Use of Medevac Decision - Patient Wishes

[helicopper 1,050]

Hypothetical Situation: You encounter a patient who is conscious and a candidate for transport to a trauma center. You request a medevac but the patient states that he/she does not want to go in a helicopter (for whatever reason, fear of flying/heights, claustrophobia, recent medevac accidents, etc.). In fact, they become more agitated at the prospect.

What would you do?

[PC_420 28]

Definitly IMO ground transport to Westchester Medical Center or nearest trauma center. The more agitated my patient gets, the more aggravated the injury can get. Plus, the helicopter crew, in a small, tight place, probably would not want to deal with such a patient due to the constraints on movement.

Edited October 16, 2008 by PC_420

[x129K 1,393]

I can guarentee you that if I am conscious - I AIN'T going in a helicopter.....

[x635 4,066]

I can guarentee you that if I am conscious - I AIN'T going in a helicopter.....

Same here....

I've actually encountered this situation. The patient was advised that they could be sedated for flight, and they agreed.

However, if the patient refuses, have the patient sign a refusal (for that mode of transport), transport via ground, and document.

[xfirefighter484x 234]

My thoughts would be to contact medical control and consult with them. If the pt REALLY qualifies for a medevac, defer the decision to med control. Granted pt wishes come into play, it also comes down to what is in the pt's best interests medically.

[JM15 386]

You can't force someone to do what they don't want. If they don't want the chopper have them sign something, and explain why you think that it is necessary.

[x129K 1,393]

Chances are - if they are in such condition that they could benefit from air transport - having then SIGN something will be impossible.

Documentation is very important on your end.

[smwells 7]

If the Patient is alert and oriented, explain the reason to expiditing transport via medevac.

Still declines - advise medical control, and document. Dont further delay transport, get on the road.

[tdc202 0]

Go with Pt wishes and talk to med control? Then document everything that happened and what was said and if possible have pt sign pcr

[Guest]

Can you give a hypothetical where a patient could have a serious trauma warranting use of a helicopter and the patient being A/Ox3?

Also, if the helicopter hasn't already been called, waiting until on scene and the patient is already assessed and potentially ready to be transported by ground seems like wasting time. How long would it take to get the helicopter to the scene, landed, loaded, and what have you? I think it would be faster just to load and go, instead of debating the issue and waiting for the helicopter to show up... but, I'm probably biased in my view, since I've only ever worked in cities.

[helicopper 1,050]

Can you give a hypothetical where a patient could have a serious trauma warranting use of a helicopter and the patient being A/Ox3?

Also, if the helicopter hasn't already been called, waiting until on scene and the patient is already assessed and potentially ready to be transported by ground seems like wasting time. How long would it take to get the helicopter to the scene, landed, loaded, and what have you? I think it would be faster just to load and go, instead of debating the issue and waiting for the helicopter to show up... but, I'm probably biased in my view, since I've only ever worked in cities.

I can think of a number of situations where a patient may be conscious and a candidate for a trauma center. I've seen many patients from car accidents, penetrating trauma, falls, crush injuries, assaults, etc. where level of consciousness isn't the issue but candidacy for surgery is.

It doesn't matter whether the helicopter is requested, responding, or on-scene for this situation. If the patient doesn't want to go in a helicopter what do you do? That's all. No need to complicate this with more "what-if's" or "if this then that".

If Medical Control says transport by air but the patient still refuses what are you going to do? (Granted I think that medical control will probably defer to the patient's wishes)

And I fully agree that documentation is critical!

[NWFDMedic 58]

It certainly is a touchy situation and I've had it happen. Any flight medics here, let it be known that I have a DNM order in place, similar to my DNR. Seriously though, I had a patient that we called for a medevac for, we were well over a half hour from a trauma center, and she needed to be in a trauma center. The extent of her injuries was such that the flight medic told me that her ability to make an informed decision was compromised secondary to probable hypoxia, etc. That patient was taken pretty much against her will to the trauma center and (by the way) almost immediately to surgery.

