San Diego's emergency medical pilots tell hair-raising stories

(EMS) helicopter "is an ambulance with a rotor system"

"It was my first training flight with Mercy Air," says J.P. Wilson, a large, white-haired man. "I had gone through the ground school, and I was scheduled to fly with Jeff Emery. I got here about eight o'clock, and right at eight o'clock we got a call out here on Interstate 5. We took off. Jeff was doing the flying. As we got over the scene, it was easy to find because all of southbound Interstate 5 was completely blocked off. We were told to land in the middle of the freeway. Jeff set up and started to land, and we're all thinking traffic accident. There were a tremendous number of emergency vehicles, and what caught my eye was a lot of police force. Then some of the police officers were stringing crime-scene tape -- that yellow tape. "After we landed, Jeff and I were sitting in the aircraft, and the medical crew went out to the ambulance. You keep the aircraft running, usually, on the scene. The nurse came back and opened Jeff's door and said, 'Get him out of here,' meaning me. What had happened was one of the SANDAG tow truck drivers had stopped to help this fellow and the guy had shot him. Four or five or six times. A Marine saw what was happening, jumped the fence of the Marine Corps base, grabbed the tow truck driver, and took off running under fire. The guy was shooting at them. The shooter somehow got on the Marine base or got down by the fence. Anyway, the highway patrol and military police showed up, and they told him to throw down his gun and shot at him. He died of lead poisoning shortly after that.

"We were there to pick up the tow truck driver, who was, in the slang of the business, he was circling the drain. He was dying. He'd been shot. He had multiple bullet holes. The reason they wanted me out of that aircraft was because it was one of our 222s, in which you can spin the front seat around. The nurse was convinced she was going to have to intubate him -- in other words, put a tube down his throat, protect his airway, and breathe for him -- and she knew she didn't have time on the scene to do that. Most of the time they do that in the ambulance. There's a series of drugs they administer and insert the tube and it's a controlled environment, but this young man needed to get to a trauma center in a hurry. I kind of stood there and held the door while they loaded him, and he didn't look good at all. Then I stood there in the middle of the freeway as the aircraft took off, literally standing in the middle of Interstate 5 with all of these emergency vehicles around -- lights and the cacophony of multiple radios on the same frequency repeating. And I'm thinking, 'Man, this is going to be a cool job.'

"That afternoon as I was driving home after I'd finished training, they were talking about the shooting on the radio, because it was pretty big news in San Diego. They said he was in fair condition at Scripps. About 30 to 45 minutes after he was shot, he was getting wheeled into a trauma center and going into surgery. That felt pretty good to be part of that, even as a knuckleheaded observer."

J.P. Wilson, who is 51, lives in Bonita with his wife and two children, an 11-year-old daughter and a 7-year-old son. He began piloting helicopters for Mercy Air after a 22-year career in the Navy.

"I was a forester by training," he says, when we talk one morning in the crew quarters at the Carlsbad airport. "That's what I went to school for. I was working up in Idaho for the U.S. Forest Service, and we used helicopters all the time for logging and firefighting. I didn't fly them, but I flew in them all the time, and I'd always, even as a kid, been fascinated by helicopters. One day we were on a fire that was on the middle fork of the Salmon River, and the pilot dropped us off. He just tipped the nose over and went straight down into the middle fork of the Salmon River and tore out along the river bottom, and I thought, 'Hey, that looks like fun. I gotta learn how to do that.'

"I went down to Challis, Idaho, which was the closest place that had an instructor pilot. I asked him how much it would cost to learn to fly a helicopter, and I looked at my GS-5 salary as a forester -- which I think in the mid-'70s was about five and a quarter an hour -- compared the two, and realized that it wasn't going to happen.

"I started looking around, and the Navy offered me a job, which at the time was a five-year obligation. I thought I'd get out and go back to logging and firefighting, but one thing led to another and I did a career in the Navy."

Upon retiring in 2001, Wilson planned to fly for regional airlines, but his first training flight was on September 10. As the airline industry suffered following September 11, his career plans shifted. He has been flying with Mercy Air for over two years.

Mercy Air Services, Inc., which is not affiliated with Mercy Hospital, operates the only air-ambulance helicopters based in San Diego County. None of the local hospitals owns a helicopter. "We're part of a national corporation called Air Methods," says Pam Steen, a program director at Mercy Air. Air Methods has two different models. "There's the traditional side, which is mostly hospital-based programs, and then there are the independent programs like Mercy Air. It's very expensive for a hospital to have a helicopter and to be able to maintain it and use it for scene calls. It just doesn't tend to be very profitable from the hospital's standpoint, and that's why we're seeing more and more independent operators."

