EMS Units Bypassed Nearest Helicopters: Physician Says Ties to a Firm Don’t Influence Agencies’ Decisions

FORT WORTH, Texas– Late on a June night in 2006, Keenan Bridges lost control of his motorcycle on a winding stretch of Farm Road 664 in Ellis County, Texas.

The accident, about five miles north of Bridges home in Waxahachie, sent him flying into a roadside ditch, his body so battered he was unable to move and barely able to breathe.

Paramedics from the Midlothian Fire Department quickly arranged for Bridges, 45, to be transported by helicopter to a Dallas trauma center.

But instead of trying to summon the closest available helicopter ambulance, they only contacted one company, PHI Air Medical.

PHI s helicopter took more than 30 minutes to reach Bridges, who was ultimately flown to Parkland Memorial Hospital, where he was treated for broken ribs and other injuries. That helicopter was based in McKinney, 50 miles from the scene, although it is not clear where it came from.

What happened to Bridges that night was part of a pattern repeated more than two dozen times in the last two years in the area: EMS crews did not call the closest helicopter ambulance service.

In each incident, the EMS unit on the ground and PHI shared the same medical director, Roy Yamada.

Yamada, a Fort Worth physician, works as director of emergency medicine for Midlothian and in a similar role for nine other area EMS departments, most in Tarrant County. He is also PHI s North Texas medical director, a position for which he has apparently been paid almost $200,000 in 2 1/2 years.

Such ties are becoming increasingly common in the competitive air ambulance industry, in which people who oversee local EMS agencies also work for air medical providers.

But these alliances, critics say, can lead to delays in hospital care for critically injured patients as well as unnecessary helicopter flights that can cost patients as much as $10,000 when ground transport would be sufficient.

Yamada s method of compensation from PHI, $2,000 monthly for every active base it has in the region, differs from that of the doctors serving other major air medical operators in the area, state records show. Those physicians are paid annual fees unrelated to the number of bases they supervise.

Tying a medical director s compensation to the number of bases could be viewed as an incentive to increase flights, say some industry observers, because bases can only remain open when their helicopters are being used frequently.

Yamada said his EMS units are supposed to call for the closest available helicopter.

Only when proximity to the scene is not a factor would PHI be the preferred operator, he said. Because PHI s medical procedures are similar to those of the units he directs, patients receive consistent care, he said.

In a subsequent e-mail, he was more emphatic. My cities call the closest aircraft for our patients in need, without regard to the color of the aircraft, he wrote.

Dispatch and other records show that PHI has received the vast majority of the helicopter calls from Yamada s EMS units since he was hired by the company in April 2005. The records, obtained by the Star-Telegram under the Texas Public Information Act, also show more than two dozen instances in which PHI helicopters were directed to accident scenes when they were not those based closest to the scenes.

Two units under Yamada s direction — Midlothian and Dallas/Fort Worth Airport — regularly did so before recently revising their policies, the records show.

Failing to seek the closest available helicopter can affect the odds that a patient will be transported to a hospital within the so-called golden hour, the time frame widely cited as the most critical for saving lives.

Truly, the only benefit [in using a helicopter] is speed in getting the patient to definitive care, said Bryan Bledsoe, an emergency physician in Midlothian who writes about EMS issues and is an adjunct professor at George Washington University. Flying over another helicopter [base] or waiting for a helicopter [coming] from long distance totally defeats the concept.

Using one service over another because of familiarity with its medical director isn t uncommon, but it makes no sense when significant time is lost, said Michael Brunko, president of the board of trustees of the Air Medical Physician Association. A few minutes may not make much of a difference, he said.

The question is, how far do you stretch that? he said. I wish we knew.

It s so political

Yamada s relationship with PHI is part of the changing landscape of the air ambulance industry, which has seen an influx of for-profit operators as a result of increases in Medicare reimbursements for air transports.

PHI Air Medical is a unit of Lafayette, La.-based PHI Inc., a publicly traded company that primarily provides helicopter transportation for oil and gas companies operating in the Gulf of Mexico. It began operating in North Texas in 2003, entering a market long dominated by CareFlite, a nonprofit service based in Grand Prairie.

