# HEMS - taking patients for a ride



## NomadicMedic (Apr 16, 2017)

The education coordinator at my department sent this article to all of our providers and made it required reading. ("Read this and sign the last page stating you've read it")

http://www.consumerreports.org/medical-transportation/air-ambulances-taking-patients-for-a-ride/

While I agree that HEMS may be overused, and the costs may be excessive, I find it dangerous that, due to an article in Consumer Reports, a helicopter may not be utilized because a less experienced provider formed the impression that HEMS is too expensive and is out to fleece the patient.

Thoughts?


----------



## EpiEMS (Apr 16, 2017)

EMS use for transport of any kind needs to be subject to good judgment. And HEMS use is no different - it just costs more, so use needs to be even more carefully considered...
That said, pretty silly to make you guys read that when there is good literature out there that is not just a screed against HEMS billing practices. 


Sent from my iPhone using Tapatalk


----------



## FLMedic311 (Apr 16, 2017)

As a former HEMS Medic I totally agree with your concerns.  I don't think that the article should have any effect on the determining the need of HEMS use by the ground provider.  However I do feel that this article presents plenty of valid issues and concerns.  I feel there are a lot of "simple" solutions that would get quickly muddied up by both HEMS and insurance companies because in the end they just care about the bottom line, and that is unfortunate because it will have a negative impact on people that truly do require this specialized resource.  I think the issues at hand are far beyond that of the provider, and even after reading this article that for most ground providers it should be business as usual.  Use your local protocol/best judgement to determine the need for HEMS, and hope that the crew that services you is also savvy enough to recognize when they are required and will not transport simply because they are requested.  If you still have issues regarding the concerns of local HEMS use I would say contact your MPD and have a healthy conversation about them, and see if you can help localize more direct protocol for the use, and raise awareness regarding the issues


----------



## VFlutter (Apr 16, 2017)

Yes, HEMS is expensive. Everything that goes into aviation as well as 24/7 staffing is not cheap. I think the issue is lack of Medicare/Medicaid reimbursement, large number of uninsured flights, and difficulty obtaining insurance approvals. I am sure there is overuse and misuse out there but in my limited experience it isn't that common.  Almost all of what I fly is justified. It would be great if all ground services offered the same level of care we do but unfortunately that is not the case. For many patients HEMS is crucial.


----------



## hometownmedic5 (Apr 16, 2017)

I don't base air or ground decisions on money or ability to pay. That's not my department. 

My qualifier is did this patient earn a ride on the bird. If they did, and a helo is available, they get to fly. If they didn't, or it's not, they go ground. Simple as that.


----------



## Carlos Danger (Apr 16, 2017)

hometownmedic5 said:


> I don't base air or ground decisions on money or ability to pay. That's not my department.
> 
> My qualifier is did this patient earn a ride on the bird. If they did, and a helo is available, they get to fly. If they didn't, or it's not, they go ground. Simple as that.



And this attitude is exactly the problem. "This isn't my department". "I'm not the one paying the bill". No one has the stones to take responsibility.

The issue isn't that HEMS costs more than ground transport......it's that it costs a MASSIVE amount more than ground transport, and most insurers - quite rightfully, IMO - will only pay a small portion of the cost. Imagine you have a patient in pain, and you can give them fentanyl, which costs $2.99 per dose, or you can give them magicopioidamine, which statistically speaking isn't any better than fentanyl, yet costs $10,000 per dose. That's very often the difference between using HEMS and simply ground pounding. No one even asks the patient. Which is the more reasonable and responsible choice?

The HEMS industry is largely a racket. We know that very few patients benefit from HEMS, yet we still keep trying to increase transports annually.

Families go bankrupt over this stuff, all the time. Ignore it if you want, but It's no joke.


----------



## Carlos Danger (Apr 16, 2017)

Just to follow up on my previous post with a scenario:

You are out on a Sunday motorcycle ride out in the country with a couple of your buddies. As you round a curve, a car swerves into your lane so you veer hard to the right in order to miss the car. Your front wheel slides out and you end up sliding into a tree. Your right leg is messed up bad and it hurts a little to breath and you feel a little dizzy, but you never lose consciousness and aren't bleeding severely anywhere.

EMS shows up, asks you some questions, looks you over, puts you in the ambulance, starts an IV, and drives you to a nearby field, where you wait 15 minutes for a helicopter to land and for the HEMS crew to perform another assessment, load you up, and take you on a 15 minute flight to the closest trauma center. By ground it would have taken 40 minutes to drive to the same trauma center, or 15 minutes to drive to the closest hospital. You get to the trauma bay about 5-10 minutes sooner than you probably would have if the ambulance had simply driven you there.

You are diagnosed with 2 non-displaced rib fractures (no treatment needed), a concussion (no treatment needed), numerous abrasions (no treatment needed), and a femur fracture, which is fixed in the OR the next morning.

You spend about a week in the hospital. A couple weeks after you get home, you receive a bill from the HEMS agency for $28,000, which is just the portion of the $34,000 bill that your insurance won't pay. Everything else was covered by you insurer are you hit your $4,000 annual out-of-pocket maximum. The ambulance crew never even talked to you about whether you preferred ground or helicopter transport. 

That's the reality for probably large majority of HEMS patients.


----------



## hometownmedic5 (Apr 16, 2017)

Remi said:


> And this attitude is exactly the problem. "This isn't my department". "I'm not the one paying the bill". No one has the stones to take responsibility.
> 
> The issue isn't that HEMS costs more than ground transport......it's that it costs a MASSIVE amount more than ground transport, and most insurers - quite rightfully, IMO - will only pay a small portion of the cost. Imagine you have a patient in pain, and you can give them fentanyl, which costs $2.99 per dose, or you can give them magicopioidamine, which statistically speaking isn't any better than fentanyl, yet costs $10,000 per dose. That's very often the difference between using HEMS and simply ground pounding. No one even asks the patient. Which is the more reasonable and responsible choice?
> 
> ...



I'm not sure you fully grasped what I said, so I'll clarify.

I don't fly anybody who doesn't need to be flown. By needs to be flown, I mean will likely suffer grievous disability or death if they aren't at at a level 1 trauma center ten minutes ago(for your consideration, I'm 45 minutes from a L1 knife under optimal conditions(usually >1hr), and I work in one of the two towns in my state where Boston Med flight has a hanger, so I can get a helicopter in ten minutes under optimal conditions).

