GRAND RAPIDS, Mich. -- A patient's life was on the line. Dr. Steve Rockoff was talking by phone to a Carson City Hospital doctor, trying to decide: Was the case serious enough to launch Spectrum Health's Aero Med helicopter from Gerald R. Ford International Airport?
When the call came in -- a man with internal bleeding -- the $11 million flying emergency room was on the tarmac, preparing for a flight to its daytime base in Big Rapids.
Pilot Jeff Wroblewski was the only other crew member who could decide whether to fly. While Rockoff's decision would be based on medicine (details are shielded by patient confidentiality), Wroblewski's would be on the weather and the aircraft's mechanical readiness.
If either objected, the helicopter would remain on the ground.
So it was that under a clear sky, Aero Med lifted off for what was expected to be a 13-minute flight to Carson City, a trip that could take a ground ambulance more than an hour.
Since the crash of another Aero Med helicopter on the roof of Spectrum's Butterworth Hospital in May and other recent accidents around the country -- including eight fatal crashes in the past year -- some critics have questioned the safety of air ambulances.
Beyond that is a more basic issue: Do helicopters provide a useful medical service, or are they, as one critic claimed, "flying billboards?"
The evidence is mixed. Some studies suggest helicopters are no more effective than ground ambulances. Others conclude they save lives.
"It's really not the panacea we thought it was," said Dr. Bryan Bledsoe, a Dallas emergency medicine specialist and former medical director for an air ambulance service.
Helicopters play a legitimate role, he said, but too often are used with little or no benefit for the patient. Bledsoe took part in a study of 37,500 patients that showed two-thirds flown by helicopters were not that seriously injured.
Is there competition?
"It is an advertising gimmick," said Dr. Kenneth Mattox, chief of staff at Houston's Ben Taub General Hospital and a professor at the Baylor College of Medicine.
"I'm all in favor of advanced technology if the science justifies its use," he said. "I can't find any scientific evidence that shows that it's more useful than the nonuse."
Dr. Ralph Rogers, Aero Med's medical director, agreed with some of the criticism but said Spectrum's helicopter service is different.
"There are situations and there are cities where there are so many helicopters flying around and there's so much competition," he said. "That's something, fortunately, we don't have in this area."
All but one of Michigan's seven medical helicopter services are run by nonprofit hospitals. In some states, many are for-profit and often compete to be the first on an accident scene.
"I know we save lives all the time," Rogers said, although it is not possible to say how many.
How much does time matter?
Getting patients quickly into the emergency room can improve their chances for recovery without long-term disabilities, Rogers said.
He persuaded his bosses at Butterworth to add the helicopter service in 1987, before a merger with Blodgett Hospital that formed Spectrum Health. Since then, Aero Med has transported patients more than 12,500 times.
Spectrum is more conservative than most in using its helicopters, Rogers said.
Aero Med receives about 1,500 calls per year, he said, but transports only 600-700 patients.
In one out of 20 cases, after arriving on a scene, the doctor decides the patient does not need to be transported by air, Rogers said, and the helicopter returns to its base.
"The reason is because of our philosophy," he said. "This is a very important resource, and we want to make sure it's available when it's needed."
About half the calls are trauma cases, often from accident scenes. The other half are medical cases, such as heart attacks, with the patients transferred from smaller to larger West Michigan hospitals.
How are results measured?
By one common gauge -- the percentage of patients discharged from the hospital within 24 hours -- Aero Med is keeping to its philosophy of judicious use. Rogers said its rate is 11 percent, one of the lowest in the country.
"You get that triage rate lower than that, you really miss a lot of patients who would have benefited," said Rogers, who is chairman of the Commission on Accreditation of Medical Transport Systems. "What would happen is you would miss a certain number of patients who should have been transported and would have died."
By contrast, 20 percent of patients in some areas are "over-triaged," meaning they were not in serious enough condition to need a helicopter, critics say. Sometimes it's as high as 50 percent.
Unlike other air ambulances, Aero Med always flies with a doctor and a nurse. (Staff includes five full-time and eight part-time physicians, eight nurses, seven pilots, three mechanics and eight communications specialists).
While the doctor is told details about the patient, the pilot is given only general information, Rogers said. That is to avoid having emotion cloud the pilot's judgment on whether to fly, such as in the case of an injured child.
How do pros value service?
Any paramedic, emergency medical technician or state police officer on an accident scene can call for Aero Med, and most consider it a valuable service.
"It's a huge tool," said Park Township Fire Chief Scott Gamby. "It can make a difference between life and death."
Aero Med is particularly valuable in cases where an accident victim is pinned in, said Mickey Davis, fire chief for Courtland and Oakfield townships. By the time patients are extricated, the helicopter can be there to rush them to Butterworth, the area's only level-one trauma center.
"It's not in their interest to be transporting patients who don't need that level of care," said Mark Meijer, president of Life EMS, a ground ambulance service. "I think Aero Med is integrated very appropriately."
What's the cost in dollars?
A ride in the helicopter, however, costs considerably more than in a ground ambulance -- $7,000-$9,000 compared with $600-$700. Insurance covers most of the bill, but Aero Med loses more than $3,000 on each flight.
Overall, Aero Med lost $1.3 million in the year ending June 30, 2005, according to the latest figures available from Internal Revenue Service filings. Since merging with Spectrum in 2005, Aero Med has not had to file with the IRS.
That loss, however, does not take into account additional money, mostly from insurance, Spectrum receives caring for patients brought in by helicopter, likely making Aero Med a loss leader.
"The reason we do it is it's a critical part of the system," Rogers said. "If we have a level-one trauma center and we can't get them into the trauma center quick enough, it does no good."
In the case of the man with internal bleeding, pilot Wroblewski changed course en route, concluding fog in Carson City made it too dangerous to land there. He landed instead at Spectrum's United Hospital in Greenville, where an ambulance bearing the patient met the helicopter.
Aero Med carried the man to its temporary landing site on Plymouth Avenue, and a second waiting ambulance took him the last two miles.Two days later, the patient was discharged from Butterworth. Spectrum officials said only that he could have died if not for the treatment he received.