In most parts of the country, gaining influence with first responders can be a key to generating business in the air medical industry because there is no centralized dispatching system.

The tactic is identify a medical director or a very prominent member of the EMS community and hire him, said Bledsoe, a former Fort Worth paramedic and EMS medical director for agencies in North Texas.

It s natural for some EMS medical directors to be affiliated with air medical providers, Brunko said, because there is a relatively limited pool of physicians willing to take on these responsibilities. Physicians serving in both roles must be particularly mindful of their duty to put patient care ahead of self-interest, he said.

Brunko, the medical director for nonprofit Flight for Life Colorado, said he and others on the nonprofit side worry that for-profit air medical companies are creating an environment that can compromise physicians ethics.

It s no different than [a doctor] having ownership in a laboratory, he said. Are you being a little biased in who you direct your patients to use?

Yamada, 63, strongly stated that he is not using his position to help PHI.

PHI doesn t expect me to generate flights, he said. That s not part of my duty.

Yamada, who was named the state s EMS medical director of the year in 2001, said he is frustrated by the politics of the air medical industry, which he believes has made him a target.

It s cutthroat, it s horrible, he said. If I didn t want to make a difference in air medical, I d get out of [it], because it s so political.

A change in procedure

The Star-Telegram reviewed dispatch records for air ambulance calls by Yamada s units for a 2 1/2-year period starting Jan. 1, 2005.

His units generally shifted from calling CareFlite to PHI after he became affiliated with the company and continued calling PHI first throughout the period.

The Midlothian Fire Department s practice of directing its helicopter calls to PHI raises particular questions because it continued for nearly a year and a half after the company closed its base at Executive Airport in south Dallas in December 2005. After that, its helicopters were no longer the closest.

On 22 of 24 occasions between Jan. 1, 2006, and June 1 of this year, when air transport was called, Midlothian EMS personnel summoned PHI without checking with CareFlite, records show.

The calls raise the possibility that PHI helicopters from McKinney and Meacham International Airport in north Fort Worth flew past CareFlite bases at Methodist Central Medical Center near downtown Dallas and Harris Methodist Hospital near downtown Fort Worth to reach accident victims in Ellis County.

Bledsoe, who formerly served as the Midlothian Fire Department s emergency medicine director, was surprised that PHI helicopters were still being used after the Dallas base closed.

I just assumed like everybody else that CareFlite was coming down here, he said.

One of the patients affected was Bridges, who lost control of his motorcycle after attending a Mavericks-watching party on June 8, 2006.

Paramedics can be heard on dispatch recordings telling the dispatcher to put PHI on standby. The dispatcher can then be heard talking to PHI and being told that the company s Fort Worth helicopter was unavailable and that the closest likely would be coming from the company s base in Corsicana.

The helicopter that responded to the scene required 32 minutes to get there after giving an estimated time of 18 minutes, according to the time sequence detailed in the Fire Department s report. There is no mention of where the helicopter was coming from.

The accident report prepared by the Texas Department of Public Safety identified the helicopter transporting Bridges as being based in McKinney. Howard Ragsdale, director of PHI Air Medical Group, said he could not say where the helicopter came from, cautioning that it could have been anywhere in the area. Each base has a single helicopter.

Bridges said he can remember little about that night. He didn t know he had been transported by helicopter until he was told about it at Parkland, he said. And, he said, he didn t know it was PHI that had transported him until he received a bill from the company for approximately $10,000.

But a friend of Bridges who had been following him that night, Tammy Hunt, vividly recalled the scene. She said she remembers growing increasingly nervous as Bridges remained in the care of paramedics and time dragged on.

It seemed like it took forever for the helicopter to get there, she said.

Midlothian Fire Chief David Schrodt said he knew that PHI s helicopters were frequently summoned by his personnel, but he only saw it as a problem after a May 6 incident in which the Corsicana helicopter took 23 minutes to reach an accident scene.

The accident involved a woman who fell off a four-wheeler and was bleeding from her head, according to the department s report.

Schrodt said the length of time was brought to his attention by Dale McCaskill, Midlothian s deputy chief and training officer, who joined the department in January after working in Rowlett, where CareFlite is regularly used.

Until that point, I really didn t understand the dispatch process, Schrodt said.