If a patient needs to be flown, I don't worry about money. I dont fly people just so I don't have to deal with them. I dont fly people because I'm bored and want to catch a quick air show. I fly people that, without that intervention, will likely die. True, its expensive and I dont care about money because I'm not paying the bill. Sure. You got me. However, you have to be alive to ***** about the bill and I'm not losing my license because I flew somebody who couldn't pay; but I might lose it for not flying somebody who then died when they otherwise might have lived.

I don't play games with HEMS for a number of reasons, but one of the main reasons is that my clinical director used to be a medflight medic. You can't BS this guy. So no, I don't play games with calling medflight, but when I need it, I call for them regardless of my patients ability to pay.


----------



## NomadicMedic (Apr 16, 2017)

I'm curious who dies if they don't get a HEMS flight where you are?

Because really, if they're so unstable that they're going to die, they probably should not be in a helicopter. Hemodynamicly unstable trauma shouldn't be on a helicopter. At least not where I am. The flight services don't carry blood.

Isolated heads, new onset CVA and STEMIs should go... IF the airship can be to the hospital before me. But, where I am, there is often a 20-30 minute ETA (once they get off the pad) 10 minutes (or more) on the ground and then a 20 minute flight to the hospital. That's just about the same as ground pounding.


----------



## RocketMedic (Apr 16, 2017)

Your education guy has never dealt with big city traffic or sheer distance.


----------



## GMCmedic (Apr 16, 2017)

The one time Ive used a helicopter, they were just a transport for me. I could have drawn straws for any of the 7 patients on who was going to catch a ride. 

It sucks for the patient that took the helicopter but I couldnt justify waiting 30 minutes for an ambulance when I can get a helicopter in 8 minutes. At least not for that MVA. 


The other opportunity was a burn patient that met burn center criteria but did not need intubation. I chose not too, but when it was all said and done with an AMR ALS 2 bill, an ED bill, and later a "critical care" trip 2 hours away, the helicopter might have been cheaper

Sent from my SAMSUNG-SM-G920A using Tapatalk


----------



## NomadicMedic (Apr 16, 2017)

RocketMedic said:


> Your education guy has never dealt with big city traffic or sheer distance.



We deal with gridlock traffic and distance frequently.


----------



## NomadicMedic (Apr 16, 2017)

Remi said:


> Just to follow up on my previous post with a scenario:
> 
> You are out on a Sunday motorcycle ride out in the country with a couple of your buddies. As you round a curve, a car swerves into your lane so you veer hard to the right in order to miss the car. Your front wheel slides out and you end up sliding into a tree. Your right leg is messed up bad and it hurts a little to breath and you feel a little dizzy, but you never lose consciousness and aren't bleeding severely anywhere.
> 
> ...




This guy would most likely go ground for me. I'd guess half of the medics in my system would fly this guy. The next county over would CERTAINLY fly him.


----------



## VentMonkey (Apr 16, 2017)

Can any of the mods move this thread to the HEMS section?

@Akulahawk, @MMiz, @Chimpie?

Good stuff so far, though. Unfortunately it is at the end of the day a billable for-profit business. Much like private ambulance companies, private air ambulance company's struggle with reimbursements, which leaves "unjustified flights" with heavy debt to pay. 

The article makes mention of membership programs, but also raises a valid point by saying that the patient may in fact not have an option with which service actually shows up to their scene. 

Everyone feels the ugly effects of our healthcare industry's many deficiencies. As @Remi mentioned, someone does indeed need to step up, finger pointing gets us nowhere.


----------



## StCEMT (Apr 16, 2017)

@Chase, do yall carry blood products? There is only one area I can think of that I would call you guys and it really isn't a common area we work out of. I think I have maybe taken one or two nursing home calls out of there (Spanish Lake and the places a bit more removed around that way). But a real bad hunting accident out of Columbia bottoms, some trauma with a bad head injury, or something along those lines would be about the only thing I would consider calling for in the county, especially if it was 1600 and traffic was creeping along at 20mph.

In my area, there is just about 0 chance that I would personally call. I have too many hospitals within a reasonable driving distance. HEMS wouldn't be a benefit in treatment nor would the cost justify the end means.


----------



## hometownmedic5 (Apr 17, 2017)

It's not as much the death, although that needs to be considered, as much as the grievous disability.


Remi said:


> Just to follow up on my previous post with a scenario:
> 
> You are out on a Sunday motorcycle ride out in the country with a couple of your buddies. As you round a curve, a car swerves into your lane so you veer hard to the right in order to miss the car. Your front wheel slides out and you end up sliding into a tree. Your right leg is messed up bad and it hurts a little to breath and you feel a little dizzy, but you never lose consciousness and aren't bleeding severely anywhere.
> 
> ...



As described, I would not fly him.


----------



## SpecialK (Apr 17, 2017)

We have very unambiguous national criteria for calling a helicopter (the ANTS criteria) and now have a national Air Desk where experienced helicopter Intensive Care Paramedics decide whether or not to send a helicopter and if so, which one to send.  Gone are the days when Control sent one just because road personnel requested it.

The criteria are as follows:

*Access: *Where road access is so difficult a helicopter is the only feasible means of patient access
*
Number*: The number and condition of patients is such sufficient personnel cannot reach the scene in a reasonable time by road.
*
Time*: The patient has a “time-dependent” problem and use of a helicopter will significantly shorten the time for clinical personnel to first reach the scene, OR time for the patient to be transported to an appropriate hospital
Time-savings are:
Time-critical patient: more than 15 minutes faster than a road ambulance
Time-urgent) patient: more than 30 minutes faster than a road ambulance
*
Skill*: Where the patient has a ‘skill-dependent’ problem (e.g. requires RSI) and use of a helicopter will significantly shorten the time for that skill to be delivered to the patient (see above)

A helicopter ride costs the patient $0.


----------



## VFlutter (Apr 17, 2017)

StCEMT said:


> @Chase, do yall carry blood products? There is only one area I can think of that I would call you guys and it really isn't a common area we work out of. I think I have maybe taken one or two nursing home calls out of there (Spanish Lake and the places a bit more removed around that way). But a real bad hunting accident out of Columbia bottoms, some trauma with a bad head injury, or something along those lines would be about the only thing I would consider calling for in the county, especially if it was 1600 and traffic was creeping along at 20mph.
> 
> In my area, there is just about 0 chance that I would personally call. I have too many hospitals within a reasonable driving distance. HEMS wouldn't be a benefit in treatment nor would the cost justify the end means.



We do not currently but are working on it and probably will soon. 