The emergency medical services (EMS) helicopter "is an ambulance with a rotor system," Wilson explains. "We're an advanced life-support ambulance with a highly skilled medical crew with a rotor. We don't do cliff rescues. We don't do beach rescues. We don't go out in the water and pick people up. If somebody's been hurt or is sick, we go get them. Here at Carlsbad, it's mostly what we call scene-call work, which is highway accidents, the Marine Corps on the base has things happen up there, industrial mishaps, construction site accidents. We also do 'inner facilities' here, which is taking a patient who is in a hospital already to a higher level of care at a different facility. For example, we go up to Fallbrook quite often. They have a good community hospital, but it doesn't offer all of the test equipment or all of the specialties that are offered at Palomar or Scripps La Jolla."

Since April 2003, Imperial County has had an emergency medical services helicopter. It's owned by Corporate Helicopters of San Diego, a company based at Montgomery Field whose dozen other choppers are used in a variety of ways, including TV news, aerial surveys, and the film industry. Stephen McNabb, the general manager of Corporate and a pilot, says the emergency medical services helicopter is sometimes used in San Diego. "If the County of San Diego requires what they call 'mutual,' or mutual assistance, they will call the Imperial County sheriff's office. The sheriff will call us, and then we can respond."

In Imperial County, with a population of 150,000, many of the emergencies are accidents in the sand dunes at Glamis, Buttercup, and Gordon's Well, and increasingly at Superstition Mountain and Ocotillo Wells, where McNabb says people are migrating to escape the sheriff and BLM presence at Glamis.

"A lot of the more serious accidents that I've been involved with have been out in the dunes where people, you know, in the fall there are almost 200,000 people that show up at the dunes," McNabb says. "It's just like another city. There's a lot of dune riding, dune buggying going on. And a lot of drinking. Some of the crashes there have been really horrific."

McNabb describes a typical call. "Two in the morning, you're sort of hanging out or maybe taking a quick nap or something, the sheriff's office calls on what we call the bat phone. We pick it up, they say, 'Hey, we've got an ATV rollover in the sand dunes. Here's a general location.' Maybe a latitude, longitude, a GPS coordinate, if they've got it. 'Here's who's responding. A ground ambulance is on scene right now. Here's sort of an initial patient status.' We get suited up, if we're not already suited up, in our flight suits. We grab our equipment. The nurse grabs the medication, and we just make a mad dash out to the helicopter. The equipment is a whole-body-monitor system that's typically kept inside the crew quarters. It's portable, and they'll take it on scene.

"The pilot will immediately get in and start spinning up, start the engine, get it going. The crew hops inside. We take off. We check in with the sheriff's office to get more definitive answers on location and patient status. We check in with our 24-hour dispatch and let them know what's going on. They're getting prepared in back for what's going to be happening. The pilot's focusing on navigation. In Imperial County there are not a whole lot of lights. It tends to be pitch-black out there most of the time. There's not a whole lot of reference, so he's focusing on getting them moved safely.

"And then I would say it's maybe 10 to 15 minutes en route time to get there. We sort of survey the area as much as we can, looking for obstacles, power lines, other people who might be in close proximity to the landing area. Then we're in touch with the ground crew, so maybe they can give us an idea of where the winds are. We figure out where we want to land. We've done a lot of training with the fire departments and police departments out there, so they understand what we're looking for and what we need. They're really good at setting aside a large area for us to land in. We'll circle around. We'll have the Nightsun searchlight, which is super-, superbright. Turn that on. Shoot the approach. The flight nurse and paramedic are looking out both sides in case they see anything that might be dangerous that we might need to wave off on. We come down and land. As soon as we land, I'll take the power off.

"They'll run out of the helicopter and start assisting the patient. Stabilizing the patient. Putting them on the backboard or some type of board. I'll keep the helicopter spinning unless it's going to be a long time on scene.

"Typically we stay separate from the activity at the scene. On a scene call, we stay with the helicopter and keep it spinning. If we shut down because it's going to be more than 15 minutes on the scene, the pilot will get out, but even then he won't really get involved, because we don't have any proper medical training to provide assistance. At that point our job is more coordinating with the fire and police departments to ensure that we can get out of there safely. Make sure that the crowd that is there is kept away from the helicopter. Even if we do get out of the helicopter we don't get involved with the patient care. Whoever's on the scene, the police department or the fire department, will help them into the helicopter. Strap them in. Board up and go.

"Then it's taking off and navigating, figuring out which hospital is most appropriate. If it's a child, we probably are going to take them to Children's Hospital in San Diego. If it's a burn, we typically like to take burns to Loma Linda, just through the Banning Pass. Or if it's nothing specific, we can go to Palm Springs or San Diego."

