I think I am done with helicopters

[Eli]

Looking back at our service's use of air transport in the past couple of years, I'm not seeing any real benefit. I work in an area about an hour away from the larger hospitals.

Looking for research for the benefits of shaving a few minutes off of arrival times, I didn't come with anything too specific. A cardiologist I've talked with doesn't think 15 minutes one way or an another to a cath lab on a STEMI would justify the use of a helicopter. That's about the best I have.

Anyone know of research on the subject pertaining to trauma, MI's or CVA's?

 

[VFlutter]

IMO the real benefit of HEMS is the flight crew themselves and not the time saved on transport. A critical patient will benefit from having a highly skilled and experienced provider with advanced protocols. However that benefit is only significant in a small population, most notably trauma. For a STEMI there really isn't much HEMS will do more than a ground ambulance except for quicker transport.

 

[Ecgg]

IMO the real benefit of HEMS is the flight crew themselves and not the time saved on transport. A critical patient will benefit from having a highly skilled and experienced provider with advanced protocols. However that benefit is only significant in a small population, most notably trauma. For a STEMI there really isn't much HEMS will do more than a ground ambulance except for quicker transport.

I think you understating the time saved component. It's time saved along with experienced providers with enhanced scope of practice that contribute to reduced mortality rates.

I recall there were some studies done (Canada? Australia?) looking at crew composition and profiles of the missions. I will see if I can find them.

 

[Eli]

I think you understating the time saved component. It's time saved along with experienced providers with enhanced scope of practice that contribute to reduced mortality rates.

Well, yes that is true. I have used them in the past because their advanced airway capabilities were superior to what I had available. Just not something I've had to do recently.

 

[chaz90]

IMO the real benefit of HEMS is the flight crew themselves and not the time saved on transport. A critical patient will benefit from having a highly skilled and experienced provider with advanced protocols. However that benefit is only significant in a small population, most notably trauma. For a STEMI there really isn't much HEMS will do more than a ground ambulance except for quicker transport.

This is true. Now what happens when the primary flight crew you call has seen very few patients in their entire career and has more restrictive protocols than you do?

 

[Ace 227]

I know in my area a big benefit of calling a helicopter is that they carry blood products.

 

[Ecgg]

Well, yes that is true. I have used them in the past because their advanced airway capabilities were superior to what I had available. Just not something I've had to do recently.

Here are some studies for you

http://azdhs.gov/bems/documents/news/articles/TraumaHelicopterEMSTransport.pdf you can read more in this link provided.

Summary

The Air Medical Service professional crews should have physician-level skills even though most of the helicopter programs in United States are provided by nurse/paramedic teams 32. Less than 5% of helicopter programs have a flight physician and the majority of flight physicians are residents-in-training. The physician’s judgment and skills are needed in 25% of flights and the flight physicians perform more procedures without altering the scene time compare to other crewmembers. These factors have shown to improve trauma patients’ outcome and mortality. Residency training does not provide adequate preparation for physicians practicing as flight physicians 1 and EM residents need special HEMS training before flying. The flight physician is an important, but small part of the air medical service, and will hopefully function as a valuable resource in the future development of the medical air transport in United States.


http://archive.ispub.com/journal/th...hould-we-train-them.html#sthash.iuvUBpMy.dpbs

 

[Ecgg]

This is true. Now what happens when the primary flight crew you call has seen very few patients in their entire career and has more restrictive protocols than you do?

Then why are you calling them?

 

[chaz90]

Then why are you calling them?

We fly with them if it's a patient that we've intubated that needs a higher level of monitoring. The closest Level One is 1.5-2 hours away by ground, so there is a legitimate place for them here based on distance. Blunt trauma or penetrating trauma with hemodynamic instability is typically handled by ground transport to one of the local trauma centers for initial stabilization. For anticipated neurosurgical need though, flight to the Level One becomes necessary.

 

[Handsome Robb]

This is true. Now what happens when the primary flight crew you call has seen very few patients in their entire career and has more restrictive protocols than you do?

You call them, tell them to keep their hands to themselves and fly in with them oh wait.... Ya'll already do that. Well idk about the hands to themselves or not but I know you do the flying part

 

[Carlos Danger]

This is true. Now what happens when the primary flight crew you call has seen very few patients in their entire career and has more restrictive protocols than you do?

Let me guess.....state police?

 

[chaz90]

Well, it's either that or you cross your fingers and hope Lifenet is dispatched to take the flight for some reason.

 

[chaz90]

Let me guess.....state police?

Yep

 

[Eli]

Here are some studies for you

Thanks! These are a great start.

 

[Arovetli]

While it is difficult to pull off at times, if your system has some type of coordinator or if you can arrange a meeting with key representatives and you all sit down and lay the entire process out, you can find where the slow downs are and how to correct them.

Often shaving a few minutes off prehospital transport doesn't produce an overall benefit because one of the many other pieces is moving sluggishly.

Medicine does terrible at process management...but it is improving.

I think studies are great, but when it comes to this type of administrative function, they are looking at an amalgamation of various systems, or at a particular system, and the performance of these systems may not readily translate into what works in your system.

It may weaken a bit, the importance of the study.

For what you are describing, a roundtable of the key players and a bit of medical six sigma may work best to improve outcomes.