If you want to consider someone who meets trauma criteria who may be c/a/ox3, I would say a motorcycle accident patient with some road rash and bilateral femur fractures from an up and over collision. Now granted, we don't know if there are more injuries, but if those ended up being the extent of his injuries, he could very well be alert and oriented. He is also someone who will not be treated in a local hospital, most wont even treat simple femur fractures these days. While he may be stable for ground transport to a local trauma center, I wouldn't want to be the one debating an hour transport from upper Sullivan County versus a medevac.

[Oswegowind 17]

No need to upset them more, however if there is a solution such as drugging them (for lack of a better thought) and they agree, then that is acceptable. Making someone more uncomfortable can hurt them more than help them. Remember, we try to calm down psychs, not get them more agitated. Comfort is a part of your job!

[Guest alsfirefighter]

I think we all know my answer to that question...lol...at least you should Chris..you helped train me!

Also as Chris stated just because they are A and O x 3 doesn't mean they don't fit the criteria for transport to a trauma center and air evac. I've had plenty of GSW's, stabbing victims, unarmed assaults with obvious abdominal trauma with significant hypotension, bilateral femur fractures, a leg amputation, an eye impalement...do I need to go on? But then again with the exception of when I worked up north part time, which I had a level 2 at my disposal I generally do not fly based on my location in regard to the level 1 and skill level comfort.

[RescueKujo 130]

Chris-Exellent thread and scenerio. There are some well thought answers and good explanations of those thoughts. Good job everyone!

[ckroll 101]

"If you want to consider someone who meets trauma criteria who may be c/a/ox3, I would say a motorcycle accident patient with some road rash and bilateral femur fractures from an up and over collision. Now granted, we don't know if there are more injuries, but if those ended up being the extent of his injuries, he could very well be alert and oriented. He is also someone who will not be treated in a local hospital, most wont even treat simple femur fractures these days. While he may be stable for ground transport to a local trauma center, I wouldn't want to be the one debating an hour transport from upper Sullivan County versus a medevac."

Fascinating, but I can hardly believe we are having this discussion.

First, if a patient says no to anything, then the answer is NO. It ends there. The next consideration is not documentation of the refusal, but getting the patient to the nearest appropriate facility. Calling medical control, arguing, documentation all take time and if time is critical, get moving by ground, call for an air intercept if the patient deteriorates to the point where they can no longer make an informed decision.

Second, the assumption seems to be that the need for surgery has a helicopter ride as a prerequisite. It does not. In large part, air transport takes as long as ground transport and it is harder to monitor and work on a patient enroute. Unless there is a need for RSI, the air transport has limited value added.

Third, if a frightened patient is being sedated solely for the purpose of putting them in a helicopter, that is so far beyond protocols as to approach criminality. Like air transport, sedation is high risk and should be used ONLY when needed and for its intended purpose.

Fourth, NYS BLS protocols spell out transport decisions for us.

2. If mechanism of injury and/or physical findings do indicate major trauma:

a. Transport the patient to the nearest designated Regional or Area Trauma

Center if the total time elapsed between the estimated time of injury and

the estimated time of arrival at the Trauma Center is less than one hour

(see Appendices for a list of the New York State Designated Trauma

Centers); or

b. Transport the patient to the nearest hospital emergency department if:

(1) The patient is in cardiac arrest; or

(2) The patient has an unmanageable airway; or

(3) An on-line medical control physician so directs.

(4) If total time elapsed between estimated time of injury and

estimated time of arrival to the trauma center is more than one hour

or if transport time from the scene to the trauma center is more

than 30 minutes , contact medical control.

If faced with this situation, I would think hard about whether or not air transport was the best decision in the first place. [ And in Putnam/Westchester it is hard to justify air transport]. If air transport is indicated, I would make a concerted effort on the way to a landing zone to convince the patient. If the patient refuses, keep rolling to a hospital, stabilize patient and then and only then start making calls to MC about options.

[helicopper 1,050]

Fascinating, but I can hardly believe we are having this discussion.