Depending on where in Imperial County the emergency has occurred, flight time to San Diego, which has both Level I, the highest level of care, and Level II trauma centers, can be 45 minutes to an hour. Desert Regional Medical Center in Palm Springs, a Level II trauma hospital, is a 45- to 55-minute trip. Although the flight time to Loma Linda University Medical Center, a Level I center in San Bernardino County, may be an hour and a quarter, "If certain heart ailments exist or if there are extensive burns involved," says McNabb, "the flight nurse may elect to skip Desert Regional and fly to Loma Linda. And if for some reason we can't get to Children's Hospital in San Diego, Loma Linda also has a very good pediatric ward."

Mercy Air employs the crews who staff its two San Diego helicopters, one of which is based at Gillespie Field, in El Cajon, and the other at McClellan Palomar Airport, in Carlsbad. Typically an emergency medical services crew consists of one pilot, one nurse, and one paramedic, but, says Steen, "We work with UCSD's Emergency Residency Program." During some months of the year, resident doctors at UCSD take six to eight shifts each per month on a Mercy Air helicopter as part of their training. At Corporate Helicopters, the nurses and paramedics are provided by another San Diego company, Medevac, which also provides the dispatch and housing at the Imperial County Airport for the on-call crew.

Mercy Air quarters its on-call crews in converted hangars at Gillespie and Palomar. Crew quarters have a kitchen facility, common room, bathroom, office area, and sleeping area. The common room at Gillespie Field has comfy La-Z-Boy chairs and a TV. The day I visited, the team had just left on a call. Someone's clogs had been kicked off in the middle of the room. A pair of jeans lay in a heap on the floor.

At Corporate, McNabb says, "The pilots are five days on and five days off. The five days on, they have 12-hour shifts. On the five nights on, they have 12-hour shifts. So 9:00 a.m. to 9:00 p.m. and 9:00 p.m. to 9:00 a.m. We switch back and forth. Sometimes you're days, sometimes you're nights." At Mercy Air, the shifts run 8:00 to 8:00 and are for four days at a time. Four pilots at Gillespie and four at Palomar rotate the shifts.

"All of our pilots live in San Diego, and all the nurses and paramedics," McNabb says of the El Centro crew. "If you've ever been to Imperial, it's a challenging place. It's difficult to find the qualified pilots or nurses and paramedics for this program out there. What's tough about our program is that it's a two-hour drive from San Diego. Typically the night pilot -- you know, he's on from 9:00 p.m. to 9:00 a.m. -- if he likes he can drive two hours back and spend the day with his family here before his next duty shift. It's kind of awkward because it's during the day and the family could be at school or at work, but he could do that. The day pilot is sort of stuck there for the whole five days."

Most local EMS pilots are men. "I think that's a function that many of the pilots come out of the military and go into civilian helicopters," McNabb says. "Women have been a fairly recent phenomenon in the military side of the house, and they just haven't been showing up in a lot of numbers in the civilian side. We have one female pilot. She's fairly new. She's just going through the ranks and doing the student instruction. She's wonderful. You know, I flew with females in the Navy. I think it's great."

Pam Steen, Mercy Air's program director for San Diego, Riverside, Orange, and Imperial Counties, says, "I have 17 pilots. We have a float pilot also because we do a lot of training and we need someone to help cover. Out of the 17 pilots we have one woman. She's located up in Orange County."

At Mercy Air, the average age of the pilots is "late 40s, early 50s," says Steen. "A lot of them are ex-military, either Navy, Marine, Army; we don't have any Air Force. Most of them are from that Vietnam era, and they're getting older. We are getting some younger faces coming onboard, but most of the pilots tend to be older."

There's no mandatory retirement age. "The airline pilots, like Southwest's, do have an age limit," McNabb says, "but I don't think there is an age limit for this. Actually, we have two pilots who are pushing 60. The oldest pilot that we have is 57. I know people as old as 60, 62. You don't see much beyond that. Usually what happens is that their eyesight goes. They sort of figure out, 'I can't fly anymore.' They just give it up. What's funny is that some pilots will have glasses on their nose so that they can see the instruments close, and then they look up and [look above their glasses]. They are wonderful pilots, absolutely great pilots, but they have the glasses-on-the-nose thing."

Jeffrey Emery, who is 48 and a pilot at Mercy Air, was trained by the Marine Corps. "I always wanted to fly as a kid. I went into the Marine Corps at a young age. My goal always was to work on aircraft or to fly them. I made that progression. I started working on jets in the Marine Corps. After a certain period of time I was accepted for an officer transition course and performed well through the whole thing and was selected to be in the aviation pipeline. Got into that. Did an intro flight in a helicopter and said, 'This is great. I can see the ground. I can see the trees. Which is a lot better than jets up there at high altitude.' I decided I was going to go with helicopters."

