What is wrong with this picture?

[Capman]

Hunter', let me re-iterate that the confusion was my fault. I realized that when when the responses pertaining to med control came in.

Rid', sorry for the confusion.

Carry on.

[Doczilla]

Looking at this case, I see a few issues:

1) The crew with the responsibility for transporting the child felt uncomfortable with taking him. That said, it's their call whether to involve another level of care, in this case, flight service.

2) The transporting crew, who had ultimate responsibility for the patient, acquiesced to the demands of the first responders.

3) The flight service turned out to be unnecessary.

There are a few articles recently in Annals of EM on the dangerous nature of helicopter EMS, and how the death rate per 100,000 man-missions has tripled in the last decade, while number of sorties has expanded greatly. This should serve to reinforce the fact that calling for a helicopter is not a benign thing, and carries a real risk to the patient as well as the 3-4 man crew of the bird.

Here, approximately 80% of patients flown to the children's hospital by the helicopter are discharged home from the ED. This is telling us that we are GREATLY over-triaging pediatric patients, allowing the sphincter-factor and our own perceived shortcomings in pediatric care to influence our transport decisions. The helicopter service is not about to dispel these myths: the flight service had $12M in operating costs last year, and generated $42M in revenues for the hospital. Flight services are a money-maker for the hospitals that run them for a number of reasons: 1) it's easy to bill for and recuperate the costs of operations, 2) it extends the reach of the hospital into areas that would be served by other, closer hospitals, giving them access to insured populations away from their city center, and 3) it's a great PR thing to show the community how high-tech and cutting-edge the hospital is. So they are more than happy to reinforce the feelings among ground services that they have procedures (RSI), training (can't argue), and speed that ground services don't have.

It's up to the crews to make these decisions, and it's not an easy call to make. Really, once you factor in the time to spin up the bird, prep the landing zone, fly out, land, load the patient (with all the straps and securing systems and blankets and monitors and all that stuff that helicopters use), fly back, unload the patient, take the elevator down to the ED, how much time is really saved over loading the patient into the ambulance and driving there? Further, the golden hour is ONLY proven to be of benefit in patients who go immediately to the OR, which comprises a scant minority of patients in this day and age of advanced imaging. Is the 10 minutes of saved transport time really of benefit to the patient, in light of the CONSIDERABLE cost and additional risk? Just because a patient is very sick, even critically ill, doesn't mean they need a $3000 ride in a helicopter. Add to this the fact that many patients are paralyzed and intubated SOLELY because they are going on a helicopter (for monitoring and patient control) when they could be safely managed without this in a ground unit. Now we are exposing patients to greater medical risk by "preparing" them for transport. And is calling for a helicopter simply an attempt to relieve the anxiety ground crews feel when caring for truly ill patients?

We have to re-examine our overuse of helicopter based EMS. The hospitals, for the reasons above, certainly aren't going to do it. The public, despite a rising death toll, isn't questioning it, even as we have more helicopter services and more accidents per mission.

'zilla

[island emt]

Quote : We have to re-examine our overuse of helicopter based EMS. The hospitals, for the reasons above, certainly aren't going to do it. The public, despite a rising death toll, isn't questioning it, even as we have more helicopter services and more accidents per mission. "

'zilla

A standing round of applause for you Doczilla.!!! This is something that i have seen in recent years with the proliferation of air -evac services.

There is a time & place where rotary wing evac is the appropriate method of transport. however they are being overused for the everyday non life threatening type of calls that make it hard to justify. Has anyone done a study on what percentage of patients flown from scene to a trauma center are discharged within 24 hours? Granted there are times such as TBI or multi-systemic trauma in which the patient won't survive the hour plus ground transport times we have to a level 2 trauma center, where the helicopter is warranted , burn patients that need to go out of state are another reason to call for the helicopter. Just because you have a serious PI motor vehicle crash does not , especially if your ground tx times are under 15 minutes.

Now back to your previously scheduled debate /slam of fire department medics.

[DwayneEMTP]

Wow Doc, thanks for taking the time to present both (more?) sides of the issue...pretty dang cool.

This kind of information is what makes posts from the 'the counsel of elders' such a gift.

Dwayne

[Ridryder 911]

Doc points out good points similar to Dr. Bledsoe.. and even as a blue blood Flight Nurse/Paramedic I agree most of the time is for the "system" not the patients sake.

The scenarios does describe a long distance, as well as a severe or critical patient. Over triaging as Doczilla describes occurs in a lot of referral to Level I's by ground and even by local ER's. As one who used to set up and develop Level I's, over triaging is a common occurrence.

When I read most trauma scenarios I usually read .. transport rapidly, to a Level I Trauma Center"... when most of the patients could had been stabilized at a Level II. With that in mind, one has to weigh the dangers of attempting to stabilize and then make arrangements to a Level I trauma center. Delay in stabilization for transport versus direct transport by ground or air...