First, if a patient says no to anything, then the answer is NO. It ends there. The next consideration is not documentation of the refusal, but getting the patient to the nearest appropriate facility. Calling medical control, arguing, documentation all take time and if time is critical, get moving by ground, call for an air intercept if the patient deteriorates to the point where they can no longer make an informed decision.

Second, the assumption seems to be that the need for surgery has a helicopter ride as a prerequisite. It does not. In large part, air transport takes as long as ground transport and it is harder to monitor and work on a patient enroute. Unless there is a need for RSI, the air transport has limited value added.

Third, if a frightened patient is being sedated solely for the purpose of putting them in a helicopter, that is so far beyond protocols as to approach criminality. Like air transport, sedation is high risk and should be used ONLY when needed and for its intended purpose.

If faced with this situation, I would think hard about whether or not air transport was the best decision in the first place. [ And in Putnam/Westchester it is hard to justify air transport]. If air transport is indicated, I would make a concerted effort on the way to a landing zone to convince the patient. If the patient refuses, keep rolling to a hospital, stabilize patient and then and only then start making calls to MC about options.

I happen to agree with your first point - the patient has the right to refuse. I'm just curious, if the patient is alert and oriented and doesn't want to go to the hospital what difference does calling medical control make? Sure, "call medical control" is a nice, safe answer to most questions but in this case what does it get you?

On your second point, there is definitely a large number of people who think that a trauma patient is best served by a helicopter ride. I happen to disagree. Where appropriate the helicopter is a great resource but in my opinion it is often used inappropriately. This places the patient, flight crew, and others on the ground at risk unnecessarily!

Sedating trauma patients in the field in order to force them onto a helicopter does seem extreme and I question the thought process. If you need to sedate to intubate or perform other treatments that's one thing but to do so just to get them onto the "air ambulance" is ridiculous.

The recent spate of medevac crashes spurred me to post this question so we can discuss it and perhaps have a little more perspective when calling for a medevac. It is a dangerous venture and should not be taken lightly.

[ckroll 101]

I happen to agree with your first point - the patient has the right to refuse. I'm just curious, if the patient is alert and oriented and doesn't want to go to the hospital what difference does calling medical control make? Sure, "call medical control" is a nice, safe answer to most questions but in this case what does it get you?

On your second point, there is definitely a large number of people who think that a trauma patient is best served by a helicopter ride. I happen to disagree. Where appropriate the helicopter is a great resource but in my opinion it is often used inappropriately. This places the patient, flight crew, and others on the ground at risk unnecessarily!

Sedating trauma patients in the field in order to force them onto a helicopter does seem extreme and I question the thought process. If you need to sedate to intubate or perform other treatments that's one thing but to do so just to get them onto the "air ambulance" is ridiculous.

The recent spate of medevac crashes spurred me to post this question so we can discuss it and perhaps have a little more perspective when calling for a medevac. It is a dangerous venture and should not be taken lightly.

My assumption was the patient doesn't want the helicopter, not doesn't want the hospital. If in my heart of hearts, if I think there is an underlying injury, or condition that would benefit from ALS or vital signs are badly out of bounds, I want the patient to talk to an MD. If I think the refusal is an appropriate choice, then no, I wouldn't bother MC. Contacting MC is a requirement for ALS if there is a significant presenting problem that may benefit from it. Refusing any care and refusing a helicopter are different scenarios.

A noncompliant sweaty 300lber with a pressure of 90/60 who hit a deer last night with his bike is going to talk to an MD before refusing. The point I intended to make was that if transport was necessary and going to happen, I would not waste time at scene arguing the helicopter point. I'd get moving and cancel the helicopter if the patient refused it and make sure the facility to which I was transporting was ready.

The most terrifying moment of my life was dead of night at the Mahopac firehouse when a helicopter landed in difficult conditions that then deteriorated rapidly. As it lifted off, the call went out that the helicopter, still in sight, was making an emergency landing. There really wasn't room, the wind was fierce....and they opted to puddle jump to PHC instead and ground transport from there.