It is really dependent on the area. Most hospitals in our area are becoming more capable as well as the EMS services. We closed my previous base because call volume steadily declined over the years. Hospitals whom used to send out all STEMI/CVA etc how are keeping and treating. Then you have ground services who are trying to do CCT so HEMS becomes harder to justify. 

But over on the other side of the river you have EMS and hospitals that are much different and many call for our services not the rapid transport. I have called a 2 min ETA to the Trauma Center form a scene with a Level One. May sound crazy but for some of these patients they would not have survived the 15min drive without interventions (RSI, etc).

Personally I would love the option to have a fly car or go by ground if we are not flyable. I think the level of care we provide is what is the biggest benefit to most of the patients we serve.


----------



## EpiEMS (Apr 17, 2017)

You know, this issue reminds me of something that @Tigger said in another thread:



Tigger said:


> To me the problem with tiered systems has always come down to "you don't know what you don't know." I am not comfortable with our lowest educated providers making the determination that the patient needs a higher level of care.



The case seems to be similar here (ground providers calling for higher levels of care by air), but the costs are of orders of magnitude higher...So how can we mitigate this risk effectively? I'm not convinced there are enough evidence-based criteria out there. Can anybody point some out? (Not to mention, there is a paucity of evidence that HEMS is cost effective, especially if not carefully used.)

Anecdotally, I am lucky in that I have never had to call for HEMS (and hopefully won't ever need to) - I am 15 minutes away from one ACS Level II (without L&S - L&S maybe save 2 minutes) , and 30 from a ACS Level I (and Level I peds). I cannot imagine many circumstances where HEMS would really save me much time or add much value over going to the Level II


----------



## SpecialK (Apr 17, 2017)

EpiEMS said:


> The case seems to be similar here (ground providers calling for higher levels of care by air), but the costs are of orders of magnitude higher...So how can we mitigate this risk effectively? I'm not convinced there are enough evidence-based criteria out there. Can anybody point some out? (Not to mention, there is a paucity of evidence that HEMS is cost effective, especially if not carefully used.)



The best way I've seen, and what is used in many places, is centralised, clinically-led air ambulance dispatch be it fixed wing or helicopter.  London uses it and has done for almost thirty years, Scotland uses it, Australia uses it, Ontario uses it, New Zealand now uses it (early days) and I am sure some other places I have left off.

Road personnel call Control, describe the problem and what the patient needs and experienced air ambulance Paramedics in the control room decide what is the best helicopter, or indeed the best resource, to send to the patient and from where.  It might be the closest helicopter or it might not be for a number of reasons.  In some places these staff also scan incidents to determine whether or not to send a helicopter first-up before the road crews request one too and can do further interrogation of callers etc particularly for bad sounding things particularly if in the middle of nowhere.  They can also turn out road based responses e.g. of a HEMS team with a doctor as well. 

In the absence of anything else why not see if you can give it a try?


----------



## NomadicMedic (Apr 17, 2017)

Sounds good in theory, but the entire system is different in the US. 

In the majority of places, the Helicopter service is an independent, private company with no connection to the local agencies. (There are some government agencies that staff HEMS, but they're few and far between) 

We don't have a clinically trained person at our dispatch centers that can make care guided transport decisions. They follow a simple decision tree. And as for best resources, in many cases, it's either a ground paramedic or a helicopter. 

Most helicopter services here don't staff with a doc. A flight nurse and Paramedic is the usual crew. 

Most locales don't have a physician or critical care team to send as a ground based unit. 

Another huge disparity between EMS in the US vs the European model. 




SpecialK said:


> The best way I've seen, and what is used in many places, is centralised, clinically-led air ambulance dispatch be it fixed wing or helicopter.  London uses it and has done for almost thirty years, Scotland uses it, Australia uses it, Ontario uses it, New Zealand now uses it (early days) and I am sure some other places I have left off.
> 
> Road personnel call Control, describe the problem and what the patient needs and experienced air ambulance Paramedics in the control room decide what is the best helicopter, or indeed the best resource, to send to the patient and from where.  It might be the closest helicopter or it might not be for a number of reasons.  In some places these staff also scan incidents to determine whether or not to send a helicopter first-up before the road crews request one too and can do further interrogation of callers etc particularly for bad sounding things particularly if in the middle of nowhere.  They can also turn out road based responses e.g. of a HEMS team with a doctor as well.
> 
> In the absence of anything else why not see if you can give it a try?


----------



## VentMonkey (Apr 17, 2017)

Right, but as this article, and many have eluded to:

Is the HEMS industry even capable of remaining a viable commodity in spite of its less than consumer friendly costs?

Clearly, Medicare reimbursement restructuring created this massive growth in competition between companies within the industry who are (literally) putting bases in hangars on the same airport property directly in sight of one another's airframes.

Where's our breaking point? When do we stop the profit driven double downing, much like...any, and all for profits within the EMS industry?


----------



## EpiEMS (Apr 17, 2017)

@VentMonkey, so I think you're referencing the idea of service duplication. There's a ton of study in this area...especially for hospitals. The whole certificate of need concept was built to "mitigate" this risk, but there is a limited amount of evidence for their success (and ample evidence of harm) for CONs. Now, maybe EMS is different, but I don't think so.


Sent from my iPhone using Tapatalk


----------



## E tank (Apr 17, 2017)

This is a big conversation.

 IMO, HEMS should be treated like any expensive, subspecialty care. Not every hospital has a cath lab or interventional radiology lab. Insurance covers these, not in small part because, as expensive as they are, they supplant far more expensive alternatives (surgery) in plenty of cases. Further, HEMS programs in Maryland or Wisconsin are not the same as HEMS programs in Idaho or Wyoming. Comparisons to other countries' systems, as noted above, are apples to oranges. 

For starters, gov't tax breaks (not subsidies) to not for profit hospital based programs would help, I think. But with so many NFP programs offering "memberships" that are valid within "networks" affiliated services,  patients living in those areas would do well to pony up the 60 bucks a year or so. 

There are too many helicopters and they're over utilized.


----------



## E tank (Apr 17, 2017)

E tank said:


> There are too many helicopters and they're over utilized.



I need to amend that statement. I really don't know that there are too many helicopters. I retract that statement. I'll stick to  the idea that they are over utilized, though.


----------



## E tank (Apr 17, 2017)

EpiEMS said:


> @VentMonkey, so I think you're referencing the idea of service duplication. There's a ton of study in this area...especially for hospitals. The whole certificate of need concept was built to "mitigate" this risk, but there is a limited amount of evidence for their success (and ample evidence of harm) for CONs. Now, maybe EMS is different, but I don't think so.



