Over use of Medivac

[ny10570 745]

Maryland has long been a leader in Trauma care with the most extensive Medivac system I'm aware of. Here's an article out of Jems.

http://www.jems.com/news_and_articles/news...vac_system.html

BALTIMORE -- Almost half of the patients flown by helicopter to Maryland trauma centers are released within 24 hours, making some lawmakers wonder whether the state's vaunted Medevac system is overused.

[RescueKujo 130]

I know here in San Diego County there's a problem with people in the suburbs wanting to use the helos way too much. All the trauma centers are within 20 minutes drive within the metro area (5 throughout the county with Children's SD the exception). In our contract cities, I hear fire captains putting the helos on standby before they're even onscene. 9 times out of 10 the helos is taken off standby, not even used. I agree there's areas of the county where the helos need to be used.

As for the stat of almost 50% being released within 24 hours, I haven't seen a MRI or CT Scanner small enough to fit into either an ambulance or helo. Until the day EMS gets those bitchin Star Trek hand held scanners that Dr McCoy and others used, it is mechanism+signs and symptoms= mode of transportation in my book.

As a news anchor used to say in San Diego, "That's my opinion, what's yours?"

[NWFDMedic 58]

Well, until we can see inside a patient, it is very hard to determine whether a patient needs a trauma center or a local hospital. Although the latest studies out there tells us that mechanism is a relatively poor indicator (in motor vehicle crashes), we still have a trauma protocol that's based largely on mechanism. It's easy to tell the patient who might need a trauma center; it's not so easy to tell the patient who might not.

I wonder how many of those 50% of patients released in 24 hours were under the influence of drugs or alcohol. For my money, if I have a patient in a significant crash who is altered, they are going to a trauma center whether they smell like a brewery of they have a needle sticking out of their arm.

I suppose a lot of the released patients also come from areas not accessible to a trauma center who may have a local hospital with limited ability. I am lucky enough to work my full-time shifts in an area where I'm always within 30 minutes of either a level 1 or level 2 trauma center. Assuming the patient is not an extensive extrication, I'm going by ground unless they are either a specialty case (burns, pediatric) that would require a specific facility or if I'm near the level 2 and not the level 1 if they are severe enough to need airway control. However, there are areas in my relatively suburban region that don't have access to trauma centers or even an aggressive local hospital.

[RWC130 594]

GREAT TOPIC!

In this area I remember when AeroMed first came around, then STAT Flight and now LifeNet.

You also have the New York State Police "LifeGuard" and bordering NJ and CT Medivacs.

Medivac requests continue to grow not only for "scene calls" but also for

critical patient transports from hospital to hospital.

Are they needed? Absolutely!

Let's not forget not that long ago you didn't have Choppers available to you, (none in this area)

in fact you were lucky if you had Advanced Life Support.

Remember "Load and Go" ?

Do I think Medivac is over used? NO

NWFDMedic you make an EXCELLENT point!

Well, until we can see inside a patient, it is very hard to determine whether a

patient needs a trauma center or a local hospital.

Personally, I would rather send a patient up in the chopper to a trauma center to find out they were not

as bad as I thought then transport by ground to a local hospital to find out the patient is critical and the local hospital

cannot handle the patient delaying life saving measures.

Obviously every patient does not need a trauma center or a chopper, you have to be comfortable

with your patient accessment skills, that takes time and experience.

Is anyone ever wrong for calling the chopper? I would have to say probably not, but that is

my own opinion. (broken toe does not apply here!) lol

We are fortunate in this area to have Trauma Centers close by such as Westchester Medical

and Jacobi. Not everyone is, in some areas you might have a local hospital ride by Ambulance

45+ minutes and a Trauma Center up to 2 hours if not more?

I would not abuse Medivac but if you feel it's needed

go ahead and CALL THEM!

Just keep in mind sometimes depending on where you are

it might actually faster to TX the patient by Ambulance.

[ckroll 101]

To use a helicopter or not is a different decision than whether or not to go to a trauma center. If one reads the guidelines for using helicopters, most of Westchester and Putnam should be using ground transport to the medical center. My experience has been that landing, evaluating and loading a patient is more or less equivalent to driving it.

Several years ago Putnam Valley responded to gunshot wounds. As fate would have it, I was due at Valhalla to have bloods drawn for a Lyme research study for which I am a guinea pig, so I could not go on the call. 10 minutes after the call was dispatched, I headed down the Taconic at highway speed, listening to the call back home. It was beautifully run with no down time. As I was parking my car at Munger pavillion, I stopped to watch the helicopter land at the WMC ER.