I think the helicopter crew made excellent decisions all along. The flight was doable on lift off and then it all went to hell. They got it down and did a spectacular job. That said, I will never ask a flight crew to take away my burden of care without thinking very carefully about the need and the consequences.

My husband is a fixed wing pilot so we fly regularly. I know that even the most careful preparation can still result in unforeseen weather. Watching my husband agonize over flight safety for pleasure trips, I can't even imagine the pressure to make the call to fly in seconds. My sense is that helicopter transport has to have some tangible benefit before I'd ask a crew to risk their lives.

[helicopper 1,050]

The most terrifying moment of my life was dead of night at the Mahopac firehouse when a helicopter landed in difficult conditions that then deteriorated rapidly. As it lifted off, the call went out that the helicopter, still in sight, was making an emergency landing. There really wasn't room, the wind was fierce....and they opted to puddle jump to PHC instead and ground transport from there.

I think the helicopter crew made excellent decisions all along. The flight was doable on lift off and then it all went to hell. They got it down and did a spectacular job. That said, I will never ask a flight crew to take away my burden of care without thinking very carefully about the need and the consequences.

My husband is a fixed wing pilot so we fly regularly. I know that even the most careful preparation can still result in unforeseen weather. Watching my husband agonize over flight safety for pleasure trips, I can't even imagine the pressure to make the call to fly in seconds. My sense is that helicopter transport has to have some tangible benefit before I'd ask a crew to risk their lives.

This is my point exactly. Some people tend to glamorize the use of a medevac and have department apparel emblazoned with images of the helicopter or catchy phrases boasting about how often they use them. All to often, patients receiving the extremely expensive air ambulance ride are discharged the same or very next day. This isn't what the use of medevacs is all about.

I think the decision making tree for the use of medevac needs to be tightened up a bit so that there is less "questionable" use of the service. This makes it safer for those involved and keeps the valuable resource available for when they are actually needed.

[StOpGoBlUE 11]

well since i was reading this id figure i would comment on it..

on october 19th at aprox 5:30 pm i was riding an atv with my friends. in putnam valley/ kent area at this time i was going up a hill and my bike just stalled out on me and me and my bike went for a tumble ride down the hill backwards were the bike had landed on me and my friends had to lift it off.. i was there for about 45 mins before ems personal reached me with the atv and 6 wheelers.i was also a 1/4 mile into the woods .i was a/ox3 with -loc ihad pain in my left knee, my pelvis, and my midline back, well as the medic aproched me i heard him yell for the helicopter b4 he even found what my injuries were now me being an emt i fel the need that i did not need a helicopter cause my vital were stable and i had full motory but he made me aware of becuause of my MOI i had to be flown.. soo i was flown to the wcmc told i had crack on my pelvis fluid in my knee and a compression fracture of my L2 disc onto a nerve and i was discharged 2:00 am.. now my ? to you is even if i deny it can they still fly the helicopter due to my MOI..

thanks charlie

also want to say thank you to the putnam valley fire dept and ems / medic and the crew on the medivac thhat day evry1 did a great job and my utmost respect goes out to them.. the accident and pics are on there wbesite putnamvalleyfire.com

[notch138 7]

The PT has the right to deny any treatment and/or transport. Like said before you can also make the PT injury worse by makeing them upset. However you should also contact medical control and advise them of what you have and your pt's wish's.

[Guest alsfirefighter]

I lost track of this thread so this is a bit late...but I wanted to touch on the sedation comment.

I personally don't feel that it is unethical to offer or administer sedation to a patient if it were to assist them with anxiety for a medevac ride....IF IT IS TRULY WARRANTED. Patients are offerred sedation and benzo's for all sorts of medical procedures, including the ability to get into a MRI or CT Scanner, so why not for air transport? If the medevac flight nurse/medic is comfortable with it and they are able to do it, I say no problem. If the ED physican that decides to fly out a patient and the patient tells them they are afraid of flying and he offers it to them, is that not informed consent? Can I as a provider not do the same? I also find air transport inter facility as somewhat odd often, being I take critical trauma patients by ground to WMC and I see patients stabilized with good meds on pumps fly out of my primary transport location.

