"Call the bird!" Why?

[FFEMT150 214]

I decided to start this thread as to not hijack x635s thread about the car vs bike in peekskill. My question for you all is this: why with an average ground transport time of around 20 minutes would you call for a medivac? This is not intended to bash any agency or provider. I am sure a persons decision to call a bird is validated. I am simply asking why one would be called. I know there are members on the site from rural areas with long transport time even to a general hospital and ask that you also weigh on on the subject. Thanks guys. Looking forward to reading some of your posts.

Stay safe.

[SECTMB 612]

So, we're operating a PIAA and the medic requests the bird. As the bird comes in for the landing, a worker in a nearby building under construction, in an effort to see what the heck is going on, falls from the second floor. If I remember correctly, the bird came back for him after dropping off the first patient from the PIAA.

[INIT915 1,119]

There could be reasons even that distance away, but they're few and far between. Lengthy extrication, as an additional ALS unit at an MCI, perhaps others. Hard to tell from today's events, without being there, what might have prompted it.

[SteveC7010 58]

I live in the southern Adirondacks. The nearest Level 1 Trauma Center is Albany Med which is about an hour and 15 minutes from my home. From the far north end of our ambulance district, it's another 20 minutes at least; and even more if it's up one of the back country roads and into the woods. So we use the birds a lot, and have many saves because of the time saved over ground transport.

I used to live in Ontario County and worked full time as a Dispatcher II for Rochester-Monroe County 911. Inside Monroe County, we rarely used the helicopters. Primary reason was short ground time and choice of two trauma centers, even from the edges of the county. The only exceptions were MVA's with long extrication times and other rare situations with long time frames prior to getting the patient into the ambulance. Ontario County on the other hand used the birds a lot. Mercy Flight Central is based in north central Ontario County and has very short response times to anywhere in that county so they are a very valuable resource.

It's all about the time. In the situation that prompted this thread, I tend to agree with the original question of why call the bird with a 21 minute ground time. But not being on the team that treated the patient, it's not fair to judge either.

I would offer that if you can have the bird on the scene when the patient is packaged and ready for transport, there can be benefits, even with relatively short flight times, over ground transport. If there is any appreciable wait for the bird when the patient is ready to go, the value drops off rapidly. But it's the more distant situations that really prove the value of air transport.

Side comment here... Living and working in the Rochester area was good when it came to burn patients. Strong Memorial is one of the best burn centers in the US and being close meant that we got our burn patients there fast and had lots of good outcomes. Up here, the nearest burn centers, I believe, are Westchester or Syracuse. Both are several hours by ground from here at a minimum. Couple that with the fact that helos don't fly under certain weather conditions, and it you have a very scary situation for EMS dealing with burns.

[FireMedic049 597]

I've spent 20+ years in EMS working in areas remote from trauma facilities to just down the street from them. I've spent the last 15 or so in a metro county that is somewhat fly happy despite having 4 trauma centers within reasonable drive times for most of it. IMO, in the vast majority of cases, the use of medevacs in areas that are within this middle area, has more to do with ALS providers who are not confident providing advanced care to trauma patients for the duration of the ground transport time rather than with the patient actually needing care beyond the normal scope of practice for a street medic. Now there are certainly cases in which timely provision of critical care level care in the field is warranted, even if it delays arrival at the hospital by a few minutes.

As for the "time saving" aspect of medevacs, in this middle zone, it's often a toss up as to whether or not it truly saves time. I know of numerous incidents in my area in which units have spent a majority (or more) of the time it would have taken them to get to the hospital by ground, sitting at an LZ waiting for the helicopter to arrive. I know of a number of incidents in which patients from the same incident have been transported to the same hospital by ground and by air and excluding extrication delays, the ground units almost always get their patients into a treatment room faster than the air units can when you factor in waiting for them to arrive on scene, the transfer of care and then time to move from the helipad to the ER.

[16fire5 693]

I would offer that if you can have the bird on the scene when the patient is packaged and ready for transport, there can be benefits, even with relatively short flight times, over ground transport. If there is any appreciable wait for the bird when the patient is ready to go, the value drops off rapidly. But it's the more distant situations that really prove the value of air transport.