Since May, Midlothian has required its personnel to seek the closest available helicopter, departing from a process that was based on paramedics requesting whatever service they felt comfortable with, Schrodt said.

He said that to his knowledge there were no directives from Yamada regarding the department s using PHI.

Midlothian s change in thinking also occurred less than two weeks after the Star-Telegram contacted McCaskill to ask how the city handled its air ambulance calls.

Our medical director, Dr. Yamada, has influenced some of that by saying he wants, if at all possible, for PHI to respond based on response time, he said at the time.

After initially talking to the Star-Telegram, Yamada did not respond to an e-mail seeking comment on the number of calls to PHI in Midlothian.

Making connections

At D/FW Airport, EMS personnel began contacting PHI for helicopters in mid-March 2005 and used the company exclusively until airport officials conducted a detailed review of the situation in the spring.

The review was initiated after CareFlite President and Chief Executive Jim Swartz sought to learn why the airport s EMS unit wasn t calling his service when its base at Methodist Central in Dallas is the closest to the airport.

I just wanted to make sure they recognized where all of our assets are and took that into account, he said recently.

The airport s review found that all but one of its 14 helicopter calls between Jan. 1, 2005, and April 1 of this year were to PHI. The lone call to CareFlite during that period was in January 2005, three months before Yamada became affiliated with the company.

Alan Black, the airport s vice president for public safety, said in a recent interview that he was unaware of any directive from Yamada to use PHI.

He said he could not account for how PHI came to get all of the airport s business.

I mean, it evolved, he said. If it would have happened all at once, where one day we were using CareFlite and the next day PHI, it would have been an obvious thing. But because it did evolve over time, it wasn t obvious.

D/FW instituted a system using both services in June after previously allowing paramedics to decide on their own, he said.

Black, who served as the airport s fire chief before being promoted to his current position in August, said that rotating calls between PHI and CareFlite makes sense because it allows for connections with both services, an important factor for the airport.

We live and die out here based on how well we do in a plane crash, he said. PHI can t save me if I ve got a plane crash. I m going to need every helicopter I can get. The last thing I need to do is alienate a provider such as [CareFlite].

Documents from the airport s review indicate that the official who conducted it, Jim Crites, scrutinized Yamada s relationship with PHI but wasn t troubled by it.

Crites, the airport s executive vice president of operations, noted in his report that Yamada served both PHI and the airport but was not listed in filings by the Securities and Exchange Commission as a shareholder or director of the company.

When informed recently that Yamada s pay is tied to the number of operating bases in the region, Crites said the matter does give me pause and further convinces him that the airport is best served by dividing its business between the two services.

Delayed response

Different questions stemming from the use of PHI s helicopters have surfaced in Keller, one of seven Tarrant County communities with EMS units under Yamada s direction.

Keller EMS began routing its calls to PHI in June 2005, a few weeks before the company s base at Meacham became operational. The arrangement was ordered by Scott Parsley, the department s EMS division chief.

Parsley noted in his directive that PHI would contact another service if it could not provide an acceptable estimated time of arrival.

But since the system was implemented, Keller has experienced a series of incidents in which helicopters were delayed in getting to accident scenes, records show.

One involved a teenage boy who was severely cut and bleeding after he fell through a sheet of plate glass at Keller High School in August 2006.

After providing an estimated time of arrival of 10 minutes, PHI informed Keller dispatch 14 minutes later that its helicopter had yet to leave Meacham, according to the incident report.

CareFlite was then dispatched to the scene.

PHI s response has been that at the time the Meacham aircraft was down getting their AC worked on and that their dispatch did not know what their full status was, Parsley later wrote in an e-mail to his dispatchers. If it helps, y all did a good job working through the mess, and the young man is at home recovering.

Parsley also wrote that he was concerned that CareFlite had required 20 minutes to reach the scene after giving an estimated time of arrival of 14 minutes.

Parsley declined to be interviewed for this report.

An e-mail Parsley sent to a PHI official in February indicated that he was considering changes that would include having dispatchers check the availability of the Meacham helicopter through EMSystem, an online service for first responders, and calling CareFlite themselves.

Yamada s relationship with PHI was reviewed in June 2005 by Keller s city manager at the time, Lyle Dresher, records show.