The problem with trying to qualify the utility of "certificate of need" laws is that the heterogenicity of health care delivery across the United states is vast. An entire state medical system with a catchment of less than a million and a half, give or take, does not need 7 heart surgeons, 3 neonatal ICU's and a cath lab at every inpatient hospital. But that same system may utilize as many helicopters as a metropolitan area of 9 million. 

Some of what drives this stuff is quality of life for folks working in these sub specialty areas. One cath lab suite could handle the work of three in some towns,  but call would be hell and the elective schedule would go 10 hours a day every day. Getting subspecialists to come to a town like that isn't always that easy. 

Anyway, more fodder...


----------



## VentMonkey (Apr 17, 2017)

E tank said:


> I need to amend that statement. I really don't know that there are too many helicopters. I retract that statement. I'll stick to  the idea that they are over utilized, though.





E tank said:


> There are too many helicopters and they're over utilized.


Why? I actually agree with this. There are too many, and they can often be over utilized. That said, I have seen a remarkable trend in better judgment overall with many of our county's paramedics.

While not every flight nurse or paramedic will like this statement, it's true, and truths hurts. H_EMS_ is still every bit the part _EMS_, and egos are just as plentiful...

...unfortunately.


----------



## E tank (Apr 17, 2017)

VentMonkey said:


> Why? I actually agree with this. There are too many,...unfortunately.



It may be Vent, I just don't know. What's the threshold for too many? That's a hard number to come up with. The unit availability should never be 100% but what should it be for the best, most reasonable  utilization of the resource for the most possible legitimate transports?  Again, a lot comes down to where  you are. Its tough.


----------



## VentMonkey (Apr 17, 2017)

E tank said:


> It may be Vent, I just don't know. What's the threshold for too many? That's a hard number to come up with. The unit availability should never be 100% but what should it be for the best, most reasonable  utilization of the resource for the most possible legitimate transports?  Again, a lot comes down to where  you are. Its tough.


It does; add to this our every growing population as a first world country. 

My county alone is a good example. We're already half a million or so within the city limits, yet also have some extremely rural roads and coverage areas that can, and will take ground responders longer to get to a patient than it will us. This is a good thread topic.


----------



## Tigger (Apr 17, 2017)

EpiEMS said:


> You know, this issue reminds me of something that @Tigger said in another thread:
> 
> 
> 
> The case seems to be similar here (ground providers calling for higher levels of care by air), but the costs are of orders of magnitude higher...So how can we mitigate this risk effectively? I'm not convinced there are enough evidence-based criteria out there. Can anybody point some out? (Not to mention, there is a paucity of evidence that HEMS is cost effective, especially if not carefully used.)


At the very least I wish every HEMS transport was reviewed for efficacy. While we review all of our calls for clinical issues, operational ones like these are not often brought up, which I hope will change. Also, someone needs to have the authority to say "that was not an appropriate HEMS utilization."  While I understand that no two patients and calls are alike, at a certain point we need to identify trends and put a stop to excessive use. 

We are also certainly struggling with how to deal with flying moderately injured patients out of the backcountry. Most of these patients do not need a helicopter but it is dangerous to extricate non-ambulatory patients out of some of our ATV areas. So many of these patients get flown, and probably stuck with unnecessary bill. While HEMS is of course more risky than ground transport, I'd say being strapped to a stokes on the back of a mule coming out on 8 miles of what are charitably called roads is also rather dangerous.


----------



## Tigger (Apr 17, 2017)

At the very least I wish every HEMS transport was reviewed for efficacy. While we review all of our calls for clinical issues, operational ones like these are not often brought up, which I hope will change. Also, someone needs to have the authority to say "that was not an appropriate HEMS utilization."  While I understand that no two patients and calls are alike, at a certain point we need to identify trends and put a stop to excessive use.

We are also certainly struggling with how to deal with flying moderately injured patients out of the backcountry. Most of these patients do not need a helicopter but it is dangerous to extricate non-ambulatory patients out of some of our ATV areas. So many of these patients get flown, and probably stuck with unnecessary bill. While HEMS is of course more risky than ground transport, I'd say being strapped to a stokes on the back of a mule coming out on 8 miles of what are charitably called roads is also rather dangerous.
What at @SpecialK describes for activation would be excellent. Though the helicopters are provided in a different manner in this country, there is no reason why crews could not consult their own (hopefully educated) clinical supervisor to get approval for HEMS use.


----------



## SpecialK (Apr 18, 2017)

NomadicMedic said:


> In the majority of places, the Helicopter service is an independent, private company with no connection to the local agencies. (There are some government agencies that staff HEMS, but they're few and far between)



In the UK and New Zealand the ambulance service and HEMS are separate entities.  In some, but not all, cases some clinical crew come from the ambulance service but some employ their own staff.



NomadicMedic said:


> We don't have a clinically trained person at our dispatch centers that can make care guided transport decisions. They follow a simple decision tree. And as for best resources, in many cases, it's either a ground paramedic or a helicopter.



Pretty much everywhere it's either a ground or helicopter response.  The trick is deciding which one and if a helicopter is going to be sent, which helicopter if more than one is available.

If you do not have somebody clinically trained in the control room (not sure how exactly that's possible but righto ...) then you could always you know, get some? At some point in history it was a "new" idea for the people doing it as well? Not sure how that can't be solved?



NomadicMedic said:


> Most helicopter services here don't staff with a doc. A flight nurse and Paramedic is the usual crew.



Shouldn't make a difference really.



NomadicMedic said:


> Most locales don't have a physician or critical care team to send as a ground based unit.



Many do not, but again, this shouldn't be a problem, it's not a requirement.

Doesn't sound like there's anything preventing this from being tried?


----------



## VFlutter (Apr 18, 2017)

Remi has been in this business much longer than I so


Tigger said:


> At the very least I wish every HEMS transport was reviewed for efficacy. While we review all of our calls for clinical issues, operational ones like these are not often brought up, which I hope will change. Also, someone needs to have the authority to say "that was not an appropriate HEMS utilization."  While I understand that no two patients and calls are alike, at a certain point we need to identify trends and put a stop to excessive use.



There are some companies who will take anything and everything but that is not always the case. We get tons of training on flight utilization and medical necessity then have all our charts review by documention specialist. If you are constantly taking flights that get denied by insurance then you will hear about it. It doesn't do most companies any good to take flights that don't meet insurance criteria and will never collect on the private billing. 

