Manitoba's STARS air ambulance slammed in draft provincial report

Manitoba’s STARS air ambulance crews lack adequate training, are not familiar with pediatric patients and do not understand patient oxygen needs, according to a damning draft report commissioned by Manitoba Health to review the air ambulance provider.

Dr. Stephen Wheeler, medical director of B.C. Air Ambulance and Critical Care Transport, slams the Shock Trauma Air Rescue Society in a report he delivered to government Dec. 23, citing 12 cases in which patient care quality “came into question,” including two missions in which the patient died and one that left a child with brain damage.

In one case, according to the report, STARS ran out of oxygen in flight, something Wheeler said “should never happen.”

In another case, the air ambulance crew ran out of epinephrine while transporting a severely allergic man who had been stung by a bee to hospital, says the report. The patient died.

“As a group, the nurses and paramedics lack adequate training and experience to work in the air medical environment,” Wheeler writes in his report.

“Compared to other air medical transport programs across the country, its training program is remarkably brief and cannot provide the necessary amount of training required for modern, complex, critical-care transports.”

'We strongly disagree,' says STARS

“We strongly disagree with the report,” said Dr. J.N. Armstrong, chief medical officer of STARS.

Armstrong said Wheeler wasn’t given enough time to work on the report and got many things wrong.

“The report had tight timelines and we've been working with Manitoba Health and the consultant who generated the report to provide more information, more background, more context around a lot of the points around the report to help with this draft report and move it along," he said.

STARS says many of the facts the report cites are not accurate. For instance, it says no STARS mission has ever run out of oxygen in flight, and the crew did not run out of epinephrine while transporting the man who had been stung by a bee.

Armstrong also disputes Wheeler’s criticism of the service’s training program, saying it isn’t fair to compare it to other provinces' training programs.

Wheeler writes in his report, “I have attempted to be as comprehensive as possible but, understanding that STARS Manitoba and the Manitoba Department of Health wished a timely report, I acknowledge some areas may require further review.

“However, I believe the essential issues underlying the problems have been captured here.”

The Manitoba government temporarily suspended STARS on Dec. 2, citing safety concerns.

• STARS air ambulance flights suspended in Manitoba
• Ground ambulances beat STARS times while service suspended

On Tuesday, Health Minister Erin Selby said the report into STARS is not yet complete.

“Dr. Wheeler continues to work with STARS as does Manitoba Health. There were some issues raised that are concerning, and my focus is on those recommendations and making sure that we have all those in place,” she said.

Among Wheeler’s recommendations:

• STARS should redesign its training program and immediately supplement its crews with experienced flight personnel for a minimum of six months.
• STARS should limit its transport of pediatric patients to trauma scene responses, and not carry out routine patient transfers between facilities, while it reviews its pediatric training. Emphasis should be on pediatric airway assessment and management.
• The methods of dispatching STARS “lack co-ordination and need improving,” he writes.
• Quality control must improve because “overall, an emphasis on creating and maintaining a culture of quality is missing.”

One of the reviewed cases involves an 18-year-old with a bee sting allergy who went into shock after being stung.

The report says he was attended by local crews who began to transport him by ambulance to the local hospital five minutes away.

According to the report, STARS “requested the local crew stop; STARS landed on the highway” and intercepted the transport.

The STARS crew changed the breathing tube on the patient in the back of the ambulance, which required “two attempts,” according to the report.

The report states that during the STARS flight, the crew ran out of the anti-allergy drug epinephrine, and the patient died at the Health Sciences Centre.

Training program ‘falls far short’

In a section comparing other provincial helicopter ambulance programs, the report concludes that STARS Manitoba’s 10-week training program is “grossly insufficient” and “falls far short of training models in B.C. and Ontario,” where air crews must train for 12 to 24 months.

A review of crew biographies reveals that only one STARS paramedic had any previous flight experience and that in other provinces, most paramedic trainees and flight nurses have “extensive experience as ICU or emergency room nurses.”

Manitoba’s STARS crews are also not familiar with pediatric patients, as evidenced in three separate cases reviewed in the report.

One case identifies a 23-month-old child who “could have been transported without intubation” but was intubated anyway. Subsequently, the tube “migrated down into the right main stem bronchus causing hypoxia,” according to the report.

Hypoxia is a condition in which the body is deprived of an adequate oxygen supply.

In May 2013, two-year-old Morgan Moar Campbell suffered brain damage following a STARS flight in which his intubation tube became dislodged. The report states that “the endotracheal tube became dislodged due to the crew’s unfamiliarity with the tube clamp.”

Campbell-Moar’s parents are currently suing STARS. The STARS defendants deny that any of them were negligent, and said all steps were taken and done in a careful and prudent manner. They also deny that the boy was harmed.

The case remains before the courts.

Another case identified in the report involves a child who was injured alongside an adult patient in a motor vehicle accident last summer.

The STARS physician elected to go with the adult patient and left the child with STARS crews, despite a medical protocol that required a physician on every STARS pediatric mission, the report states.

Oxygen, intubation issues 'a common theme'

Intubation problems and difficulties maintaining oxygen are identified as “a common theme arising out of most cases,” Wheeler’s report states.

The report identifies “a lack of appreciation of what constitutes a difficult airway” and “a lack of sophistication in dealing with airways.”

One case review of a cardiac patient states that “en route in the helicopter, the oxygen supply exhausted and the patient became severely hypoxic.”

The report concludes that the crew did not understand the oxygen needs for the trip and the case demonstrated a significant unfamiliarity with the on-board equipment.

The situation was critical but “the patient was resilient and managed to survive the transport," the report states.

A 39-year-old patient “very close to Winnipeg” did not survive a Nov. 28 transport after STARS was called to transport her, “even though it would have been faster by ground,” according to the report.

The report says the patient had a pulmonary embolism and was in shock, but before she reached the hospital in Winnipeg, the portable oxygen tank she was depending on ran out and she died.

That case prompted the grounding of STARS in December.

At the time, Selby announced that she has instructed her department to suspend STARS flights, after concerns were raised about the woman's death.

Wheeler’s report states, “All air transfer organizations go to great lengths to ensure this does not occur, as the consequences can be catastrophic.”

He added that “running out of oxygen should never happen.”

The cases reviewed by Wheeler left him with the impression that “there is still an aspect of reactive quality assurance” and that STARS is not focused on “making ongoing efforts to improve efficiencies and effectiveness at all levels.”