After leaving the Marines, "I worked at a local company doing flight instruction and tours," says Emery. "I did Sky 10 as a fill-in pilot for Kyle Anastasio for about a year and a half before a position opened up at Mercy. I applied for that position out in the high desert in Victorville, so I had to drive out there my first eight months with the company. I've enjoyed it ever since. I've been flying for them for about five and a half years."

McNabb, who was born in Richmond, Kentucky, learned to fly helicopters in the Navy. "I actually had a private airplane license prior to joining the Navy and then flew the Navy's T-34C airplane during training," he says. He stayed in the Navy seven and a half years, with two duty assignments at North Island. He flew helicopters the whole time he was in.

In the civilian world, McNabb says, "You could easily spend $100,000 to be trained to be an EMS helicopter pilot. They would have to get their private helicopter pilot's license. Then they'd get their commercial. Then they'd have to get their instrument, which is a separate ticket. Then it's just a matter of building time. If you're not in the military, the way that you build time is that you instruct. You instruct a piston helicopter for probably a couple hundred hours. Hopefully, you get to transition to a turbine. Fly turbines for several years to build up more time on turbines, and then move on. It would take a lot of money and a lot of time.

"The military, in my opinion, is by far the best way, because the military spent a million dollars on me to get me trained, and I was flying a heavy twin-engine helicopter when I had, like, 200 hours, which is unheard of out in the civilian world. It just doesn't happen. The amount of experience, and the amount of time that I got that experience in, was just so incredible. To pay $100,000, it just can't compare. It's doable, and people do it, but it just takes time and money. It definitely takes time and money."

One of the factors Mercy Air and Corporate consider when hiring a pilot is how many hours he or she has flown.

"We require a minimum of 6000 hours of flight time," says Steen, of Mercy Air. "They are interviewed -- I am at times on the interview panels -- but the ultimate decisions about pilots are made by the aviation managers. There are pilots on the panels that do the interviews and decide qualifications and choose people that meet minimum qualifications and are the best qualified for the position. A lot of times we want them to have the IFR [instrument flight rules] training if they're going to be at a base where they need to have that. A lot of our pilots are multiaircraft pilots. We train them. A good number of our pilots are able to fly both aircraft."

Usually the pilots fly VFR -- under visual flight rules. But when clouds are low or visibility is diminished, the FAA requires that pilots be instrument rated to fly and that they fly under instrument flight rules, which means they must file a flight plan. Because of San Diego's marine layer, IFR conditions are common here. Mercy Air's San Diego pilots are instrument rated.

Corporate also requires that its pilots be instrument rated. "We have to have people who are instrument rated," says McNabb. "They get that training at a flight school. They typically pay for that training or they develop that experience doing other jobs, like scenic tours. We look for instrument hours, instrument certification. We prefer people with their airline transport pilot, or ATP, certification, which is the highest level of certification. And people who have experience flying the specific type of helicopter that we operate. People who have Long Ranger experience have a definite plus in their understanding of this particular aircraft.

"We prefer 3000 total hours and a certain number of turbine hours. There are turbine helicopters and piston helicopters. A piston is similar to an automobile, and turbine is basically a jet engine. We want people with experience operating a helicopter with a jet turbine engine.

"We hire people according to their technical competence in terms of flying ability, certifications, hours of experience," McNabb continues. "Corporate Helicopter typically puts them on a probationary period, sort of like a trial period, to see if it's working for that person or if something is really not panning out. The good thing about having a nurse and a paramedic onboard is that they can provide me, as a general manager, with some real-time feedback with 'Hey, this pilot is kind of spooked' or 'He's pushing the envelope with weather' or something."

Before entrusting the medical crews' and patients' lives to a pilot, both companies do background checks. Mercy Air, Emery says, checks "driving record, criminal-investigation record, your prehistory, they go back and get records from your previous employers."

"We do a DMV test," McNabb says. "An FAA check -- that's what's important to us. We want to know if the pilot's been involved in accidents or incidents in the past. If he or she has had a clean record then that's a good indication."

"All our hireds have initial drug testing," Steen says. "The FAA requires that pilots and mechanics be tested."

"You do an initial drug screening just to get hired on," Emery says. "After that it's a random screening. You never know. You just show up to work and the paperwork can be sitting there, and it says, 'Go do this.' The initial drug screening and the initial record checks all happen prehiring, before you can even start training."

At Corporate as well, "All of our pilots are on the drug program," McNabb says. "We have an initial screening upon hiring, and then there's a random drug poll. If their name comes up, they go over and do a test. They could do it three days in a row. It's totally random. We're all in that program."