Also it does not take a helicopter to ruin someone's finances from medical cost. When I was in college I ended up going to the ER as a Level One then kept for a few hours and sent home. Bill was $16k+ after insurance. The insurance company tried to deny a bunch of stuff since they didn't think I met trauma criteria (which I didn't) so I personally got billed for the $4500 "Level One Activation".  

So I do not blame HEMS companies completely, they are doing what everyone else in medicine does. They need to collect big when they can because the majority don't collect.


----------



## EpiEMS (Apr 18, 2017)

Tigger said:


> At the very least I wish every HEMS transport was reviewed for efficacy. While we review all of our calls for clinical issues, operational ones like these are not often brought up, which I hope will change. Also, someone needs to have the authority to say "that was not an appropriate HEMS utilization." While I understand that no two patients and calls are alike, at a certain point we need to identify trends and put a stop to excessive use.



This is a really good point - and I think this should be a best-practice at the agency level. Perhaps something to bring up to the medical director, even, given that HEMS transport is a "treatment" in and of itself?


----------



## DrParasite (Apr 18, 2017)

SpecialK said:


> Road personnel call Control, describe the problem and what the patient needs and experienced air ambulance Paramedics in the control room decide what is the best helicopter, or indeed the best resource, to send to the patient and from where.  It might be the closest helicopter or it might not be for a number of reasons.  In some places these staff also scan incidents to determine whether or not to send a helicopter first-up before the road crews request one too and can do further interrogation of callers etc particularly for bad sounding things particularly if in the middle of nowhere.  They can also turn out road based responses e.g. of a HEMS team with a doctor as well.


Hi, former air medical telecommunicator here..... We originally dispatched for 4 helicopters (up from 2 back in the day), and when I left, I think we had something like 10, just covering NJ.  We never turned down a request (except when it was unsafe to fly, IE, weather), and it was always whomever was closest (with a little bit of politics thrown in), but helicopter transports are big money.  That was why lawsuits were initially filed to open up the medevac system to private entities (and boy did it open up)

http://www.nj.com/south/index.ssf/2016/07/southstars_grounding_means_no_more_free_air_medica_1.html
http://www.nj.com/burlington/index.ssf/2016/10/legislators_call_for_south_jersey.html

back to the topic at hand....

So all you guys, who rarely have a nice thing to say about any dispatchers, are going to let them decide whether you, the person in the field, needs a helicopter? 

or even better, your going to trust a "experienced air ambulance paramedic" who now works full time in control, and hasn't seen a real patient in 10 years, and allow them to overrule your clinical judgement?

In the litigious US, assuming the ground paramedic calls for the helicopter (and rightfully so), but the dispatcher doesn't feel the patient warrants it (because the paramedic didn't paint a good enough picture), and the patient dies as a result...... who should pay the punitive damages?

Honestly, it makes more sense to have the medevac approved by an field supervisor, medical director, or someone in the EMS agency's administration, if you can't trust your paramedics to call for the HEMS appropriately.  Or if HEMS are being called inappropriately, than the agency should be responsible for QA, and for providing appropriate guidelines for when a helicopter should and should not be used.

If you joe public can't trust you to call for additional resources appropriately, why should they trust you to treat the patient?


----------



## EpiEMS (Apr 18, 2017)

E tank said:


> The problem with trying to qualify the utility of "certificate of need" laws is that the heterogenicity of health care delivery across the United states is vast.



Doesn't this speak to why state-level CON laws aren't necessarily the best way to limit duplication of services (if, indeed, they do)?



Chase said:


> So I do not blame HEMS companies completely, they are doing what everyone else in medicine does. They need to collect big when they can because the majority don't collect.



Fair point - but I don't think this is the whole story. Price discrimination doesn't necessarily mean that they are shifting costs. And costs, obviously, are not immutable, so perhaps there is a more fundamental issue?


----------



## SpecialK (Apr 18, 2017)

DrParasite said:


> So all you guys, who rarely have a nice thing to say about any dispatchers, are going to let them decide whether you, the person in the field, needs a helicopter? or even better, your going to trust a "experienced air ambulance paramedic" who now works full time in control, and hasn't seen a real patient in 10 years, and allow them to overrule your clinical judgement?



Sorry? When did I ever say ambulance personnel said anything bad about the control room staff?

And where did you get the idea the air desk staff don't see patients? Every single one of them still works on the helicopter. 

It's not about overruling anybody; it's about ensuring the most appropriate resources are sent to patients who need them.  Helicopters are overrated, and overused, and historically there has been some quite poor decision making by ambulance personnel about what needs a helicopter and what doesn't and historically the control room staff have had limited assistance in deciding which helicopter to send.

Helicopters are overrated, overused, very expensive (i.e. scant resource) and often cover a very large area so need to be used wisely.  Take for example a patient who is one hour by road from the hospital; when you add up time to take off, fly, land, load, take off again, fly back and unload it's just as quick to take them by road.  There is also very limited room to treat a patient in a helicopter, particularly this is worse at night as the lights are dimmed to maintain night vision for the pilots. 



DrParasite said:


> In the litigious US, assuming the ground paramedic calls for the helicopter (and rightfully so), but the dispatcher doesn't feel the patient warrants it (because the paramedic didn't paint a good enough picture), and the patient dies as a result...... who should pay the punitive damages?



Again, you are looking at this the wrong way.  It's not about denying anybody. and certainly wouldn't be the role of the control room allocating staff to do so because they are not clinically trained.  This is why in many places the job of air ambulance tasking is undertaken by experienced air ambulance clinical personnel in a central hub to determine whether or not to send a helicopter and if so, which one to send. 

If you have, as you say, ten helicopters, which of the ten do you send? What if the closest one is not available? What about crewing configuration? Are they all the same in terms of, for example night or weather flying capabilities, which hospital does the patient need to go to and does this change what is done? is what the patient needs available by a road based response? do we send the helicopter before, or at the same time as, a ground ambulance?

Just like how if you call an ambulance the closest ambulance is not automatically sent to you no questions asked, the same needs to be true of helicopters, just because a crew requests a helicopter, you don't blindly send them a bloody helicopter ....some of the jobs I've seen helicopters turned out for have ended up being utter rubbish and it didn't actually make one iota of difference to the patient except for a "little bit quicker" ride to the hospital.  This is not a good way to use a resource regardless of what it is.  

The new method (and that used in many places internationally - see previous) is much better it seems as it allows for much more informed decisions to be made about what the patient needs are and how best to meet them rather than just sending them helicopters willy nilly as was previously done in the past with some very questionable results.

