Thank You For Not Flying

[Grumpy 1]

As an Aviation fan and retired firefighter, I was very interested in an article in the July issue of Air & Space Smithsonian magazine. It's called: Thank You For Not Flying. I reccomend it to all fire & rescue personnel, especially the decision makers. I've always thought the people in charge called for the heliocopter too many times too soon. The article seems to show that is true. Consider the author's credentials and forget the part about vollies getting free pizza. I don't think that has to do with our area. I'm sorry I can't give you a link to the story. The mag is online at www.airspacemag.com. I don't think the article is there.

[mfc2257 464]

By BRYAN E. BLEDSOE M.D.

In a small community hospital in rural Indiana, a 63-year-old man is suffering from heart problems. The treating physician determines that the patient’s condition is serious and makes arrangements to move the patient to a larger hospital with more resources and specialists. A medical helicopter is called to make thetransfer. No one questions the increased cost of using the helicopter — or the extra risk inherent in flying.

There is nothing remarkable about this scenario. Every day, patients in communities across the United States are transported by medical helicopter. But the 63-year-old patient on this flight didn’t arrive at the larger hospital; the helicopter transporting him crashed en route. With the others on board too seriously injured to help him, he strangled to death on a restraining strap. The injured crew and pilot were transported by another helicopter to a trauma center. The National Transportation Safety Board (NTSB) ruled the cause of the accident pilot error; before the flight, the altimeter was known to be malfunctioning.

This disaster is one of 35 medical helicopter accidents that occurred in the United States in 2004 and 2005. Since January 2005, nine crashes resulted in 23 fatalities, a rash of medical helicopter mishaps not seen since the 1980s.

It is widely assumed that medical helicopters provide a significant advantage for patients and save lives. However, recent studies have begun to demonstrate that few patients actually benefit from medical helicopter transport, even during most emergencies. Helicopter transport is appropriate for patients who have conditions that require a time-sensitive intervention, such as life-saving surgery or cardiac angioplasty. These conditions are rare.

Medical helicopters were first used for civilian health care in the 1970s. Initial scientific studies in the 1970s and 1980s indicated that patients transported by helicopter had improved outcomes over those transported by ground. Therefore, many hospitals purchased helicopters and began offering helicopter transport. Today, there are nearly 800 medical helicopters in the United States. In metropolitan Phoenix, Arizona, alone there are more medical helicopters than can be found in all of Canada.

One of the reasons for this proliferation is a change in health care regulations. In the late 1990s, the air ambulance industry was successful in pushing federal regulators to increase Medicare payments for air transports. With an improved reimbursement scheme, an opportunity suddenly opened up for commercial operators to enter the arena.

Many helicopter transport companies opted for less expensive, pre-owned, single-engine aircraft — scores of which had already put in decades of work ferrying oil rig workers to platforms in the Gulf of Mexico. Many of the commercial operators also kept salaries fo pilots and medical personnel relatively low in order to field additional aircraft. Medical helicopters became commonplace.

Recently, researchers have again studied the helicopter transport of ill or injured patients and have drawn considerably different conclusions from those of the researchers working two decades earlier. There is increasing evidence that only a fraction of the patients transported by helicopter derive any significant benefit over patients transported on the ground, a change likely due to improved capabilities of land ambulances.

A 2002 Stanford University study evaluated 947 patients delivered consecutively to a California trauma center by medical helicopter and found that only 1.8 percent needed immediate surgery for life-threatening problems. The researchers concluded that only nine of the 947 patients possibly benefited from helicopter transport and that for five patients, helicopter transport was possibly harmful.

Last year, a group of university researchers, including myself, and state officials from Vermont and Wisconsin conducted a study of 37,350 trauma patients transported by helicopter from the accident scene to a hospital. We found that approximately two-thirds of the patients had injuries that, based on validated trauma criteria, are considered minor. (The abstract was published in the journal Prehospital Emergency Care, and the full article will soon be published in the Journal of Trauma.)

More research may be needed to demonstrate the scope of the problem, but questions about the utility of medical helicopters extend to the highest levels of the medical community. “There is simply not enough science [measuring the utility of medical helicopter transport],” says Richard H. Carmona, U.S. surgeon general and former medical director of the Arizona State Police medical helicopter program. “I am concerned that resources, such as medical helicopters, are used appropriately and cost-effectively for the benefit of the patient.” Carmona suggests that air ambulances be incorporated into the emergency medical system and be dispatched using a common communications system and be held to standards that decrease expenses.

Right now, the air ambulances have a lot of influence over when and where they fly. Overworked hospital physicians will gladly authorize helicopter transport — just to get a patient out of the hospital so another patient can fill the bed. Cost is often forgotten or not considered.