While newly hired pilots have thousands of hours of experience flying, unless they've flown emergency medical services helicopters, they may be unfamiliar with such aspects of the job as operating a helicopter around crowds, landing in areas with power lines, and transporting a patient whose life depends on how fast the helicopter gets to the hospital. "There is specialized in-house training that we like to do for EMS pilots," McNabb says. "What we like, first of all, is to hire people who have already had EMS experience so they are already acclimated to that type of position. If they don't, then we have an in-house training program that emphasizes off-airport landings on highways or on sand dunes or mountains. A lot of situational awareness. A lot of crew resource management, because you have a flight nurse and a paramedic with you. Working together as a team to make the mission happen is really important.

"It's also one of the few missions where once it starts happening, once you get a call to go to a scene to pick someone up, there's a lot of pressure to get the patient onboard and to the hospital. We make sure that the pilots understand the difference between having an emergency with the patient and not translating that into pushing the envelope with the helicopter or making bad decisions. There are a lot of decision-making-type exercises and training."

"One of the crazy things about EMS is that you do a lot of things that you would ordinarily never do in a helicopter, especially at night," McNabb continues. "I've had trouble when you're landing really close to the ground, like the sand and the dirt starts to get blown up and circulates in the rotor blades and you can't see. The second you can't see, then you can't land at that point, because you have no idea if you're drifting left or right. The nurses and paramedics are trained to call it and say 'wave off' or 'go around and stop.' You just sort of pull the power and put the nose down and take off again and try to find another spot that's a little less dusty or dirty. I've had a couple of those. It's a brownout issue.

"I've had a landing on Interstate 8, some surprises about power lines that you don't see. You're coming down and you've got the searchlight on -- there are so many power lines crossing Interstate 8 on the way to San Diego, and until you get down really low, there are some of them that you don't see. You just get that ugh! feeling inside. You pull up on the power and go around. It takes a lot of vigilance because you're doing things that really are not standard procedures in typical flying. The surprise power lines and the brownouts have been some of my scariest moments."

"There are some places where the risk is a little higher than others," Wilson says. "For example, when I first started working for the company I worked out in Mojave. Up there, there are not very many lights to tell you where you are. If you're going out to a traffic accident in the middle of the night on U.S. 395, there is absolutely nothing around. You can see the code lights on the emergency vehicles for 50 miles, but there are lots of visual illusions that take place in a darkened environment like that. You have to really pay attention."

Although pilots witness tragedies regularly, "there's really no psychological screening in advance of hiring," Emery says. "The company does have a behavioral counseling available through a source. It's available online as well as by direct phone line. You can call and get assistance for several things. Family counseling, as well as stress counseling. Then if there's something that is a specific incident we have a team that can be called on.

"In any job it's hard not to take the work home. In this one, I mean, since you're seeing kids and family members in anguished situations, those images can linger at home and the stories be told at home. That can be very traumatic.

"Some of the ones that stand out most in your mind are unfortunately the ones that are the saddest," Emery continues. "Usually they are children lost. The one that hit me the hardest was the 19-year-old kid who just picked up a motorcycle with his mom. He was driving it home out in Alpine. His mom was following him in her car. He went around a corner and he hit into a truck. That was kind of difficult. We got on scene. The mom was pretty frantic. Of course, it was close to home so the relatives had all come out. It was obvious once we got on scene, the nurse and the medic, that the boy was not going to survive, and not survive at the site of the impact. Those type of things are the ones that hit you the hardest and stay with you the longest."

"Probably the worst that I've been on was working up at Mojave," Wilson tells me. "Highway 58 runs from Mojave over to a place called Kramer Junction. We got a call that there'd been a traffic accident on Highway 58.

"What had happened was that a fellow driving a Suburban with his family had fallen asleep at the wheel and had gone off the road. That's quite a common accident out there. Had gone off the road, overcorrected it, then rolled the Suburban, and he rolled it many times. You couldn't even really tell it was a Suburban as we were landing.

"The wife and the husband were seat-belted, but the children in the back were not. As the vehicle rolled, the children were ejected. There were five children in that Suburban. Two were dead at the scene.

"We showed up. We took two patients with us. A very small, about a 5-year-old boy, and his 11-year-old brother. His 11-year-old brother had, as you looked at his legs as they came down through his thighs, they took about a 45-degree angle, both of them. Both of his legs were quite badly broken. The nurse in the back was sure that that youngest boy wouldn't make it.

"Another helicopter, a competitor from the area, landed and picked up one of the other children. We couldn't take him. That child died.