In reality it's nothing more than good triage, like what Control do all day every day to people who call in; deciding who should get an ambulance (which is most people - I think at last count the Clinical Hub screened out about 5-10% of calls) and of those who need one, who gets one first and from where ... exactly the same principle just applied to helicopters.


----------



## DrParasite (Apr 18, 2017)

SpecialK said:


> Sorry? When did I ever say ambulance personnel said anything bad about the control room staff?


That was more of the general "you", for those people who are always looking to complain about those in dispatch, not you personally


SpecialK said:


> And where did you get the idea the air desk staff don't see patients? Every single one of them still works on the helicopter.


really?  so people rotate from the helicopter to control, on a regular basis?  I'm not familiar with any US based system that does that, a people are usually assigned to either control or the field.  cross training might occur, but I haven't seen one that offers a regular rotations.

BTW, I think it's a great idea, and wish more places in the US operated like that.


SpecialK said:


> It's not about overruling anybody; it's about ensuring the most appropriate resources are sent to patients who need them.  Helicopters are overrated, and overused, and historically there has been some quite poor decision making by ambulance personnel about what needs a helicopter and what doesn't and historically the control room staff have had limited assistance in deciding which helicopter to send.


I will agree that they are over used, and over rated, but I think a more efficient way to correct the poor decision making by ambulance personnel would be to correct the issue at the start (IE, what are they calling for, why are they calling, ok, you guys are calling for the wrong reasons, here is why you should call for the helicopter), instead of having having experienced air ambulance personnel decide whether or not to send a helicopter.  But I think we might need to agree to disagree on this one


SpecialK said:


> Again, you are looking at this the wrong way.  It's not about denying anybody. and certainly wouldn't be the role of the control room allocating staff to do so because they are not clinically trained.  This is why in many places the job of air ambulance tasking is undertaken by experienced air ambulance clinical personnel in a central hub to determine whether or not to send a helicopter and if so, which one to send.


whether it's the ambulance control room, or the helicopter control room, it's still a person who is not on location making a decision to send the helicopter, based on their interpretation of the situation.  But I might be looking at it a different way, so I will agree to disagree


SpecialK said:


> If you have, as you say, ten helicopters, which of the ten do you send? What if the closest one is not available?


 to answer your question, if I have 10 helicopters, I send the closest one that is available.  If they are not available (maintenance, on another assignment, no staffing, etc), then they don't count, and I move to the next closest available one.  if three helicopters decline due to weather, then the requesting agency is advised the request is declined due to weather / safety reasons.





SpecialK said:


> What about crewing configuration? Are they all the same in terms of, for example night or weather flying capabilities, which hospital does the patient need to go to and does this change what is done? is what the patient needs available by a road based response? do we send the helicopter before, or at the same time as, a ground ambulance?


All should have the same crew configurations (1-2 pilots, 1 flight medic, and 1 flight medic/Nurse).  so no matter which helicopter arrives, they should have the same basic training.  ditto the weather and night capabilities, I would imagine all the training for the pilots is the same.  if the patient is a trauma, they are flown to the closest appropriate trauma center (typically as the crow flies).  if it's another specialty center (stroke, MI, etc), same thing, closest one, often determined by dispatch.  If they don't, that is acceptable, however it requires justification in writing after the fact to their coordinators as to why they made that decision (in case there is any question aftwards)

Helicopters can be requested by any public safety official on the scene (decision predates me).  so if the cop pulls up and says it's a bad wreck, they can request a helicopter before EMS arrives.  I'm not saying I agree with it, but that was how the system was set up.  typically only EMS or ALS will cancel the helicopter.


SpecialK said:


> Just like how if you call an ambulance the closest ambulance is not automatically sent to you no questions asked, the same needs to be true of helicopters, just because a crew requests a helicopter, you don't blindly send them a bloody helicopter ....some of the jobs I've seen helicopters turned out for have ended up being utter rubbish and it didn't actually make one iota of difference to the patient except for a "little bit quicker" ride to the hospital.  This is not a good way to use a resource regardless of what it is.


wait, you don't send the closest ambulance?  why not?

and for the record, we have ALL been on calls where people called an ambulance and it turned out to be utter rubbish.

But I go back to my original point.... instead of denying the helicopter, wouldn't it be better to prevent these inappropriate requests from being made in the first place?


SpecialK said:


> The new method (and that used in many places internationally - see previous) is much better it seems as it allows for much more informed decisions to be made about what the patient needs are and how best to meet them rather than just sending them helicopters willy nilly as was previously done in the past with some very questionable results.


Here are the guidelines from the ACEP:
https://www.acep.org/uploadedFiles/..._Medical_Services/GuidelinesForAirMedDisp.pdf
and from the US government:
https://www.ems.gov/ficems/june2012/Draft Manuscript for HEMS Evidence-based Guideline.pdf
and from the NJ Department of health:
http://www.nj.gov/health/ems/special-services/fly-or-drive-criteria/
and from a commercial service from NY:
https://www.mercyflight.org/content/pages/utlization

Does the international community has any objectively written guidelines, that are better than what other agencies have been using?  or are they left completely up to the helicopter dispatcher's subjective discretion?


SpecialK said:


> In reality it's nothing more than good triage, like what Control do all day every day to people who call in; deciding who should get an ambulance (which is most people - I think at last count the Clinical Hub screened out about 5-10% of calls) and of those who need one, who gets one first and from where ... exactly the same principle just applied to helicopters.


I used to have dreams about being able to tell people they didn't need an ambulance when they called 911 for BS...... I can't think of a single system in the US that allows this (and if there is one, I'll apply tomorrow!)


----------



## Tigger (Apr 18, 2017)

DrParasite said:


> So all you guys, who rarely have a nice thing to say about any dispatchers, are going to let them decide whether you, the person in the field, needs a helicopter?
> 
> or even better, your going to trust a "experienced air ambulance paramedic" who now works full time in control, and hasn't seen a real patient in 10 years, and allow them to overrule your clinical judgement?
> 
> In the litigious US, assuming the ground paramedic calls for the helicopter (and rightfully so), but the dispatcher doesn't feel the patient warrants it (because the paramedic didn't paint a good enough picture), and the patient dies as a result...... who should pay the punitive damages?


I would not want to call the flight company to see if it's appropriate, I'd rather be calling my clinical supervisor or my medical control. If they think it's inappropriate and I can't make a good case, then I would be overruled and that would be it. 

I doubt there would be any punitive damages in the above scenario as there is no way to possibly prove that the helicopter could have made any difference nor is there any expectation that a helicopter must be made available to the patients. In many states there isn't even a legal expectation to send an ambulance.