My experience is even when the helicopter is waiting for the patient they spend quite a while in the back of the bus and then moving the patient to the helicopter. I'm sure the flight paramedics and/or nurses feel the things they do are necessary but if they require 20 minutes then that has to factor into the equation.

My point is many people have cited extended extrication time as a reason to call but if the helicopter crew is going to spend almost a half hour prior to departing to get the patient to the point that they are comfortable with them in the back of the helicopter then the distance from the hospital that they become of benefit is further.

SteveC's example of the Adirondacks is exactly where they seem to be of the best use.

[Bnechis 3,961]

My experience is even when the helicopter is waiting for the patient they spend quite a while in the back of the bus and then moving the patient to the helicopter. I'm sure the flight paramedics and/or nurses feel the things they do are necessary but if they require 20 minutes then that has to factor into the equation.

My point is many people have cited extended extrication time as a reason to call but if the helicopter crew is going to spend almost a half hour prior to departing to get the patient to the point that they are comfortable with them in the back of the helicopter then the distance from the hospital that they become of benefit is further.

SteveC's example of the Adirondacks is exactly where they seem to be of the best use.

When they were 1st available to us out of Westchester they got overused.

What finally mad everyone think about its use was an extended extrication we had on a local road (car wrapped around a telephone pole). The closest landing zone was 1/2 mile away. 2 patients both critical. 1 ambulance was sent to LZ, got the crew an transported to the scene. Other went to the scene. The more critical patient was removed and transported to the copter. 10 minutes later the 2nd was extricated and was transported by ground to Westchester Medical Center. The medevac crew had advised that the 2nd patient should go by ground.

The 2nd patient was in the treatment room at WMC before the 1st patient, because the flight crew was "stabilizing the patient for flight" for close to 30 minutes.

We stopped using them after that,

[amr6334 16]

^{Well, from my outsider per se point of view. I get all aspects. I have where I live an ED that has a few beds in-house. The Fire Department will transport the pt to the ED and from there the bird will come get the pt (Perfect LZ and all). Our major trauma center is about 90 mins away. The thing that kills me is the other day they called for a chopper from a free standing ED which is a 20 min drive (without lights and sirens) to the Trauma center. Go figure. Its all about the $$$$ to some people.}

[Reliance 29]

^{Where I live we are close to a level 2 trauma center but three hours away from a level 1 center. The Lifeflight can be here in 50 minutes and have the patient in the trauma center before ground ambulances can get there.}

[50-65 205]

I too have personally seen this and just do not understand. The nearest level 2 is 20 minutes away. I have seen EMS crews wait 10 minutes for the helo. By the time the pt is transferred and off the ground, they could have been to the Level 2. By air, the level 1 is 20 minutes, 40 by ground.

So my question is, is the pt better served by waiting 20 minutes to be flown for 20 to a level 1 (total 40 minutes to ER) or diven for 20 to a level 2? The best is when the EMS crew waits for the helo, transfers the pt, and then flown to the level 2.

I think it may save time IF the helo is on the ground, close to the scene, when the pt is ready for transport and care can readily be turned over. Other than that, you're waisting time.

[FireMedic049 597]

I too have personally seen this and just do not understand. The nearest level 2 is 20 minutes away. I have seen EMS crews wait 10 minutes for the helo. By the time the pt is transferred and off the ground, they could have been to the Level 2. By air, the level 1 is 20 minutes, 40 by ground.

So my question is, is the pt better served by waiting 20 minutes to be flown for 20 to a level 1 (total 40 minutes to ER) or diven for 20 to a level 2? The best is when the EMS crew waits for the helo, transfers the pt, and then flown to the level 2.

I think it may save time IF the helo is on the ground, close to the scene, when the pt is ready for transport and care can readily be turned over. Other than that, you're waisting time.

We just had a hospital in my area obtain level 2 trauma designation. From what I have been told, the main difference between a level 1 and level 2 has little to do with the level of trauma care that can be provided at the facility. The main difference is that the level 1 is a teaching facility and may have more redundancy allowing for treatment of more trauma patients at the same time. For example, having a couple of trauma surgical teams on duty vs only one.

