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The deadly crash of a medical air transport plane off Maui last month has focused attention on the adequacy of Hawaii’s health care system on the remote neighbor islands.

The Dec. 15 accident, involving a Hawaii Life Flight air ambulance, killed pilot Brian Treptow, flight nurse Courtney Parry and flight paramedic Gabriel Camacho as they headed from Maui to the Big Island on a night mission to transport a patient to Honolulu, according to .

The crash prompted Gov. Josh Green to issue an the next day allowing the state to use the Army National Guard, Coast Guard and mainland staffing to keep air ambulance service functional in Hawaii in the wake of the crash.

The downed aircraft, a Raytheon twin-engine turboprop, sank into some 6,000 feet of water in Maui Channel about 20 minutes after takeoff from Kahului Airport on Maui, according to a released Thursday from the National Transportation Safety Board. Wreckage was found floating in the ocean near the presumed crash site.

Hawaii Life Flight is the only company that offers medical air transport in the state, said Speedy Bailey, regional director for American Medical Response, a partner firm. Another medical transport company, Air Methods, service in Hawaii in September, according to media reports. It operated as LiveSave KuPono in Hawaii.

In the immediate aftermath of the Dec. 15 accident, Hawaii Life Flight initiated a safety stand-down to give employees time to grieve, care for their mental health and perform maintenance checks on aircraft.

The stand-down meant Hawaii needed an immediate back-up plan to respond to medical emergencies through the islands.

Recognizing the urgency, Gov. Josh Green, an emergency room physician who worked on the Big Island for many years, convened an early morning meeting on Dec. 16 within hours of the crash. The meeting brought together Cabinet members along with the Hawaii National Guard, neighbor island mayors, Hawaii Life Flight and hospital executives.

“This was my life before becoming governor. I was a doctor on rural Big Island and on hundreds of occasions over the last 20 years I have relied on these very services to get my patients to a heart surgeon, a neurosurgeon, an advanced pediatrics team, an OB who dealt with complex deliveries — so I knew implicitly that we could not let any part of the state go uncovered,” Green told Civil Beat in an interview this week.

Green’s emergency proclamation, which ends Friday, enabled the state to supplement Hawaii’s medical airlift capacity with aircraft and flight crews from other states. It also allowed medical staff, licensed out of state, to work in Hawaii as certified flight paramedics and registered nurses on medical transport aircraft.

Teams from the mainland have rotated in and out to help Hawaii Life Flight start returning to normal operations, Bailey said. The timing of the accident, 10 days before Christmas, made it especially challenging to have enough staff in place to operate air missions.

“During the holidays, everyone was working very hard to make sure that people had time with their families,” Bailey said.

For Tristan Fensterman, nurse manager at the emergency department at Kauai Veterans Memorial Hospital, the emergency order unlocked assistance that was literally lifesaving. Soon after the governor signed the proclamation, one of the hospital’s critically ill patients was flown to Honoululu in a Black Hawk helicopter provided by the National Guard.

Hawaii Life Flight’s stand-down was totally necessary, he said, but the ripple effects of having no immediate medical air transport can be significant.

“It’s been a real challenge getting patients off the island,” he said.

“When you press pause, the creek just immediately starts backing up,” said Fensterman, a former flight nurse who knew the crew that perished. “There are days when it’s a little slower than others but medical transfers never stop. This was a really big deal.”

While things are returning to normal, Green said some days have been more challenging than others. There are shortages of medical personnel, lack of specialized care and inadequate hospitals and clinics on Hawaii’s neighbor islands.

“We could wake up one day and start with three fixed-wing planes and two rotors – two helicopters – and a jet that was flown in, and by the end of the day we might not have enough pilots to man them all. We might not have enough people doing maintenance,” the governor said. “It just basically demonstrated all of the challenges there are.”

While patient care was not compromised during the recent emergency, the incident highlighted how sorely dependent Hawaii’s neighbor islands are on medical air transport and that’s not an enviable situation to be in, said Dan Brinkman, a registered nurse who is chief executive of Hilo Medical Center on the Big Island.

“We definitely want to grow some of the services on the neighbor islands because transport is always a tricky situation,” Brinkman said.

He’s hoping that Hawaii lawmakers will approve a $50 million appropriation so the Hilo hospital can expand its intensive care unit by 19 beds and add an additional 36 patient beds. If more space becomes available, there may be less need to send patients to Honolulu, Brinkman said.

Green agrees that Hawaii needs a major health care build-out on the neighbor islands so that the state can wean itself off its dependency on medical air transport.

It’s always going to be a challenge to have highly specialized care available throughout an island state where communities are often sparsely populated and far-flung. But having more doctors, nurses and other trained medical personnel for primary and specialized care is urgently needed, and Green said he’s committed to trying to make that happen.

“We’ll be expanding access to care in the neighbor islands through scholarships, loan forgiveness and recruitment” of medical workers and through other initiatives, he said.

Meanwhile, deepwater search and recovery efforts are pending from the Dec. 15 crash, the NTSB report says. Neither the plane nor the bodies of the missing crew have been recovered.

A review of voice communications from the plane indicates the pilot was flying an east-southeasterly route along Maui’s north shore before turning the plane southbound to follow a predetermined route, according to the report. The pilot was communicating with an air traffic controller and following instructions guiding him toward the Big Island’s Waimea-Kohala Airport.

About 20 minutes into the flight, the pilot said the plane was “off navigation here … we’re gonna.. we’re gonna give it a try,” the report says.

A few seconds later, in a final radio transmission, a voice presumed to be the pilot’s is heard saying, “Hang on.” No further communications followed.

Another pilot flying in the area spotted the air ambulance in a spiral descent until it hit the water.

Civil Beat’s health coverage is supported by , Swayne Family Fund of Hawaii Community Foundation, Cooke Foundation and