----------



## Carlos Danger (Apr 22, 2017)

Chase said:


> There are some companies who will take anything and everything but that is not always the case. We get tons of training on flight utilization and medical necessity then have all our charts review by documention specialist. If you are constantly taking flights that get denied by insurance then you will hear about it. It doesn't do most companies any good to take flights that don't meet insurance criteria and will never collect on the private billing.
> 
> *Also it does not take a helicopter to ruin someone's finances from medical cost.* When I was in college I ended up going to the ER as a Level One then kept for a few hours and sent home. Bill was $16k+ after insurance. The insurance company tried to deny a bunch of stuff since they didn't think I met trauma criteria (which I didn't) so I personally got billed for the $4500 "Level One Activation".
> 
> So I do not blame HEMS companies completely, they are doing what everyone else in medicine does. *They need to collect big when they can because the majority don't collect.*



So you are saying it's OK for HEMS programs taking people to court over bills for a service that the patient didn't need and probably didn't consent to, just because the HEMS programs "need to collect big when they can"?

Also, it isn't about taking flights that are denied by insurance. Many insurers do pay a portion of the HEMS bill, but that doesn't help the family much who then gets billed for the difference, which in some cases is tens of thousands of dollars. If the flight was truly medically necessary that's one thing, but they rarely are. It also doesn't necessarily make it all OK if the insurer covered the whole bill. Because we are still talking about insurers being billed for an unnecessary service, which drives up costs for everyone.

An analogy would be if everyone who presented to the hospital with any complaint of chest pain or discomfort was immediately whisked to the cath lab for angiography. And we kept doing it because "catheterization is the definitive treatment for AMI" and "time is muscle" and we simply ignored the fact that few patients benefitted and most weren't even having an MI. In fact in spite of knowing that, we built more and more cath labs, right next door to each other in some cases. And we had no qualms sending large bills out to people for procedures that we knew they didn't even need. A hospital could never get away with that, of course - it'd be called fraud, and people would end up in prison. HEMS can do almost exactly the same thing though, and it is called a public service. 

A HEMS transport is a medical procedure, not unlike a heart cath or a surgery. It carries costs and risks and potential benefits. Like any procedure, it should only be done when the expected benefits outweigh the risks and the costs, and preferably when the patient understands that analysis and consents. I think if we analyzed HEMS transports objectively the same way we analyze other procedures, we would be pretty blown away with how loosely we apply that cost/risk:benefit analysis.


When I interviewed for my last HEMS job, I asked them during the interview "How do you handle patients who have a hard time paying their bill". They told me that they always bill insurance, and whatever cost is left over they will bill the patient for. But if the patient calls and tells them they can't pay the bill, they simply write it off. They don't pursue it in court, and they don't report it to collections. The programs I worked at before each had the same policy. Not to sound too holier-than-thou, but I honestly would not have taken the job if they told me that they pursue payment from people who can't pay.

Why was that so important to me? Because I know that statistically speaking, not only do a _very_ low percentage of people flown by HEMS even benefit clinically from it, but in many cases, you aren't even saving any time with HEMS. Clearly, some level of over-triage is desirable when you are talking about critical patients. But we are talking a massive level of over-triage here, like NNT's likely in the dozens, if not hundreds.

So after years of flying patients who clearly did not need to be flown and reading about AEL and Air Methods dragging people to court and putting them into bankruptcy for transports that the patient never provided informed consent for and in many cases was very obviously not even necessary, I just decided I didn't want any part of that.

I can't accept the "well the rest of healthcare does it, so......" argument mostly because the rest of healthcare doesn't do it to nearly the extent that HEMS does. There are many HEMS programs that still preach "the golden hour" and "mechanism of injury" or "we have RSI and you don't" as justifications for using them, and even though they all give lip service to utilization, the reality is that they could not care less how little their patients benefit, as long as they get paid. I also don't see many hospital patients getting sued in court over unpaid ICU bills. The unscrupulousness of some of these HEMS agencies is just not duplicated anywhere elsewhere in acute care, at least not that I've seen.

The reality is that many - possibly a majority? - of HEMS bases would simply close down if they were forced to find a way to only transport patients who really have the potential to benefit, or if they stopped billing patients who never consented to their services. Transporting patients who don't need to be transported and then billing them for it is literally a big part of their business model. Because we all know that there simply aren't nearly  enough critical or time-sensitive patients to provide the call volume that these bases need to survive. Yet they are still there.

I know there are good HEMS programs out there in regions with very long transport times to tertiary care that have high clinical and safety standards and really do strive for appropriate utilization. That's what we all like to think of when we think of HEMS. But for every program like that, there's at least one bottom feeder HEMS base that uses barely-adequate airframes and staffs with minimally qualified people and routinely gets people to the hospital in the same time the ambulance could have, could never justify what they do on clinical outcomes, and routinely sends out huge bills to people who they flew to the trauma center who probably could have gone to the local ED by POV and been just fine. So as fond as I am of HEMS, I have to agree strongly with this article.


----------



## VFlutter (Apr 22, 2017)

I agree with what you are saying and I do not think companies should be taking these patients to court when it is questionable. But should insurance and medicaid be paying more instead of just turfing it to the patient?  You have many more years in the industry then I and maybe I am just naive but i truly can not think of a patient whom I have flown that wasn't necessary. Most of that is because the local ground services lack CCT and RSI.


----------



## StCEMT (Apr 22, 2017)

Chase said:


> Most of that is because the local ground services lack CCT and RSI.


Is this on the IL side?


----------



## EpiEMS (Apr 22, 2017)

Chase said:


> But should insurance and medicaid be paying more instead of just turfing it to the patient?



I'd find it hard to imagine that they'd be willing to...

And it'd be tough to mandate them to if the service isn't warranted. Heck, I'd rather see EMS agencies that request HEMS unnecessarily pay for it...


----------



## VFlutter (Apr 22, 2017)

StCEMT said:


> Is this on the IL side?



Yes. Saint Louis and most of Missouri is much different than Illinois.


----------



## StCEMT (Apr 22, 2017)

Chase said:


> Yes. Saint Louis and most of Missouri is much different than Illinois.


Oh ok, gotcha. For some reason I thought I recalled you saying you were based out of the STL Missouri or St. Charles areas.


----------



## VFlutter (Apr 22, 2017)

StCEMT said:


> Oh ok, gotcha. For some reason I thought I recalled you saying you were based out of the STL Missouri or St. Charles areas.