I'm not sure if hospital trauma designations are consistent nationwide, but based on what I know for my state, it would probably be better to take the patient to the level 2 by ground than taking twice as long to go to the level 1 by air.

[Dinosaur 844]

We just had a hospital in my area obtain level 2 trauma designation. From what I have been told, the main difference between a level 1 and level 2 has little to do with the level of trauma care that can be provided at the facility. The main difference is that the level 1 is a teaching facility and may have more redundancy allowing for treatment of more trauma patients at the same time. For example, having a couple of trauma surgical teams on duty vs only one.

I'm not sure if hospital trauma designations are consistent nationwide, but based on what I know for my state, it would probably be better to take the patient to the level 2 by ground than taking twice as long to go to the level 1 by air.

Here are the NYS guidelines for trauma centers from the NYS DOH website.

traumastds7085.pdf

[STAT213 332]

Having worked for STAT Flight and two other air medical programs, I can hopefully offer some useful tidbits to this discussion.

The helicopter is a resource like any other. It is supposed to provide faster transport and a higher level of care. If either of those will help your patient, then use it. There is VERY good evidence to show that two things are happening right now with helicopters. 1) getting patients to LEVEL ONE trauma centers quickly and efficiently helps them. 2) there is some overuse of aircraft leading to patients being discharged within 24 hours of arrival to the receiving facility.

The days of mechanism based transport should be done, just like mechanism based treatment. So, think. Will using the a/c benefit your patient? Will it get them there faster? I have done flights 6 miles from the med center. Stupid. It takes longer to fly in that case. I can tell you though, it's really tough for a number of different reasons to show up at a scene and not take the patient.

There are a number of STAT Flight horror stories from the early years. They made some poor choices in their staffing model and did not adequately train their crews as to the mission in the eyes of the pre hospital providers. Gotta ask your customers what THEY expect. There is a great photo somewhere of Air 1 on the sprain running with a patient in the back all by themselves. Rest of the wreck had cleared. ALL OF IT. and there they were stabilizing the patient as the capt said. Dumb. But, they thought they were doing the right thing. In a way, they were. In a way, they weren't.

Enough rambling. Peekskill may or may not be a good spot for a/c usage. Waiting for life star from CT with a patient who is lying in the road, prolly not. Load and go, do your best on the way.

[wedgeclose 59]

About 20 years ago ( I may be wrong on the years) I stopped on the Sprain Brook Pkwy at 100B at the scene of a head on colision in the southbound lanes. A vehicle from the north bound lane went down the embankment and crashed head on into a mustang convertible coming southbound. I was a member of the Ossining Volunteer Ambulance Corps with only first aid training as I was a driver. I was the first "medical" person on the scene. There were two ejections and one pinned in the Mustang. The ejected were mortally injured. It took awhile for response from the NYSP due to traffic. About 10 minutes after the collision the first ambulance arrived and it was another 5 for the first Emergency Service truck to arrive. At some point StatFlight was called. This was less than two miles from the medical center. The extrication took at least 10 minutes so a total of 1/2 hour had elapsed before the driver (who was an off duty NYPD) was freed. Unfortunately, as soon as he was extricated his injuries were so severe that he died almost immediately. The bird was there by the time they loaded and got airborne he could have been in the ER before they left the ground. I agree at the outset STAT flight was overused in westchester county.

[paratrooper75 41]

So why call? Most people think of a helicopter as a "fast ambulance". While this is true, the abilities of the flight crew are far greater than the average ALS ambulance. I agree that if the transport time is going to be 20 minutes then by all means go by ground. Just remember that the air crew offers more than just a fast ride. Some of their capabilities include video laryngoscopy, RSI, surgical cricothyrotomy, pericardiocentisis, intraosseous infusions, and mechanical ventilatory management . They carry some familiar equipment like EZ-IO guns, pelvic binders, and CAT tourniquets. Some additional medications that are carried and not found on ambulances are Ancef for open fractures, warmed Lactated Ringers solution for hypovolemic patients, Mannitol for head traumas, and Tranexamic acid to help slow internal hemorrhage. All of these measures are greatly beneficial for patients with extended transport times but can also be very useful and sometimes necessary for patients that may be within driving distance to a trauma center. Hope this helps!