Dresher sent an e-mail to fire Chief Kelly King asking a number of questions regarding Yamada and PHI, including whether he had an ownership interest in the company. After being informed that Yamada was a contract employee of PHI, Dresher sent King a return e-mail saying the arrangement was not a problem.

Dresher, now the town administrator in Argyle, said recently that he isn t sure whether he would have reacted differently had he known Yamada s compensation was tied to the bases.

If we re responding to emergencies as rapidly as we can, he said, I guess that s the bottom line.

A major expansion

Yamada was hired by PHI because his knowledge of the Dallas-Fort Worth area and his work in EMS made him the best person for the position, said Jay Lance Kovar, PHI s medical director for Texas.

Yamada is a former emergency room physician who stopped treating patients when he was diagnosed with leukemia in late 2000.

He has worked with EMS agencies in North Texas since 1998 and has focused his energy in that direction since his diagnosis.

I didn t pick Roy because he was going to bring more business, said Kovar, who is the medical director for the Montgomery County Hospital District north of Houston and also directs PHI s Houston-area bases. I picked Roy because I respect the guy and he knows the area.

Kovar said management issues with the previous North Texas medical director caused him to make a change.

Yamada is paid by the departments he serves on a contract basis in varying annual amounts. His most recent contracts paid him a total of $165,500, in amounts ranging from $7,000 to $35,000, records show.

The manner in which his contract with PHI is structured means he was entitled to receive approximately $190,000 from the company in the 2 1/2 years he has been affiliated with it. PHI currently operates three bases in the area; at one time, it had four.

Yamada replaced a physician who was paid a straight $36,000 annually and had no ties to local EMS departments.

PHI s move into North Texas was part of a major expansion that ultimately would lead the company to open 37 new bases nationwide.

The company reported an operating loss of $4.4 million for its air medical segment in 2006. But it noted in its annual report that several months are typically required to build flight volumes that can absorb operating costs and generate profit.

In a memo to his EMS units in 2005 informing them of the closing of PHI s Dallas base, Yamada indicated the importance of his units to PHI.

This restructuring will make the other three bases stronger, and already the flight volumes have increased, he wrote. Thank you for your support of PHI Air Medical, as we advance the Continuum of Care that is started on the ground.

Kovar said the increased business for PHI is the result of numerous factors.

There s going to be a natural increase in flight use for PHI because CareFlite can t be everywhere at the same time, he said. And the other piece that factors into it is the individual paramedic and fire department preferences.

Kovar, who oversees six bases, said he is paid $2,000 per base each month and that he recommended that Yamada be paid similarly.

For somebody to sit around and sign some papers and not do anything else, that s a lot of money, he said. But if you re out there, you re training [paramedics], you re talking to hospitals, you re running the business, you should be paid appropriately.

He acknowledged that structuring a contract in such a manner is atypical, but he said it is simply a way of providing a high level of compensation, not an incentive-based plan.

This is just the way the company operates, he said. They put a lot of money into the clinical part. They put a lot of money into their medical directors. But they expect something out of it — a quality product.

The company

PHI Air Medical

What it does: Helicopter and fixed-wing air ambulance service.

Where it operates: 68 aircraft at 55 locations in 12 states

Based: Lafayette, La.

The parent company

PHI Inc., formerly known as Petroleum Helicopters Inc.

Core business: Transporting oil and gas company personnel to offshore drilling platforms in the Gulf of Mexico.

In business since: 1949

Publicly traded (Nasdaq) as: PHII

EMS units directed by Dr. Roy Yamada

The EMS units from the following fire departments receive medical direction from Dr. Roy Yamada. This list shows when he was hired and his most recent annual compensation:

EMS agency, When started, Amount paid

Allen 2007 $35,000

Bedford 1998 $15,000

Dallas/Fort Worth Airport 2000 $20,000

Euless 2003 $17,500

Hurst 2003 $17,500

Keller 2004 $15,000

Midlothian 2001 $10,000

North Richland Hills 2000 $21,500

Pantego 2004 $7,000

Richland Hills 2001 $7,000

Source: Departmental records



DANNY ROBBINS, 817-390-7258

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