I was at first but now just across the river


----------



## Carlos Danger (Apr 22, 2017)

Chase said:


> But should insurance and medicaid be paying more instead of just turfing it to the patient?



Even if insurance paid 100% in every case and no patient ever saw a bill for a HEMS transports, you would still have the problem of insurers having to shell out for an expensive procedure that is usually not done out of necessity. The fact that the consumer usually doesn't see the cost of healthcare and expects to pay little if anything out of pocket is part of the reason for the healthcare mess that we have. So I don't think hiding the cost by shifting it to insurers is the right approach. 



Chase said:


> maybe I am just naive but i truly can not think of a patient whom I have flown that wasn't necessary. Most of that is because the local ground services lack CCT and RSI



I don't mean to be negative, Chase. I know you are excited about your new career, and I am happy for you. I loved HEMS and still miss it. Not trying to be a downer here, just pointing out an important issue that often gets ignored. I wouldn't use the word naive; I'd say you are just learning and are appropriately focusing on the safety and clinical aspects of you new role. 

How do you know that all the flights you've done were necessary? Do you mean necessary as in, the patient almost certainly wouldn't have survived if your helicopter or another one hadn't been available? 

Take a look at the research on HEMS effectiveness.  Again, not trying to be a downer, but I'd say very generally speaking, that if a program isn't routinely saving at least 30 minutes over ground transport times and giving blood for hemorrhagic shock or doing some other intervention that simply isn't feasible for ground EMS to perform, then they probably aren't doing anything that ground EMS can't do for less money.


----------



## SandpitMedic (Apr 23, 2017)

DrParasite said:


> Hi, former air medical telecommunicator here..... We originally dispatched for 4 helicopters (up from 2 back in the day), and when I left, I think we had something like 10, just covering NJ.  We never turned down a request (except when it was unsafe to fly, IE, weather), and it was always whomever was closest (with a little bit of politics thrown in), but helicopter transports are big money.  That was why lawsuits were initially filed to open up the medevac system to private entities (and boy did it open up)
> 
> http://www.nj.com/south/index.ssf/2016/07/southstars_grounding_means_no_more_free_air_medica_1.html
> http://www.nj.com/burlington/index.ssf/2016/10/legislators_call_for_south_jersey.html
> ...








This post hits the nail squarely on the head.


----------



## SandpitMedic (Apr 23, 2017)

After three pages of posts, I've only seen one person come close to the root of the issue. 

As Remi stated, all these companies care about is their bottom line. Period. End of story. 

Some are better at safety and QA/QI and better airframes than the competition, but at the end of the day it's about $. 

That's it, so as long it is a for profit business, you will have entities scrounging to get as much as they possibly can.


----------



## SandpitMedic (Apr 23, 2017)

Regarding calls for service....

I have no option/authority of not transporting once the request is made (save for declining for safety). 
If I show up to a patient and determine they don't warrant a flight, I can't turf them, or I GET FIRED if I did. That's declining revenue, and big brother does not like that. 

Additionally, I don't have a crystal ball, and you can be the best provider ever but you still can't say anything for certain in the field. Hypothetically, even if I could decline the service...If I deem them turfable and they have a bad outcome guess who is getting sued and possibly facing charges for neglect, the company with deep pockets and little old me also. It doesn't matter if not taking the helicopter ride actually caused the poor outcome. It only matters what the lawyers will argue and can convince a jury of. "Poor Mary Jane, mother of 4, would be alive today  if that Paramedic had just transported her by air." 
No company is going to take that liability. That's the same reason no ground ambulance can refuse transport. Once you make patient contact you're stuck unless you have a strong documented reason or the patient initiates the refusal.


----------



## E tank (Apr 23, 2017)

SandpitMedic said:


> After three pages of posts, I've only seen one person come close to the root of the issue.
> 
> As Remi stated, all these companies care about is their bottom line. Period. End of story.
> 
> ...



Perhaps...but being a for profit business and providing a needed service ethically are not mutually exclusive. Don't throw the baby out with the bathwater. 

Sure there are exceptions and not-for-profit is no guarantee of safety or quality.


----------



## VFlutter (Apr 23, 2017)

Remi said:


> I don't mean to be negative, Chase. I know you are excited about your new career, and I am happy for you. I loved HEMS and still miss it. Not trying to be a downer here, just pointing out an important issue that often gets ignored. I wouldn't use the word naive; I'd say you are just learning and are appropriately focusing on the safety and clinical aspects of you new role.
> 
> How do you know that all the flights you've done were necessary? Do you mean necessary as in, the patient almost certainly wouldn't have survived if your helicopter or another one hadn't been available?
> 
> Take a look at the research on HEMS effectiveness.  Again, not trying to be a downer, but I'd say very generally speaking, that if a program isn't routinely saving at least 30 minutes over ground transport times and giving blood for hemorrhagic shock or doing some other intervention that simply isn't feasible for ground EMS to perform, then they probably aren't doing anything that ground EMS can't do for less money.



I agree with everything you are saying. However it is tough on knowing where to draw the line on the financial side of things. Do I think HEMS bills should be bankrupting people whom can not pay the bill or pay for bills which are truly not necessary? Absolutely not. But I do think HEMS provides a valuable ,albeit expensive, service. I think it would be awesome if HEMS was no-profit like London HEMS or Maryland.

I agree that a lot what we offer can be done on the ground however that is not the case in most places. I think the level of care we provide is beneficial to a lot, not all,  of patients.

I guess to be fair I should say that I feel that none of them were blatantly unnecessary like I have seen with other companies. I.e. Stroke patients outside of treatment windows, CHF on nitro and 2L NC, etc.  On scene calls I feel like most of the patients would have died or been worse off without. For CCT IFT I feel that most are sufficiently critical enough (Intubated, drips, etc) that our level of care was beneficial. I have very few flights without interventions, vent adjustments, etc. Could some of those ICU patients go by ground with a true CCT truck? Absolutely. But not all areas have adequate ground CCT. We also transport a lot of cardiac critical care (VAD, ECMO, IABP).

So again I do agree that a lot of what we do can be done on the ground for cheaper, and I do wish we had the option of ground transport, but not all ground system are up to that.


----------



## VentMonkey (Apr 23, 2017)

@Chase you're going to find yourself self "Chasing your tail". Yes, pun intended.

We had this exact same discussion on the board my first week of Creighton's CCP class. The end result was there's no quick, or clear cut answer.

Will the bubble ever burst? Inevitably, perhaps. For now, there are a dozen reasons to argue both sides of the air vs. ground debate, their viability, justifications, and sustainability.


----------