Good, rapid and thorough assessment as well as local Regional Trauma Plans of diversion and Trauma Policy is a must or least develop of them.

R/r 911

[bbledsoe]

This is a very timely discussion. This whole air medical thing is a house of cards that is about to fall. Several things are occurring.

1. The accident rate (although better this year) has gotten the attention of the NTSB and FAA. Tougher regulations (135 at all times, NVG, IFR and maybe dual pilots) is probably on the horizon.

2. The costs of HEMS was not on the radar screens of most insurance companies. Now, with the increased usage the insurance companies and Medicare are looking more carefully at HEMS utilization. Payments will stop and many have already been curtailed.

3. The General Accounting Office (GAO) was charged with investigating the HEMS phenomenon by Congress. The results should be out early this year and they will not be pretty.

4. The media in several major markets have keyed in on unscrupulous practices such as selling "subscriptions", paying local EMS agencies and fire departments $500.00 "Landing Zone Fees", and gifts and such. There was a recent story in the St. Louis media and I know of another big media outlets working on a story. One service tells subscribers to call them (HEMS) first and they will call local EMS.

Who is to blame?

1. First, us doctors. We set the criteria and sign the memoranda of transport. Perhaps doctors who authorize or sign for flights that are medically unnecessary should be billed when the private insurance fails to pay.

2. The industry. In our great capitalistic society there was an opening when Medicare changed reimbursement rates and criteria for HEMS in 2001. Operators saw this and we went from 300 helicopters to 1000. If this were not the case, why are there 19-20 helicopters in affluent areas (Dallas, Phoenix, Nashville) and few in impoverished areas (Detroit)?

3. EMS. There is nothing more exciting for many EMS providers than stopping traffic on the interstate, calling in the "birds", and shipping patients out under dubious conditions. The smell of the Jet A, the flashing lights, the noise--orgasmic. We rationalize this with such ridiculous arguments as "we sent them by air to keep the ground ambulance free." That is like saying, "We went ahead and removed the gall bladder just in case he gets gall stones later in life."

4. The payers. rest assured they are now aware and reacting.

Somewhere along the way we forgot the patient. We are placing patient's at risk when they do not stand to benefit from helicopter transport. We are placing flight crews at risk by asking them to transport non-serious cases. We should be ashamed.

HEMS, just like an endotracheal tube and a defibrillator, is another modality that can benefit a very finite number of patients. Can it make a difference? Maybe? Does the literature support HEMS overall? No. EVERY DOLLAR SPENT ON HEMS IS A DOLLAR TAKEN AWAY FROM GROUND EMS. The money spent on a single flight will buy 4-6 AEDs or send two EMTs to paramedic school.

Doczilla' is right. A large majority of patients transported by air go home from the ED (in our Jounal of Trauma article the number was 25%). In PEDS it is much higher. I would be pissed if my 6-year-old grandson was placed in a helicopter when he could just as safely and more comfortably gone by ground at 10% of the cost.

This one struck a nerve.....sorry for the tirade and my compliments to Doczilla and the others (AZCEP) who have the ability to see this for what it is.

Bryan

[bbledsoe]

I just made my first post after many suggested I read this list (which I quite enjoyed). I did not realize I was supposed to use a pseudonym and don't have a clue what an avitar is. Pardon me if I violated the rules. I guess I used my real name because I can't use the pseudonyms my wife calls me.

[DwayneEMTP]

Hell, pretty dang cool you used your name! You're legend here!!

Welcome, and thanks for adding to the City!

Dwayne

[Michael]

You're legend here!!

Welcome

Truly, Doc. And if in future posts you would be kind enough to spell out some of the more unusual abbreviations, it would help your students here. Thanks.

[Dustdevil]

I just made my first post after many suggested I read this list (which I quite enjoyed). I did not realize I was supposed to use a pseudonym and don't have a clue what an avitar is. Pardon me if I violated the rules. I guess I used my real name because I can't use the pseudonyms my wife calls me.

Hey, glad you finally took the leap, Bryan! I told you this place rocked! And now it rocks even more! It is the only EMS board I have found that actually goes beyond the normal "rah-rah" cheerleading to hold intelligent and no-holds-barred discussions of relevant -- and sometimes controversial -- issues, while still fostering a supportive community atmosphere.

No worries on the screen name. This is a pretty tight group here for the most part. A good many of us know who each other really are, behind the pseudonyms. And a few of us would have known it was you just by the content of your post anyhow!

HEMS, like most of your pet issues, is commonly a hot topic of discussion here. Many of us fancy ourselves to be your mythbusting deputies, so your moral support is greatly appreciated.