If one does not get caught up in the pageantry of the moment, the firetrucks, the lights, the thrum of the rotors, the cloud of dust, awed motorists picking sand out of their teeth.... Once a patient is loaded into an ambulance, if rolling to the med center takes 30 minutes or less, and getting to a landing zone, transferring the patient and getting the bird lifted off takes 20 minutes...and it almost always does... and flight time is 10 minutes, then transport is a wash and the helicopter is expensive and not without danger.

For me to use a helicopter, there has to be an airway issue or need for extended transport, say to Jacobi for a venomous snakebite. An argument can also be made that better prep for surgery can be accomplished by a good medic and crew during ground transport to a trauma center. If it's an MCI and it's a resource issue, then the helicopter may be valuable for resources, not necessarily speed of transport.

That said, every situation is different and if EMS thinks it's the right thing to do, it is easier to explain why you used it than why you didn't.

[Guest alsfirefighter]

Good topic and excellent points NWFD and RWC but I can't say that I agree with all of them.

The abuse...ok let's not call it abuse...lets use a feel good word, like..the "misuse" of air resources in Westchester alone is something that is often discussed and is sometimes extremely obvious when you look at the locations where they are called from. No I cannot see inside my patient, but I can make a common sense decision on what actually is the better transport decision based on location and we can say the protocol is mechanism based but I always make my decisions based on mechanism along with obvious or high suspicion of serious injury. Being a provider on the fringes of where using a medevac saves time or not, I would say that if you were go over my actual trauma's and even perceived trauma's where the patient needs a good trauma evaluation, not immediate treatment over the past 10 years, I bet I've used a medevac about 1% of the time if even that. Then again I know of some providers who are a stones throw away from the med center and have rates above 95%, one instance where they were right on the highway leading to the place and flew a person out, while another medic at an incident farther north had a signficant head trauma that the patient could have benefited from RSI and the speed of the flight didn't have that option because of the latter. I'm not one that is easily swayed by others on scene when they consistantly ask "do you want the bird?" 6,000 times, but I've seen providers with a wave of the hand say "yeah, just fly em'." When it was obvious that the need for a medevac wasn't needed. Do I think the medevac is over used....yes in some regards it seriously is. Kujo said it well...mechanism + findings= transport decisions. Not just "car 1 on scene....launch stat flight." Or as I've stated ground is faster but for some reason they still get a short flight and large bill.

I know I've said it before, but things do evolve, protocols change and if I really wanted to sit and follow directions from a book, I would have gone to the culinary institute and been a chef. Even chef's add a little something. I'm a medical provider that "practices" within the medical field. I do what is best for my patient in conjunction with training, experience and the guideance of medical control if needed. Use your head and your senses and you will make good decisions. I don't doubt for a minute that withing that 50% there are a large majority of patients many of us on here would not fly out.

Is anyone ever wrong for calling the chopper? I would have to say probably not, but that is

my own opinion. (broken toe does not apply here!) lol

Yes, they are and if there is a good QA/QI program in place, such decisions can be made. Read the above experience.

Personally, I would rather send a patient up in the chopper to a trauma center to find out they were not

as bad as I thought then transport by ground to a local hospital to find out the patient is critical and the local hospital

cannot handle the patient delaying life saving measures.

The key to this statement is "as bad as I thought," which means you took the time to assess the patient, which I have seen far to many providers just call based on how the vehicle looked and non-ems trained fire and law enforcement personnel as well. I agree with you whole heartedly on that statement, however, the other point here is, the best option may not be to fly them out, ground transport is often the answer based on time and to the CORRECT FACILITY!

In many of these threads I see a few posts with a consistant theme that makes out as if some sort of miracles occur in a medevac that doesn't happen anywhere else. Good outcomes of medevac transport translates from good ground care whether that be by the ALS provider on scene or the flight crew before the patient gets loaded. Why do you think there are times that the flight crew takes so long if they get in the back of the ambulance? Because there is very little room in the bird and they have to get as much done as possible before getting in there.

I always love how they will look into how the system may be overused but don't necessarily look into some of the other causes which could be a training issue. Make sure providers know the protocol for medevac request, how to do good solid assessments and how to recognize injuries/illnesses and how they present. Training, training, training.

[ny10570 745]

There is also a concern about how many of the 50% admitted over 24 hrs actually benefited from the flight. An uncomplicated femur fx will get you admitted to the ER but you may not necessarily need the flight. Allegedly this investigation has spawned a retro analytical study to look the documented finding by providers on scene vs actual injuries treated in the hospital. Apparently they're taking a detailed look to see if the problem is in assessment or procedure. I have one friend in the system down there but he's pretty low, maybe some here knows more.

