueled with a patient on board.
The Bee has asked NorCal EMS what time that copter reached UC Davis Medical Center and found the helipad already full, what time it left to refuel, and what time it returned and delivered the patient.
"The whole point of helicopter response is speed and quality of care," said Dr. Bryan Bledsoe, a physician and former flight paramedic who researches medical helicopter safety. "If you're not using the closest helicopter, you're losing speed," he said, and stopping to refuel costs speed, too.
PHI Air Medical, the company whose helicopter refueled, said such a stop could take as little as 10 minutes, but declined to supply its flight times, saying that would violate the patient's right to medical confidentiality.
"That's nonsense," said Bledsoe, who teaches emergency medicine at the University of Nevada medical school. Confidentiality laws are meant to keep a patient's medical condition private, not something like ambulance transit times, he said.
It was unclear whether the patient on that flight survived, or was one of the two who later died at the medical center.
Refueling with a patient aboard does not violate federal regulations. But it's done infrequently, said Marty Marshall, director of emergency service at Enloe Medical Center in Chico, which treated 13 of the injured bus passengers. Marshall, who heads Enloe's flight program, said he has refueled while carrying a patient only once in 23 years.
After the crash, four victims were taken by helicopter to UC Davis Medical Center. Ambulances brought another two.
How closely the air arrivals were spaced wasn't clear, but other helicopters were arriving with unrelated injuries, and two were on the helipad when the PHI copter arrived.
By contrast, one person was delivered to Sutter Roseville and one to Mercy San Juan -- nearby level II trauma centers equipped to handle nearly everything that would confront a level III trauma facility like UC Davis Medical Center.
"They were definitely underutilized," said nurse Russell. "Each are level II trauma facilities with helipads."
Russell recalls people at the fact-finding meeting discussing that some helicopters departing the crash scene with injured patients were given no destination, or were simply told "go where you normally go."
A NorCal EMS memo written before the meeting said "several" helicopters were "transported to UC Davis without heads up to ED (Emergency Department) staff."
UC Davis spokesmen said the hospital had been told of all arrivals, but declined to answer more detailed questions about incoming flights, saying the holidays made it too difficult to reach people involved.
"We do not coordinate arrivals of air transports. We don't have a dispatch office anymore," said medical center spokesman David Ong. "What happens is the air transport agencies coordinate amongst themselves who is going to be arriving here and at what time."
Helicopters are supposed to notify a registered nurse, someone designated as a "mobile intensive care nurse," that they are arriving, Ong said.
Medical center representatives could not clarify whether the helicopter that refueled was told en route that both of the hospital's helipad landing sites were already full, or whether anyone suggested an alternate trauma center the pilot might have been able to reach without refueling.
Nationally, relatively few hospital helipads are actively controlled, Bledsoe said, and the potential flaws of pilot-to-pilot coordination are beginning to concern more communities surrounding hospitals.
"Multiple helicopters trying to land at the same hospital, that needs to be avoided," he said. "That was the issue in Flagstaff (Arizona) where two ran into each other and killed seven."
Meanwhile, getting helicopters to the site of the casino bus crash also hit snags, according to REACH Air Medical Services in Santa Rosa, which was asked by Enloe to take charge of that part of the response.
REACH used a computer program designed to include the exact latitude and longitude of every helicopter in the region, so the closest copters could be dispatched quickly, said Brian Bricker, the company's communications center manager.
The trouble, he said, was that three helicopters hadn't been programmed into the computer.
"It was a computer oversight on our part," he said. Bricker declined to say which helicopters were omitted.
Crash response was further complicated because the site was rural, and because so many people were injured. Resources had to be pulled in from across traditional EMS boundaries.
Primary responsibility for coordinating where patients should be sent fell to Enloe in Chico, which needed to know availability of doctors, beds and emergency rooms in at least eight hospitals, from Sacramento to Chico.
Patients went to Oroville, Marysville, Woodland and beyond, and in theory just two people, a nurse at Enloe and a designated paramedic at the scene, were responsible for telling each ambulance or helicopter where to take its patient.
The nurse and paramedic relied on phone calls and an automated system that wasn't kept fully updated that evening, said Bob Kiuttu, Enloe's head of emergency management systems.
The paramedic on the scene, Chris Aicega, said each helicopter should have been given a specific destination, but he couldn't be certain they were, because someone else relayed those orders to pilots. Aicega said he hadn't known on that night that Sutter Roseville and Mercy San Juan even had helipads.
Several longtime emergency and air officials said they couldn't remember another crash or other disaster involving this many serious injuries and deaths in such an isolated part of the north state.
"Thirty-plus patients were transported to eight different hospitals in under three hours," Kiuttu said. "In rural America on a small county road, that's really pretty impressive."
The crash itself, which injured a busload of Hmong and lu Mien immigrants who spoke little English, was a paramedic's nightmare, said Graham Pierce, California director of PHI Air Medical.
"There's not a paramedic out there that hasn't dreaded this call -- a bus rollover loaded with critical patients, non-English-speaking," Pierce said. "You can imagine how chaotic a scene like that would be."
Learning from episodes like this can help victims of future disasters, said Rudnick, the top physician at NorCal EMS.
"Whatever you can glean from just what happened can help you potentially save people's lives and have better outcomes next time," Rudnick said.
Among changes his agency is planning is a regional air dispatch system that would take over directing helicopters during emergencies.
There is no money for that now, however. At the earliest, he said, setting up regional air dispatch could take a year.
Call The Bee's Carrie Peyton Dahlberg, (916) 321-1086.