Likewise, at accident scenes, helicopters are easy to call for. Helicopter operations often provide volunteer fire departments and ambulance squads with free pizzas, coffee cups, key chains, and even medical equipment, and encourage the rescue workers to call for the helicopter before they arrive at the scene — long before they have a chance to even lay eyes on their patients. This adds to a system already out of control.

Many families are now being left with air ambulance bills ranging from $8,000 to, as in one case in Arizona, $40,000. Patients are being billed because Medicare administrators and private insurance carriers are more carefully scrutinizing compensation for helicopter transport, possibly because the number of flights paid for by Medicare alone was 58 percent higher in 2004 than the number paid for in 2001. Many of the for-profit helicopter operators hire collection agencies to aggressively pursue patients for payments of these unexpected bills.

Besides cost, safety is a consideration. The proliferation of medical helicopters has been accompanied by a marked increase in the number of accidents, prompting the NTSB to issue a safety advisory for medical helicopter operators last January. The bulletin recommended that ambulance operators improve qualifications of dispatchers, enhance preflight risk assessment, use night-vision imaging, and install terrain awareness and warning systems in all medical aircraft. The air medical industry is slowly beginning to initiate measures to enhance safety and clearly wants to dissociate from the idea that operators are the sole source and solution to the problem.

“Air medical providers are taking the NTSB recommendations seriously,” says Edward Eroe, president of the Association of Air Medical Services. “We want to partner with them to improve safety, as we all have to work together to make real improvement.”

But the increase in the number of medical helicopters has also resulted in a marked decrease in the number of qualified pilots, flight nurses, and paramedics available for hire. The rise in demand, accompanied by the retirement of Vietnamera pilots from the medical helicopter ranks, has caused many medical helicopter operators to drop the minimum number of flight hours they require of pilot applicants. Furthermore, because flights equal revenue, some pilots are being pushed to fly in questionable conditions.

The tremendous increase in the medical helicopter accident rate prompted Johns Hopkins School of Public Health researchers to evaluate emergency medical service helicopter crashes from 1983 through April 2005. They found that being a member of a medical flight crew is now among the most dangerous occupations in the United States — six times more dangerous than standard occupations and

twice as dangerous as mining and farming — similar in riskiness to the duties of combat pilots in wartime.

Here in the land of plenty, we have created a system that has taken a useful tool — the medical helicopter — and transformed it into the most dangerous and most expensive transport modality available.

be.

[Grumpy 1]

I'm not gonna hit the quote button, but that's the article. Glad that many of you are on the ball with PC procedures. GEEKS are appreciated! What does the EMT Bravo crowd think about the article?

[ny10570 745]

While it doesn't necissarilly apply to our area it does address the much larger issue of transport abuse. Any one who has done transport can attest to the large number of 'lett jobs and cab rides we end up giving out only to hope they get covered by medicare. As for abuse of stat flight outside of a couple of short trips a year, I don't see much abuse. But maybe I'm missing it.

[jps385 0]

This is a huge problem in our area. How many times do we flya patient when we could drive them to the medical center in the same if not less time? If you look around Westchester county it is a rare location where ground transport time to WMC is greater than 25 minutes. If there is no delayed extrication there is rarely justification for the flight. How long does it take to take a patient to the LZ and transfer care? We often delay definative aptient care so we can play chopper. I have seen many incidents where we are on a highway facing the hospital with transport times of 10 minutes yet we still wait and delay.

This is not ideal patient care by any stretch.

[JBE 328]

This is a huge problem in our area.  How many times do we flya patient when we could drive them to the medical center in the same if not less time?  If you look around Westchester county it is a rare location where ground transport time to WMC is greater than 25 minutes.  If there is no delayed extrication there is rarely justification for the flight.  How long does it take to take a patient to the LZ and transfer care?  We often delay definative aptient care so we can play chopper.  I have seen  many incidents where we are on a highway facing the hospital with transport times of 10 minutes yet we still wait and delay. 

This is not ideal patient care by any stretch.

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I really only have one incident to draw upon but this post pretty much sums up my feelings. We had a wreck out on Nichols Street back in '96. PT was suffering from a concussion, fib/tib fracture and possible skull fracture. The captain on scene yelled and screamed for Stat Flight. We got Stat Flight and patient was transported. Later on, PT was found only to have a concussion, a few busted teeth and broken leg. Injuries that could have been handled at PHC. In the time it took for Stat Flight to get there, we could have had her packaged and being transported to PHC. Upon arrival at PHC, she could have been assessed by a doctor and if there was a need for her to be transported to WCMC, it would have been addressed then.

[WAS967 97]

PT was suffering from a concussion, fib/tib fracture and possible skull fracture.