[Guest alsfirefighter]

That's it??!!!??? A good topic like that and that is all that is being discussed? Come on people....no matter if your thoughts have been covered by someone else...chime in.

For those of you helo happy people..chime in...sway my thought. LOL.

[helicopper 1,050]

There is also a concern about how many of the 50% admitted over 24 hrs actually benefited from the flight. An uncomplicated femur fx will get you admitted to the ER but you may not necessarily need the flight. Allegedly this investigation has spawned a retro analytical study to look the documented finding by providers on scene vs actual injuries treated in the hospital. Apparently they're taking a detailed look to see if the problem is in assessment or procedure. I have one friend in the system down there but he's pretty low, maybe some here knows more.

As I've stated in many threads prior to this one, I am a strong advocate for the appropriate use of helicopters for transportation. Note the qualifier though. I don't think if you're within a ten minute drive to the medical center (or any other designated trauma center) there is any medical benefit to air transport and for the majority of cases within a 30 minute drive to a trauma center the benefit is only marginal at best.

I think that the art of medevac decision making has been lost and replaced by factors not related to the patient. If you look at the military origin of medevacs, the premise was getting a surgical candidate to a surgical setting as fast as possible. We've bastardized that to take a "trauma patient" to a "trauma center". In my opinion, we should get back to the basics and focus on patients in need of surgical intervention and not isolated extremity trauma or transport decisions made solely on mechanism.

It would be great to see an analysis of medevac transports in our region to see if there is an issue or simply unfounded speculation. Until that time, I won't be convinced that we're doing the right thing. How many medevac transports result in a surgical admission to the hospital? How many result in a general admission to the hospital for more than 24 hours? How many are treated and released from the ER? Without answers to these and many other questions, it's hard to say what's appropriate or not and I'm not aware of anyone asking these questions to figure it out.

Employees of medevac providers even say that they will use a ground unit for some interfacility transports because the total time will be less than air transport would take.

All this said, I think there are many cases in more isolated parts of this region where the use of a medevac is indicated and entirely appropriate.

[crcocr1 8]

I agree with Chris192 and previous posts. If a patient has no critical physical findings, is hemodynamically stable, and not a high-risk patient (such as a child), s/he should travel by ground to a trauma center. It is safer and more prudent, especially when it takes time to land a Medevac. In a way, by calling a Medevac when it is not absolutely medically necessary, we are abdicating our roles as medical providers to provide competent medical care. I think this comment is more appropriate for BLS providers who "feel more comfortable" when an ALS provider rides-along during a BLS transport, but equally is appropriate here.

[Guest TCA-ALS25]

Greetings all from beautiful Philadelphia PA (Home of the NL East Champions - the Phillies)

OK,..don't kill me!

Anyway, in PA, the new ALS protocols that will roll out in November address the overuse of helicopters as well.

The new rule in PA is: if you can ground pound it in 30 mins or less, do it! and MOI isn't a criteria anymore. Here in Chester County, two Level 1 trauma centers are, in good weather, 20 minutes or less away, yet we call in a helicopter for just about everything. Local community hospital ERs must now start accepting more of the bumps-and-bruises MVA patients as well to stop the over-abuse.

Now, conversely, they want us to use helicopters MORE in cases of STEMIs and CVAs under the 2-hour limit to get them to interventional hospitals.

Go figure.

[SRS131EMTFF 471]

http://www.cnn.com/2008/TECH/science/09/30...pers/index.html

[JM15 386]

Maryland Medevac Pilot Was Told Crew Didn't Want to Drive

Robert Little, robert.little@baltsun.com

The Baltimore Sun

The emergency operator who dispatched a medevac helicopter to Waldorf on a mission that ended in a fatal crash told the pilot that ambulance crews called for the aircraft because they "never want to drive to the hospital."

That, along with the revelation that the case was initially assigned an even lower medical priority than first reported, raises new questions about whether the flight was necessary - and whether Maryland and other states generally are using medical helicopters excessively. A report earlier this year found that nearly half the patients flown to hospitals in Maryland are discharged in less than a day, and the September crash was one of 26 fatal crashes of medical helicopters nationwide over the past six years.

On tapes of the conversations between dispatchers and emergency workers on the night of Sept. 28, a 911 operator in Waldorf describes the patients involved in an auto accident as being "Category D," meaning that neither the patients nor their vehicle met the criteria for helicopter transport. Instead, both were being flown based on the judgment of emergency workers at the scene, though state officials say paramedics later assigned the patients a more urgent assessment.