"The two that we took both lived. I imagine the one has still got rehabilitation difficulties, because his legs were quite badly broken. The other one, we were sure the little guy was not going to make it, but they administered some drugs at Loma Linda University and took him right in to the neurosurgeons, and before we got our paperwork finished they were saying he was coming around.

"That was pretty horrific and kind of opened my eyes, because I've driven tired before with my family. I don't do that anymore."

Mercy Air's San Diego helicopters are a Bell 222 and a Boeing MD Explorer 902, both turbine-engine aircraft. They can cruise at 150 and 120 miles per hour, respectively, and both have room for two patients. "The one here at Gillespie Field is the Bell 222, an IFR ship, twin engines," Steen says. "IFR means that they fly by instrument flight rules versus visual flight rules. They file a flight plan with the tower and are able to go up in weather that you normally would not be able to go up in. We have one more helicopter in San Diego. The other is an MD Explorer 902, which is also twin engine, and that's located at Palomar Airport.

"The Bell that's here is probably about $2 million. The 902, when it was bought -- it's about two and a half years old -- cost approximately $4 million."

Kelly Foreman, business development coordinator and flight nurse for Mercy Air, describes the 902. "We've got it tricked out with a glass cockpit and all the bells and whistles known to mankind. It's sleek; it's comfortable. Plus it has the EMS package in the back. The 222 is like having a Ford Taurus. It's been on the line for a significant period of time. The 902 is the equivalent of a brand-new Lexus SUV."

The Corporate helicopter is a single-engine turbine. Corporate transports one patient at a time. "Our Long Ranger you can probably get on the market for around $800,000 or $900,000," says McNabb. "There's the helicopter, and then there's a medical interior that goes inside. The medical interior for that aircraft costs $120,000. The medical interior has oxygen. It has suction. It has AC power for defibrillators, the heart monitoring and blood pressure and things like that. It has a lot of stuff. The Long Ranger is a fairly economical bird in that it's visual flight rules only, meaning that we always have to fly with reference to the ground."

What the companies charge for the flight is based on the distance the patient is transported. One person, speaking off the record, estimated $6000 as the typical price tag for a flight within San Diego County.

"We're a private company," Steen says of Mercy Air. "We do not receive any funding from the county or the state or the federal government. We bill the patient's insurance, and that is how we are reimbursed. It is obviously much more expensive than for ground transportation because it's incredibly expensive to maintain helicopters and the crews. Our crews function at a higher level than a ground paramedic unit. We staff with a nurse and paramedic team. Also on some days we have a nurse/nurse team or a nurse/UCSD resident physician team. The lowest level of crew you would get is a nurse/paramedic, and the highest would be a nurse/physician. We can provide a higher skill level and give medications and do procedures that the average paramedic unit would not be able to provide."

"There are two types of patient transport," McNabb explains. "There's interfacility, from hospital to hospital, which we do. And then there's scene call. You're just landing anywhere, picking the patient up at the scene where he or she is injured, and taking them to the hospital. In Imperial Valley you could spend upwards of $15,000, because there are no trauma centers in Imperial County. We either have to fly to Desert Regional in Palm Springs or here to San Diego, so it's a fairly long distance to take the patient. It also depends on certain transfers, like if you have an infant or some other type of special case, they might actually carry a doctor onboard. Then the price is adjusted to accommodate for that.

"It's expensive, too, because most people can't pay," McNabb continues. "One person pays for four flights -- you pay for the three people ahead of you who had no insurance."

Steen says Mercy Air's decision to have two helicopters in San Diego is based on the volume of calls. "You look at how many calls you have and being able to meet that demand. If our call volume would go up significantly, we would consider putting in a third aircraft. It's based on call volume as well as how long it would take you to get from point A to point B."

The helicopter based at Gillespie gets about 60 calls per month. "Up at Base 5 in Carlsbad it's probably like high 60s or low 70s," Steen says. "The calls out of this base tend to be longer distance so you tend to get less of them. The calls out of the North County tend to be shorter calls. A lot of that has to do with the trauma system. They are utilized quite a bit by Oceanside, Vista, San Marcos, those towns, because the nearest trauma center for North County is Scripps La Jolla. It would be a significant distance for the paramedics to drive down and back. They'd have quite a bit of out-of-service time. Because of the distance factor, we are used more frequently for calls up there."

"Out in Imperial it's very cyclical in terms of patient load," McNabb says. "The fall, winter, and spring are really busy with people out there recreating in the sand dunes. The summers are just blazing hot, so there's not a lot going on. In the summer we might get a call or so a day. In the winter months it can be nonstop. Just go-go-go-go-go. When you're not working, you're just there either studying helicopter procedures and systems or doing some side work. Sometimes our company has a manual update and wants to get your program updated. We also let the pilots do some preventative maintenance. If the aircraft needs to be washed, if it needs to be greased, we have them do that.