 

[Carlos Danger]

Looking for research for the benefits of shaving a few minutes off of arrival times, I didn't come with anything too specific. A cardiologist I've talked with doesn't think 15 minutes one way or an another to a cath lab on a STEMI would justify the use of a helicopter. That's about the best I have.

Anyone know of research on the subject pertaining to trauma, MI's or CVA's?

• Association Between Helicopter vs Ground Emergency Medical Services and Survival for Adults With Major Trauma (JAMA)
  
  
• Helicopters and the Civilian Trauma System: National Utilization Patterns Demonstrate Improved Outcomes After Traumatic Injury (Trauma & Acute Care Surgery)
  
  
• Trauma Services at the last place I worked did a retrospective review (though not published, which is why I can't post a link) that showed drastically better rates of airway management by their flight program than ground EMS.

The problem with both HEMS and EMS research is that there are so many variables that are difficult or impossible to account for. Training, protocols, transport times, experience of the crews, QI, etc can all vary drastically from place to place and at least partially explains why two very similar studies can show significantly different outcomes when they are done in different parts of the country. It makes it difficult to generalize the findings of a study done in location X to the EMS program in location Y.

I think with longer transport times of sicker patients it's pretty clear that HEMS helps. Airway management alone tends to be much better.

The problem is that HEMS is so overused in many places, that it's easy to look at a bunch of ISS 7 patients who were flown when it would have only taken 20 minutes to go by ground, and say "flying doesn't help".

So it just depends on where you are, how sick the patients are, how time will be saved by flying, and what important interventions the flight crews might be able to do that the ground medics can't.

 

[Arovetli]

• Association Between Helicopter vs Ground Emergency Medical Services and Survival for Adults With Major Trauma (JAMA)
  
  
• Helicopters and the Civilian Trauma System: National Utilization Patterns Demonstrate Improved Outcomes After Traumatic Injury (Trauma & Acute Care Surgery)
  
  
• Trauma Services at the last place I worked did a retrospective review (though not published, which is why I can't post a link) that showed drastically better rates of airway management by their flight program than ground EMS.

The problem with both HEMS and EMS research is that there are so many variables that are difficult or impossible to account for. Training, protocols, transport times, experience of the crews, QI, etc can all vary drastically from place to place and at least partially explains why two very similar studies can show significantly different outcomes when they are done in different parts of the country. It makes it difficult to generalize the findings of a study done in location X to the EMS program in location Y.

I think with longer transport times of sicker patients it's pretty clear that HEMS helps. Airway management alone tends to be much better.

The problem is that HEMS is so overused in many places, that it's easy to look at a bunch of ISS 7 patients who were flown when it would have only taken 20 minutes to go by ground, and say "flying doesn't help".

So it just depends on where you are, how sick the patients are, how time will be saved by flying, and what important interventions the flight crews might be able to do that the ground medics can't.

there must be an echo in the room...

 

[mycrofft]

Five is four

Helos take time to get going. So their true potential worth is in areas with prolonged transportation due to bad infrastructure, absence of receiving facilities, absence of EMS responders of any sort, etc.

Helos are limited in number. So every call has to be weighed against whether the next call, or the prior call, would have been better served by a helo response.

Helos need at least a helispot to load patients. Sometimes that isn't available without moving the pt a ways.

Civilian helos are crowded. Limits what can be done, and how many patients can be moved.

An unpressurized helo poses its own set of stressors on a patient and crew.

Helos are more weather-vulnerable than ground units. Potential for grounding, potential for turbulence.

Helos require a base to operate out of, special maintenance, special fire safety measures, special ground ops safety measures, specially trained and certified crews.

Helo ops are expensive.

Why not use the National Guard units? Rarely, they do.

 

[Summit]

I was told once that until the 80s military physicians on military helicopters provided the bulk of HEMS?

 

[Arovetli]

Helos take time to get going. So their true potential worth is in areas with prolonged transportation due to bad infrastructure, absence of receiving facilities, absence of EMS responders of any sort, etc.

Helos are limited in number. So every call has to be weighed against whether the next call, or the prior call, would have been better served by a helo response.

Helos need at least a helispot to load patients. Sometimes that isn't available without moving the pt a ways.

Civilian helos are crowded. Limits what can be done, and how many patients can be moved.

An unpressurized helo poses its own set of stressors on a patient and crew.

Helos are more weather-vulnerable than ground units. Potential for grounding, potential for turbulence.

Helos require a base to operate out of, special maintenance, special fire safety measures, special ground ops safety measures, specially trained and certified crews.

Helo ops are expensive.

Why not use the National Guard units? Rarely, they do.

But HEMS can be lucrative.

Auto insurance reimburses very well in medical injury claims, but it also reimburses on a first come, first serve basis.

He who bills first gets paid first.

Choppers are quick to transport and quick to bill, and have perfected the art of getting to the gravy first.

The different insurance structure (automobile vs. traditional medical) contributes to their success.

Plus they are cool, and like Air Evac, they can have nifty business models that incorporate a nominal annual subscription with a promise to not bill you over what insurance pays.

They sell cool, and they sell "peace of mind", and they sell community.

Air Methods, publicly held HEMS, is profitable and as of today, their stock is up

Make them unprofitable and they will largely disappear.

Money wins.