[FireMedic049 597]

So why call? Most people think of a helicopter as a "fast ambulance". While this is true, the abilities of the flight crew are far greater than the average ALS ambulance. I agree that if the transport time is going to be 20 minutes then by all means go by ground. Just remember that the air crew offers more than just a fast ride. Some of their capabilities include video laryngoscopy, RSI, surgical cricothyrotomy, pericardiocentisis, intraosseous infusions, and mechanical ventilatory management . They carry some familiar equipment like EZ-IO guns, pelvic binders, and CAT tourniquets. Some additional medications that are carried and not found on ambulances are Ancef for open fractures, warmed Lactated Ringers solution for hypovolemic patients, Mannitol for head traumas, and Tranexamic acid to help slow internal hemorrhage. All of these measures are greatly beneficial for patients with extended transport times but can also be very useful and sometimes necessary for patients that may be within driving distance to a trauma center. Hope this helps!

While this may all be true, in my experiences, it is a very small percentage of patients that would truly benefit from these things vs getting to the hospital quickly in this mid-range distance from a trauma center. The paramedic in charge of caring for the patient on the ground needs to be able to distinguish between patients that could benefit from these critical care offerings and those in which would likely see no appreciable benefit from air transport and make the appropriate decision regarding mode of transport.

[16fire5 693]

From a QA/QI standpoint do they track scene time? When it takes them 20+ minutes from when the patient is provided to them to depart the scene they in many ways remove their benefit. Remember what Stat 213 just said the research shows (getting the patient to a trauma center fast is of great benifit). It didn't say they had to get them there by helicopter. The helicopter on paper seems like a great idea but I think from a realistic standpoint it's not getting patients to the trauma faster then rapid transport would. Aside from stabilizing an airway what ALS skills are really proven to improve trauma patient outcome? Haven't we known all along that putting a patient on a board, stopping hemorrhage, and giving O2 and putting them in the bus is the way to go? Why do we still see paramedics wasting time on scene starting IVs? I honestly put it in the same category as cutting the roof after the fires knocked down. They're just things people wanna do and brag about doing afterwards regardless if they were warranted at the time.

[FireMedic049 597]

Why do we still see paramedics wasting time on scene starting IVs?

It's somewhat of a pet peeve of mine and I don't have any definitive answer to that.

Personally, once the patient is in the ambulance, unless there's a critical issue that immediately needs to be addressed - like an airway problem, I want to get moving. We're 20-30 minutes from a trauma center by ground, so I want to get moving and I'll do what I need to on the way. If we're going to fly, then I want to get moving to the LZ. If makes no sense to me in the vast majority of cases to sit on scene doing stuff and potentially have the helicopter land before you get there vs going to the LZ and then doing whatever you can get done before they arrive. Unless there are extenuating circumstances, every minute that the helicopter is on the ground and not yet with the patient is wasted time.

I've ruffled a few co-worker feathers over the years telling people to get out of the ambulance so we could leave the scene.

[SRS131EMTFF 471]

video laryngoscopy, RSI, surgical cricothyrotomy, pericardiocentisis, intraosseous infusions, and mechanical ventilatory management

From my prospective as a BLS provider in VT, other than pericardiocentisis, which I am not sure about, these are all NR-P level skills. I/O is an AEMT skill and Automatic Transport Ventilation is as low as an EMT level skill.

Anything less than a 50 minutes by ground transport will not even get considered for a helicopter considering the helicopter is coming from Albany (LifeNet), Dartmouth (DHART) or Saranac Lake (NCLF). If the VTANG has a helicopter and crew ready, you might be able to get them, maybe...

Other than the renewed focus on TKs and blood products, the recent military operations have reenforced the fact that getting the pt to definitive care and stabilized is what saves the pt, not fancy toys in the field.

We were taught that other than airways/IO which should be done on scene, if you are waiting, your pt is dying.