That right there is justification enough for transport to WMC. Albiet this was in 1996, nowadays we could consider Danbury too. I agree definatly that there are instances of abust when it comes to StatFlight....I can remember a recent one where the helicopter was called to Tarrytown lakes. Think about that one for a minute.

[Guest alsfirefighter]

Ditto on WAS. What you described is multi-trauma. What led you or whomever to believe the patient "had" a concussion, which can't be diagnosed in the field, I'm sure there had to be a LOC and/or AMS or some other reason to believe there was a significant head injury and a "possible" skull fracture is an automatic trip to a trauma center. We don't just send people for the obvious but those injuries and/or conditions where we place the words "possible and potential" in front of. To have the injuries that you are describing had to be caused by a signficant MOI which is also worded in trauma protocol.

I have discussed on here before where there are what I describe as poor transport decisions with the use of a medevac and blatant abuse of the system by a minority. I rarely use Stat Flight where I work. There are times where other factors need to be taken into account. Often with head injuries where airway management is a problem and RSI is needed and the best for the patient is to be able to accomplish that and get them to the definitive care facility where all their needs will be immediately addressed.

What is the truest answer? Training and counseling based on solid QA/QI not by the agencies themselves, but through the medical center, STAT Flight and WREMAC. If you screw up and take them to the wrong facility you will hear it but if you fly them unnecessarily its ho hum. I discuss it often with my co-workers and instances in the surrounding area that I am around of know of. We need to knock off the "monday morning quarterbacking" statements to a level of education. We do it with call audits so lets up the ante's and talk real about what are doing out there because peoples lives depend on it.

[STAT213 332]

This issue is slightly near to my existance, so I will offer a few comments on it.

As for safety, though there have been a large number of crashes recently with medevac helicopters, it is still safer in the back of my helicopter than in the back of my ambulance.

I would so much rather be flown to a real trauma center than be taken to some little hospital any day.

Should you be flown 5 miles in Westchester County. Doubtful, very doubtful. Helicopters have their place. Landing in Millwood to take a conscious patient to WMC isn't one of them.

All that being said, the debate is important and should be continued. Just don't believe everything you read because someone with MD after their name said it.

[khas143 13]

This issue is slightly near to my existance, so I will offer a few comments on it.

As for safety, though there have been a large number of crashes recently with medevac helicopters, it is still safer in the back of my helicopter than in the back of my ambulance. 

I would so much rather be flown to a real trauma center than be taken to some little hospital any day. 

Should you be flown 5 miles in Westchester County.  Doubtful, very doubtful.  Helicopters have their place.  Landing in Millwood to take a conscious patient to WMC isn't one of them.

All that being said, the debate is important and should be continued.  Just don't believe everything you read because someone with MD after their name said it.

←

Common sense should be applied when requesting stat flight or any medevac. Who should be able to call for a medevac should be the question. Should it me the paramedic on scene or the fire chief who has no EMS knowledge. I would like to know whom the decision lies with.

In my job, only a supervisor can call for stat-flight, EMS experience/knowledge or not. First line officers can only put Stat-flight on standby.

There is no centralized standard for this. If Valhalla VAC calls for a medivac will they respond? It would be asinine for STAT flight to respond unless there was a very, very, very extended extrication.

Just wondering what type of policy everybody else has.

[JohnnyOV 2]

I would have to say for a small portion of westchesters departments stat flight is a vital tool that is abused. For my juristiction, as well as departments surounding us, there really is no reason statflight needs to be called unless there is an extensive extrication in progress, WCMC is a straight shot down the TSP...for some reason, our VAC is way to quick to jump the gun on calling statflight...the medics have even called them for a traumatic arrest in progress...go figure.

p.s. im criticizing my own VAC at calls I was at...so dont yell monday morning quarterbacking

Edited July 6, 2006 by EMSJunkie712

[ny10570 745]

There is no centralized standard for this. If Valhalla VAC calls for a medivac will they respond? It would be asinine for STAT flight to respond unless there was a very, very, very extended extrication.

Just wondering what type of policy everybody else has.

←

In the three medivacs out of Mt. Pleasant I am familiar with one was medical and one was a decent extrication that was still completed before the bird was overhead. The third, I believe was also medical. I can't for the life of me imagine any excuse for the bird to be used for in a medical anywhere in westchester.

[Skooter92 7]

ny10570-

A couple of years ago, a patient in the north end of the county was sent home on, I believe, a left ventricular-assist device while awaiting a heart transplant. The device malfunctioned, and the responding medic, while hand-cranking the device, called for Stat Flight. The patient was then flown directly to NYH in Manhattan.

Never say never, my man!