On a side note I had to think of our many air transport discussions and started to think what percentage of providers would have either called for at least 1 bird or even 2 for a call I did with another medic last Sunday night. 2 car offset head on, pick up vs. sedan. Sedan...all occupants ok and said they had no injuries. pick up driver...broken femur, multiple lacs, no apparant LOC, pupils sluggish, lots of pain. Passenger...severe pain to right femur/pelvic area, cannot straighten his right leg, possible LOC, multiple head lacs, severe lack to left anterior wrist, moderate blood staining to clothes...cannot remember impact.

Both patients taken by ground to WMC. How many honestly can you think of would have flown at least 1 or both?

STOP...depending on where you were in PV I may have just taken you by ground. But I can't say that after giving you a once over I might not have flown you also. I transported the passenger of the above incident and I'm sure by the time we got to WMC he might have wished to been flown with the road conditions on the way there. You may have refused, but I would have done my best to explain why I felt you needed to and why it was a good idea, which based on your injuries I call that a good decision in the end. You may have been discharged at 2 am, but you got a good once over by a true trauma team and some of the things you had could have been more significant. I can't believe I'm going to say this but provider (paramedic) interpretation does carry some weight, but some take it too far with air transport. I found that when I worked in areas with longer transport times, my clinician skills improved...assessment, critical decisions making and also medication as I often got farther down the protocols then in the more urban/short transport time I work in the majority of the time.

[ckroll 101]

I lost track of this thread so this is a bit late...but I wanted to touch on the sedation comment.

I personally don't feel that it is unethical to offer or administer sedation to a patient if it were to assist them with anxiety for a medevac ride....IF IT IS TRULY WARRANTED. Patients are offerred sedation and benzo's for all sorts of medical procedures, including the ability to get into a MRI or CT Scanner, so why not for air transport? .....

Interesting idea. Not to be overly pedantic, but it depends on what definition of ethical you're using. I wouldn't think administration of sedation is morally questionable, as it is the compassionate choice for the patient. That said, if by ethical you mean meeting professional standards, then paramedics have no authority to administer benzo's for relief of anxiety. In addition, medical control physicians do not have the authority to ask/demand that we give benzo's for relief of anxiety as it is way beyond OUR scope of practice. That said, morphine for pain relief is still on the table and in the draft for WREMAC it is above the medical control line.

"If it is truly warranted" is a good consideration. If a person is alert and oriented, and situationally aware to the point where they have the emotional ballast to be anxious over a transport decision, then that person may be stable enough that air transport to level 1 trauma vs ground transport is unwarranted. If they have altered mental status, I wouldn't consider sedating at all.

If I were faced with a person who could tell me that they would absolutely, positively flip out going in a helicopter, and I took 5 minutes to try to talk them in, and then took 3 minutes to call medical control and have them talk to the patient and then took 5 minutes to give the benzo and wait for effect only to find out that they needed more..... well, I'd be at the medical center by the time I got them loaded in the helicopter and now I'm delivering a foggy patient to a trauma center and the surgeons have no idea if the fog is drug induced or secondary to injury.

In addition, a person who is spooky about the helicopter is an unknown quantity. How much sedation does it take? What if they are minimally sedated to get them in and comfortable, some event happens mid flight and they have a panic attack anyway?

What defines truly warranted?

[Guest alsfirefighter]

