It began with a well-timed photo op on the eve of the 2011 flood, featuring Premier Greg Selinger in front of a new and reassuringly red emergency helicopter that could pluck people from accident scenes and ferry them quickly to hospital.
Now, two years later, the Alberta-based Shock Trauma Air Rescue Society (STARS) is under increasing scrutiny, facing old questions about costs and how its contract was awarded and new rumblings about the quality of patient care.
Adding to the scrutiny is a value-for-money audit by Manitoba's auditor general, slated to be released early next year.
Then there's the low-grade turf war being waged between STARS and other emergency services. There's something about those flashy blue flight suits, the "cowboy" attitude and the relentless STARS publicity machine that just rankles other provincial emergency personnel.
All this, say STARS and the provincial government, is growing pains -- irritation born of misunderstanding and the byproduct of mixing a sophisticated new service into the province's established emergency-response culture.
"Any time you introduce a new service, there's friction," said Gerry Delorme, head of emergency management at Manitoba Health. "There's a getting-to-know-you period."
According to documents obtained by access-to-information requests, there have been two critical incidents since STARS began operating permanently in Manitoba. Those are serious mistakes that cause death, injury or disability.
One critical incident garnered significant attention and is now the subject of a lawsuit. In May, two-year-old Morgan Moar-Campbell was flown from Brandon aboard the STARS helicopter for tests following a seizure. The toddler was in an induced coma, and could not breathe on his own. When the child landed in Winnipeg, it was discovered his breathing tube had been pulled out, depriving him of oxygen for many minutes and leaving him severely brain-damaged.
The other critical incident, which occurred in 2012, is largely a mystery thanks to legislation that keeps CIs confidential. It involved an equipment failure and did not result in any lasting problems for the patient.
Among the province's emergency crews, chatter abounds of STARS care gone wrong, some involving improper intubations similar to the catastrophic Moar-Campbell case.
One seasoned health professional with extensive air-ambulance experience raised concerns over the "load-and-go" ethos that prevails, even for inter-hospital transfers, where keeping the blades hot and keeping response times low are the key drivers, instead of ensuring a patient is stable. The health-care worker also questioned the level of intensive-care experience STARS crews have, saying they have been set up to fail and are "in over their heads."
"I would not let anyone I know in the back of that chopper," said the worker, who spoke the Free Press on condition of anonymity because commenting publicly would likely result in disciplinary action.
STARS' medical director Doug Martin says that criticism is based on faulty information.
The STARS medical crew -- a nurse and, often, a doctor -- have an average of 10 years of critical-care experience, mostly in ERs. Nurses must have ER experience in order to be considered for STARS. And, the paramedic on board is an advanced-care paramedic with top-level training.
In addition to the two critical incidents, there are also 10 clinical reviews underway related to STARS, many based on complaints from hospitals. None involved injury to patients.
"We look at this type of thing across the health system constantly," said Delorme.
The reviews -- relatively common in all branches of health care -- involve listening to the audio of each call, reviewing charts and speaking with staff, and are meant to improve the quality of care.
Still, the clinical reviews and critical incidents have prompted the province to tighten the helicopter's operating rules.
Last spring, the province asked STARS to bring a doctor on every pediatric flight, and more recently the province asked that a doctor be present on nearly all inter-hospital transfers. And STARS is "auto-launching" less frequently to better integrate the helicopter into the existing system so the proper care gets to each patient.
The STARS helicopter can land on the site of highway crashes, remote hiking accidents or other hard-to-access locations, and takes about 10 to 15 minutes to get airborne. Last year, "on-scene" calls accounted for a third of all patient transports. The rest were inter-hospital transfers, when a patient suffering trauma or a heart attack needs a speedy trip from a rural hospital to, typically, Health Sciences Centre.
Rural paramedics, who often complain about being understaffed, argue many inter-facility transfers done by STARS can be done more cheaply and often just as quickly by a traditional ground ambulance, especially since the STARS chopper often can't land right at a hospital so an ambulance is needed anyway. The extra millions spent annually on STARS could go a long way toward improving ground-ambulance response times, boosting training for primary care medics and hiring more staff.
Then there's the cost of STARS, which is tricky to nail down.
The province will spend about $12 million this year to operate STARS, even though the annual price tag for the Winnipeg Police Service chopper is only about $1 million. And STARS costs exponentially more than the province's other air-ambulance service, the fixed-wing Lifeflight planes that can fly anywhere in the province there's a runway but tend to work mostly in the province's far north. Last year, each of Lifeflight's 514 pickups cost an average of $12,000 each, including the cost of the ICU-trained doctor and nurse who make up the crew.
STARS' 152 transports cost more than four times as much, about $65,000 each.
Delorme and STARS staff say a rotary-wing air ambulance costs far more in fuel and frequent maintenance than the Lifeflight jet.
STARS' $12-million annual cost is expected to slowly decrease as STARS ramps up its fundraising.
More than a decade ago, Nova Scotia terminated its contract with STARS over discomfort with the fundraising model and a desire to bring the air-ambulance service under the province's umbrella.
Meanwhile, though, Manitoba auditor general Carol Bellringer has spent the last year investigating STARS, an audit triggered when concerns over the way the contract was awarded landed on her desk. Since then, opposition parties have frequently raised questions about why the province leaped into a sole-source, 10-year contract that could cost as much as $100 million, especially when there are two or three other firms in Manitoba that would likely have bid on a helicopter-ambulance contract.
STARS' relentless brand-building -- the tweeting, the press conferences, the events with local celebrities, the high-profile dream home lottery -- has also caused some friction with other first responders who have found themselves overshadowed by the non-profit, and who frequently use the word "cowboys" to describe STARS crews.
STARS staff gently shrug off the criticism, saying building a profile is vital to fundraising campaigns that will ultimately shrink the province's costs. Manitoba Health's Gerry Delorme is more blunt. He says STARS doesn't have a cowboy culture, but even if it did, it's an extremely effective service that saves lives.
"I really don't care what their culture is. I only care about patient outcomes," he said. "If they're improving patient care, I'll hold the horse."