"In the slow times it's boring, boring, boring, and then you get that call and you're just, like, the adrenaline is going and you're just racing to get out there. It's interesting. You just go from a very flat, boring state up to a fever pitch for the flight.

"We've been involved with multiple car accidents, immigrants -- we call them 'international travelers' -- that are coming across the border who become dehydrated and are near death, heatstroke-type victims, out in the sun.

"We've had somewhat abnormal accidents," McNabb says. "A couple of weeks ago a child had a bicycle accident. He was on his bicycle, and I don't know if he went off a ramp or something, but the bicycle brake handle entered his abdomen. The whole brake handle, and it got stuck, so we life-flighted him out.

"We've life-flighted people out who were not really physically damaged in terms of an accident, but something's going on seriously internally, hemorrhaging or bleeding, things like that, where you don't see a lot of blood or anything, but it's a very critical situation. I've been involved with some of those instances as well."

What happens when more than one call comes in at the same time?

"If this aircraft is already responding to a call, it deals with that call," says Steen. "If another call comes into the area, then we would dispatch the next closest aircraft. We may get the aircraft from Palomar or if need be from Orange County and Banning. We have eight in Southern California. We'll send the next closest ship, but sometimes it's easier just to ground transport the patient."

When there's more than one call, the helipad at a particular hospital may be in demand. Pilots call ahead to coordinate. "Say we pick up a patient on Interstate 8 and we're heading in to UCSD, we'll call our dispatch to let them know what's going on," McNabb says. "Dispatch will call the hospital and let them know. We're at least 30 minutes out, so the hospital will have a chance to de-conflict helicopters if they've got another air ambulance coming in from somewhere else. They'll know if it's not going to work. If it's not going to work they'll tell us to go over to Sharp or go to Palomar, wherever. Typically, you don't want to wait, because it'll be another 10 or 15 minutes before the other helicopter can get off the ground. At least with us coming in from Imperial, they have time to de-conflict. But if you show up and it hasn't happened and another helicopter is unloading, you would probably divert. UCSD is right next to Mercy in Hillcrest. And you have Sharp and Children's and Palomar. You've got choices, but it's not great, because you want to coordinate the type of care.

"Usually what happens is that you come in and another helicopter is sitting on the pad. They're just hanging out. They're already done with their patient, and they're getting ready to take off. We've never really had a problem."

Mercy Air and Corporate have mechanics on staff. Usually Corporate flies the helicopter to San Diego for work, although the mechanic can be flown to El Centro.

"Safety is incredibly important," Steen says. "There are regularly scheduled checks based on hours or parts. The aircraft have to be inspected after so many hours. Parts have times on them. A part could be used for 500 hours, and after 500 hours whether it's still good or not, it has to be replaced."

"FAA controls grounding," says McNabb. "We have a book called Minimum Equipment List. If something breaks on a helicopter, like an altitude indicator, you open the book, you look up 'altitude indicator,' and it says if you're going to fly or you're not going to fly. Generally speaking, we can operate with nonessential equipment. If your searchlight is out and it's daytime, you obviously don't need your searchlight. At night, if our Nightsun was out, we would probably not do certain scene calls if there was no other lighting available. Being that we are VFR only, we need a 1000-foot ceiling and three miles' visibility. If it's anything less than that, then we will not go.

"We're more flexible regarding wind. Twenty, 25 knots, that's probably getting toward the edge of what we can do. Add gusts in there, that's an additional problem. When you're flying, winds, as long as they're not turbulent, are actually a good thing because it puts you in a lower-power type of situation. Winds can be your friend. It's just getting the rotor started, which is the problem a lot of times. When a rotor is slowly spinning and starting to spin up, it's more unstable and it starts to flap. Twenty-five, maybe 30 knots, then it starts to get a little iffy."

"There are times of severe weather when they do not fly," Steen says of Mercy Air helicopters. "They do not fly in lightning. They do not fly over the mountains when it's snowing and icy, because we do not have de-icing equipment on the helicopters."

The pilots do not fly when they're tired or sick. "We cannot self-medicate," says McNabb. "If you are taking any type of antihistamine or cold medicine, you can't do that. If you're to the point where you need to take some medicine, then you're basically out of the game. You need to down yourself."

"Anytime that you have to take medication for sinus blocks or anything that would be conscious-altering -- you know, the little cautions on the label that say, 'This can cause drowsiness' -- then you ground yourself," Emery says. "We have an altitude problem. Anything sinus-related or that could block your sinus tubes could cause damage as you go up in altitude or down in altitude and could burst vessels."