Christy, as always I value your points and our counterpoints, but I'm not speaking of us as the field medics to sedate for flight. I'm speaking of the flight crew which generally has a flight medic and flight nurse on board. That would be their call and from what was discussed apparantly has happened. You are correct that we don't give benzo's for anxiety and no its not in the protocol, but we also know that not everything fits tidy into protocols and as I've said, if I wanted to follow step by step directions from a book for everything I do professionally I would have went to the culinary institute. One case in point that comes to mind, was one I had a couple years ago. Female patient, with severe leg and lower back spasms. She was in obvious pain and the spasms were signficantly observable and she would contract so bad her heels were hitting her buttocks and how she wasn't fully screaming I don't know. I made the decision for pain management right away for 2 reasons, first and foremost to ease the discomfort of my patient and secondly to facilitate being able to remove her from the home. The protocol dictates Morphine for pain management, but it still wouldn't have solved the problem of the spasms and contractions. So I called medical control and requested Versed (would have used valium but we don't carry it anymore). After QA/QI the case came up at a call audit and I had a couple of medics (one young one, who's stethoscope still had a shine to it, whom I didn't even know) took issue with it after I read the case, for not calling and pushing morphine. Which I then presented my side, which basically came down to, what benzo's are often used for...anxiety and its muscle relaxing properties which is what I made my clinical decision on, which is what I get paid for and which is what medical control agreed with. Spasms decreased, patient comfort increased and she didn't stop thanking me the entire way. It was discretionary use...which also falls under our spectrum which it could be argued that the case in point about flight could be made. I would never out of respect of the crew I'm going to turn my patient over to, but just counterpointing what was said.

Also as far as my "colleague" who so, how could I put it....fervishly... disagreed with my decision in the beginning, I'm glad you learned something....the change in your matter of fact facial expression was priceless brother...next time come strong, I always love a good clinical discussion. If I only knew who you were.

[ckroll 101]

Christy, as always I value your points and our counterpoints, but I'm not speaking of us as the field medics to sedate for flight. I'm speaking of the flight crew which generally has a flight medic and flight nurse on board. That would be their call and from what was discussed apparantly has happened. You are correct that we don't give benzo's for anxiety and no its not in the protocol, but we also know that not everything fits tidy into protocols and as I've said, if I wanted to follow step by step directions from a book for everything I do professionally I would have went to the culinary institute. One case in point that comes to mind, was one I had a couple years ago. Female patient, with severe leg and lower back spasms. She was in obvious pain and the spasms were signficantly observable and she would contract so bad her heels were hitting her buttocks and how she wasn't fully screaming I don't know. I made the decision for pain management right away for 2 reasons, first and foremost to ease the discomfort of my patient and secondly to facilitate being able to remove her from the home. The protocol dictates Morphine for pain management, but it still wouldn't have solved the problem of the spasms and contractions. So I called medical control and requested Versed (would have used valium but we don't carry it anymore). After QA/QI the case came up at a call audit and I had a couple of medics (one young one, who's stethoscope still had a shine to it, whom I didn't even know) took issue with it after I read the case, for not calling and pushing morphine. Which I then presented my side, which basically came down to, what benzo's are often used for...anxiety and its muscle relaxing properties which is what I made my clinical decision on, which is what I get paid for and which is what medical control agreed with. Spasms decreased, patient comfort increased and she didn't stop thanking me the entire way. It was discretionary use...which also falls under our spectrum which it could be argued that the case in point about flight could be made. I would never out of respect of the crew I'm going to turn my patient over to, but just counterpointing what was said.

Also as far as my "colleague" who so, how could I put it....fervishly... disagreed with my decision in the beginning, I'm glad you learned something....the change in your matter of fact facial expression was priceless brother...next time come strong, I always love a good clinical discussion. If I only knew who you were.

That's an interesting case that deserves a thread all its own. Why don't you post it and see what responses it gets. It goes without saying you're an excellent medic of whose judgment I have the greatest regard. While protocols are intended to be applied with good clinical judgment, my reading of them is that we are not given the flexibility to go beyond scope of practice. That said, a good medic can still make the case for it to OLMC, and I think we agree, has to before doing something like that. In point of fact, most OLMC is by and large unaware of what paramedic protocols say.

As a 6 year medic, I would be very circumspect about going that far over the line. Points to consider are how proficient the medic and how adventurous the Service Medical Director, and nature of injury. Given your situation with a medical emergency, that is quite different than perhaps a new medic with a commercial agency working a trauma.

All that said, it must happen all the time that people are anxious about medevac. In hospital is a whole different ball of wax than in the field. How often do flight medics/nurses sedate for anxiety in the field? Do they do it under the flight medic's standing orders or is it a nurse who has the permission from their medical control?