The question of when helicopters are appropriate has gained increasing attention in the medical community, as the number of fatal medevac crashes surged. A review by The Baltimore Sun of crash records and other documents related to the 26 most recent fatal accidents in the United States found that at least eight involved patients who waited longer for a helicopter than a ground ambulance might have needed to drive them to a hospital. At least six involved patients discharged soon after a helicopter dropped them off at a hospital, or who survived a lengthy ambulance ride after the helicopter sent to get them went down.

http://www.emsresponder.com/article/articl...p;siteSection=1

Edited December 7, 2008 by Chris192
Compliance with copyright policy

[JetPhoto 626]

As an avid scanner listener I have heard several calls for a medevac to go on stand by just because of the type of call. I also have heard several calls that by the discription of the accident should have had a medevac. I can't remeber any victim that I was taking care requested a bird for that didn't end up in Westchester.

I loved an incident today in Orange County where 911 went back and forth between between "put the medevac on stand-by" then "Launch it" L/Z gets set up "EMS said no medevac was needed" the fire chief says xyz EMS tech says yes to one person but another EMS tech said no. The victim was transported by ground.

Was the medevac really needed? or is it really incompitance?

[NJMedic 96]

Greetings from the Garden State.....

Evidence and research has shown that the concept of the Golden Hour has no medical signifiance. Evidence and research has also shown the MOI alone should not be sole decision maker in determinimg if a patient needs to go by helicopter or to a trauma center.

Here in NJ the decision to call or cancel a helicopter rests with the highest medical authority on the scene. Remember we are treating the patient, not the car. I don't care how bad the car looks, I've seen patients walk away with no injuries from totaled cars and fatal injuries on cars that could be repaired in a week at a local body shop. I've seen fire chiefs and BLS personnel give me grief for cancelling helicopters because it was not medically needed. I'll be damned if 4 people are going to risk their lives transporting a patient in their helicopter when the need wasn't there.

I've been to jobs were "someone" called for a helicopter when they could actually see the Level 1 trauma center from where the were. I've seen agencies call from medevac when the call came in too close to quitting time.

I don't get excited about called a helicopter. Our policy is that medevac will only be used if ground transport will take longer then 30 minutes. On countless occasions I have seen patients arrive at our trauma center by ambulance before another patient from the same accident was transported by helicopter.

From my location in New Brunswick I have 19 helicopters within a 30 minute flight time. At least in NJ one single agency determines if any helicopter can fly. There is no shopping for a medevac program that will take a flight when the weather minimums would ground any other program.

The concept of flying patients "just to be safe" is killing pilots and flight crews every year. Too many times I've seen patients discharged from the ED after being flown in by helicopter. The NTSB this week issued its annual list of "Most Wanted Safety Improvements," and topping the list for aviation: Emergency Medical Services (EMS) Flights, making the list for the first time. In the last 11 months, there have been nine EMS accidents, resulting in 35 fatalities. The economic losses from these crashes are around $100 million, assuming a statistical value of $3 million for each life lost, some $500,000 for each injury, and about $5 million for replacing each helicopter. If anything, the costs are on the low side and could be substantially higher.

The costs are certainly greater than any safety improvements, and the toll over the last 12 months is the worst in the history of such operations.

If scheduled airliners were crashing at this rate, more than one per month, there would be an enormous and anguished public outcry about the crisis in air safety.

In 2006 the NTSB issued a Special Investigation Report in which 55 emergency medical service (EMS) accidents were reviewed for common causations. As a result of the NTSB’s review, four recommendations were issued to the FAA. Among these recommendation was that flight programs conduct flight risk evaluations to determine if the EMS flight is worth the risk. I doubt the lack of assessment skills or that MOI is going to pass muster when the risk benefit ratio is determined.

[helicopper 1,050]

Great discussions... let's keep it going!

Here's an update from the Maryland incident...

http://wjz.com/local/medevac.lawmakers.system.2.878187.html

Excerpt:

After the September crash, state officials issued new protocols requiring consultations between first responders and a physician in all Medevac requests for trauma patients who don't have obviously serious injuries.

That's part of the reason for the decline in helicopter flights, Bass said. Field response officials are thinking more carefully about the need to fly patients, he added.

A panel of national experts who examined Maryland's emergency helicopter system concluded that more patients are flown in helicopters to trauma centers in the state than in comparable states or regions with Medevac programs.

More on HEMS safety...

http://ihst.org/images/stories/documents/f...entoct08web.pdf