"We don't allow any type of alcoholic consumption within 10 hours of flying," McNabb says. "Zero point zero percent blood alcohol. We strictly regulate crew-duty periods, the 12-hour periods, so that the pilot doesn't become fatigued. But if for some reason, through extenuating circumstances, they become very tired, then they have the discretion to take themselves down. If something's not right, they will never be reprimanded for taking themselves down. The nurse and paramedic have no problem. They say, 'If you don't feel right, then let's not do it,' because their lives are in his hands."

How does a pilot focus on flying when a patient may be dying right behind him?

"I don't look at them," Wilson says. "I have to focus on the flying. My job is to get the medical crew and the patient safely from wherever we are to the hospital. That takes a lot of focus. Especially here in the San Diego area because of the traffic, a lot of air traffic. And then there's airports and control zones that are highly restrictive, so you have to pay attention. I've not been affected really by something going on in the back, because what I'm paying attention to is the aircraft and flying."

"The fortunate part is that we don't see a lot of it," Emery confirms, "because it is going on behind us, but we do hear the screams of pain and anguish. The nurses and medics are always talking, so we have an idea of what they're doing and what the patient's status is. We just fly the aircraft and get it from point A to point B. You can compartmentalize in that aspect. You have a busy task and a challenging task flying the aircraft, especially in some of the weather environments we have. It's easy to say, 'Okay, that's going on behind me and I need to focus on what I'm doing.' After the flight's over there are a lot of questions that get asked. 'What was the patient's status? How is he or she doing?' "

"We have a blackout curtain that's in between us and the patient and medical team, so it's physically separated," McNabb says of the Corporate helicopter. "The way that our helicopter is set up is that the patient's legs are right next to me. Typically an injury is up top. There is some physical separation between us and them. If it's starting to get bad, you're listening to them, you just turn down the intercom. That will turn the volume down. It'll allow you still to listen in case they need something, but it helps drown it out mentally.

"And usually the pilot is busy enough too, especially here in San Diego. They're busy talking to air traffic control and coordinating with the hospital and coordinating with dispatch. There's enough going on for the pilot that you don't even think -- unless something really, really bad is going on, unless they're having to start doing compressions on the patient's chest because they've coded, then you really don't get involved mentally or otherwise. It's not too bad to block out."

"If someone has not made it, you kind of know," Wilson says. "You can tell from the conversations when the medical crew's talking to the ground. You can pick up from what they're saying how serious this really is. If they start CPR in the back of the aircraft, that's not a good sign. They have so many drugs and so much capability to keep people going, CPR's kind of a last resort, so when you hear them starting that, you know it. That's part of the job. When I first started the job it was a big concern of mine, that it would bother me, that I would take it home or that I would somehow be bothered by it. It hasn't been a problem. I don't know. Maybe it sounds kind of callous."

"I do think it takes some adjustment to say, 'Okay, someone just died in my helicopter,' " McNabb says. "It's tough, especially when the nurse and paramedic are doing everything that they can, and then halfway to the hospital you find that you've lost them. It's tough. We do have provisions for counseling for the pilots if they feel they need someone to talk to or at least to think through what just happened."

About seeing a lot of blood, Wilson says, "I thought it might bother me when I first started the job, because the kind of work the medic and nurse do has never been appealing to me, but it hasn't really affected me."

"Blood's okay unless you look at it," McNabb says. "We do have, the way the helicopter is situated is sort of like a pan, the way they've got it set up; it's what we call coin mat. It's a rubberized mat that's in the bottom so it'll collect. It doesn't just get everywhere. There's no cloth. There's no carpet trim or anything like that, so it's not too bad to clean up. Hopefully, most of the time what happens is that they get the patient stabilized before they put them on the helicopter. Hopefully, the bleeding and that sort of stuff is under control. The nurse and paramedic clean the inside of the helicopter. They've got hospital-grade detergents for that. Blood isn't so bad for me because you really can't smell it.

"If it's burnt flesh," McNabb continues, "that's what really -- the aroma of that sort of permeates and makes you kind of want to open the door to get the smell of that out of the cockpit. You say, 'Ooh, that's really strong.' "

"Those are the most difficult," Emery agrees, "as far as it just makes a whole flight uncomfortable, with the smell and the pain that the victim is going through. Everybody, I think, has a fear of being in one of those situations."

To cope, some staff have what Emery calls a warped sense of humor. "It's traumatic to you, so you try to buffer it by finding other things to laugh at or taking other things and twisting them into a form of humor so that you can bury yourself against that grief and anguish. It hits the medical staff more than it does us. We also have to help them get through that."

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