Key West resident Larry Capobianco was riding his scooter on Virginia Street in March when he hit a curb and was thrown over the handlebars. Knocked out, he awoke at Lower Keys Medical Center, where he drifted in and out of consciousness.
Capobianco, diagnosed with bleeding in his brain, later was airlifted to Ryder Trauma Center in Miami by a LifeNet helicopter stationed at the Stock Island hospital. The landscaper recovered and was released in Miami two days later, but said he has yet to recover from the bill he received for the flight.
"I have Blue Cross/Blue Shield of Florida, but my limit is $4,000 and the flight was $27,000," Capobianco lamented. "I got stuck with the remaining $23,000 balance. When you get down to it, I don't have any idea how I'm going to pay this."
Capobianco's central gripe is that had he known the Monroe County Sheriff's Office Trauma Star helicopter was available, he would have opted for that publicly funded aircraft that is free for Florida Keys residents.
Technically, everyone is billed for a Trauma Star flight, but those who can prove they live in Monroe County can apply for a waiver that covers the cost of the flight for residents with or without insurance, according to a county ordinance. People who don't own property in Monroe County, don't rent or otherwise cannot prove their Keys residency do not qualify for the Trauma Star waiver. Nor do those injured while "involved in felony criminal activity," the ordinance states.
The issue over which helicopter is used, LifeNet or Trauma Star, has long been a volatile subject, particularly among Lower Keys residents. The issue involves multiple scenarios.
Unless Trauma Star is already in use or out of service, county paramedics, firefighters or deputies in need of immediate transport of a critically injured patient directly from the scene of an accident generally summon the publicly funded air ambulance. However, policy for the city of Key West instructs emergency workers to first contact LifeNet, summoning Trauma Star only if the former is not available, according to city records.
"If the LifeNet helicopter in Key West is not available, LifeNet dispatch will contact the Monroe County sheriff's communications center to dispatch Trauma Star," the Key West policy states.
Then there are patients who have already been admitted to Lower Keys Medical Center and require fast transport to a mainland facility. The hospital uses LifeNet for inter-facility transfers. The latter can include emergency trauma patients who recently were admitted or patients who have been under a physician's care at the hospital.
In total, Trauma Star has taken off from its Marathon airport headquarters 563 times since 2009, according to Sheriff's Office records. The specific number of LifeNet flights in the same time was not available, but AirMethods Business Manager Ray Lauer estimated there were between 900 and 1,000 flights in the same period, with most being inter-facility transfers. AirMethod operates LifeNet.
Key West's policy was written in December 2008 and it remains the protocol for Key West police and firefighters today, said Assistant City Manager Mark Finigan.
Key West paramedics with the private company LifeStar Response do not play a role in which helicopter is used, said the company's regional Vice President Doug Tisdale.
"We are not in the business of choosing," Tisdale said. "We contact the [Key West] 911 call center and they advise that we need a helicopter. We don't know until dispatch tells us who is responding. It's a matter of clinical care and we just want whoever can get to us quickest."
The Monroe County Sheriff's Office's and county firefighters' guidelines vary somewhat based on where a patient is located. From Stock Island to Mile Marker 95, deputies and firefighters are to call Trauma Star first, then LifeNet, then Air Rescue South (Miami-Dade Fire Rescue) and then Air Rescue North (also a Miami-Dade Fire Rescue resource).
For patients from Mile Marker 95 to the county line, they are to call Air Rescue South first, then Trauma Star, then Air Rescue North and then Air Rescue 85 (Broward County).
"It all depends on where the patient is," said Mike Rice, administration chief for the Sheriff's Office. "If you're hurt at Mile Marker 108, then our dispatchers call Miami first. We handle the entire county with the exception of Key West, which has its own dispatchers, but it's a fluid relationship and we often help each other."
Miami-Dade Fire Rescue helicopters do not charge patients for their flights, Rice said. Air Rescue 85 based in Broward County does charge, he said. Their charges are similar to what Trauma Star charges prior to any waivers to patients, which is roughly $14,000 from the Lower Keys to Miami, Rice said.
For those already being treated at a hospital, the helicopter called depends largely on whether the patient is at Lower Keys Medical Center, Fishermen's Hospital in Marathon or Mariners Hospital in Tavernier.
And it's with those hospital-to-hospital transports where Capobianco and others have voiced complaints about a lack of options at Lower Keys Medical Center and the roughly $27,000 cost of a LifeNet flight to those without insurance.
Nicki Will, CEO of Lower Keys Medical Center, said LifeNet is the primary helicopter used by the facility, but the decision ultimately is made by doctors based on patient needs.
"The hospital generally does not get involved and the decision is driven by the patient's needs, and a physician determines that," she said. "It is not the physician's role to explain what helicopters are available. Our responsibility it to provide the best care we can."
She stressed that hospital administrators do not make the decision, only doctors -- or the patient if they are able.
The state doesn't require hospitals to ask or inform patients that a cheaper or free helicopter may be available.
"The Florida Department of Health's Division of Emergency Medical Operations is not aware of any law that would require hospitals in Florida to let a patient or emergency contact choose which helicopter they want to be transported in or from if there is more than one helicopter available," said Florida Department of Health Press Secretary Jessica Hammonds.
Will added that there is "no financial relationship between Lower Keys Medical Center and LifeNet."
"No money flows between us," Will said.
Lauer of AirMethods said the same.
"There is no money going from LifeNet to the hospital or vice versa," he said. "We bill patients directly with no association to the hospital."
He added that his company does not ask the hospital whether a patient has insurance.
"That is not something we discuss," Lauer said, adding that the company has no monthly or yearly quotas for flights.
In February 2010, then-County Commissioner Mario Di Gennaro unsuccessfully sought to pass an ordinance requiring that hospitals notify patients of their options for air transport. He began working with the county attorney on the ordinance after his newborn grandson was flown from Lower Keys Medical Center to Miami Children's Hospital. Di Gennaro was irked because rather than calling Trauma Star, hospital officials opted to call for the Miami hospital's jet.
"I couldn't get to first base with it," Di Gennaro said of the ordinance. "The hospital wasn't on board. They said they were dealing with medical crises and that it was a time-safety issue. I don't think we can force hospitals, which are private companies, to do anything. What I wanted was for us to just request that they use Trauma Star first, but it didn't work out."
There are no contracted helicopters at Fishermen's or Mariners hospitals, representatives said.
"It all depends on the patient," said Dianne Weitz, spokeswoman for Fishermen's. "Whatever service -- Trauma Star, Miami-Dade [Fire Rescue] or Miami Children's or whoever -- is called depends on the patient's needs. We give the patient a choice if they are able. We give them their options. It also depends on who is available, of course."
Mariners calls Trauma Star first, then Miami-Dade Fire Rescue if Trauma Star is unavailable, said hospital spokeswoman Sheila Konczewski.
"If Trauma Star is unavailable, then dispatchers at our air transfer center in Doral start looking," for the next closest helicopter, Konczewski said.
It was all very confusing to Key West landscaper Capobianco, who has since put a sticker on his insurance card that reads "Trauma Star only." He suggested others do the same.
"Nobody I've talked to understands any of this," Capobianco said. "Now I'm getting letters saying they [LifeNet] are going to collection. As a resident, I wasn't really given a choice. I'm telling my friends who need a helicopter to tell everyone at the hospital, 'Gimme the one that doesn't cost anything.' "
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