# I think I am done with helicopters



## Eli (May 17, 2013)

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?


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## VFlutter (May 17, 2013)

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.


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## Ecgg (May 17, 2013)

Chase said:


> 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.


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## Eli (May 17, 2013)

Ecgg said:


> 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.


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## chaz90 (May 17, 2013)

Chase said:


> 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?


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## Ace 227 (May 17, 2013)

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


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## Ecgg (May 17, 2013)

Eli said:


> 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


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## Ecgg (May 17, 2013)

chaz90 said:


> 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?


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## chaz90 (May 17, 2013)

Ecgg said:


> 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.


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## Handsome Robb (May 17, 2013)

chaz90 said:


> 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


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## Carlos Danger (May 17, 2013)

chaz90 said:


> 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?


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## chaz90 (May 17, 2013)

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


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## chaz90 (May 17, 2013)

Halothane said:


> Let me guess.....state police?



Yep


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## Eli (May 18, 2013)

Ecgg said:


> Here are some studies for you



Thanks! These are a great start.


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## Arovetli (May 18, 2013)

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.


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## Carlos Danger (May 18, 2013)

Eli said:


> 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.


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## Arovetli (May 18, 2013)

Halothane said:


> 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)
> ...



there must be an echo in the room...


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## mycrofft (May 19, 2013)

*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.


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## Summit (May 19, 2013)

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


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## Arovetli (May 19, 2013)

mycrofft said:


> 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.
> 
> ...




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.


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## the_negro_puppy (May 19, 2013)

Our primary choppers here have an Intensive Care Paramedic and Doctor on board so the can add significant value in certain circumstances. They are used primarily for trauma and rescue.


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## Carlos Danger (May 19, 2013)

mycrofft said:


> 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.
> *
> ...




If helicopters were properly utilized, you would only need a handful in each state, they would be based in the areas where they are most likely to be needed, and their use would be infrequent enough that worrying about "the next call" would never be an issue.

Only certain airframes are considered by some to be prohibitively small (B206, some would say the A-star series). The most commonly used models (Eurocopter's EC series) are very cozy compared to an ambulance, but you can pretty easily do anything you need to do in one. Airway management, IO or CVC placement, chest tube placement, IABP transfers, isollette transfers, etc have all been done repeatedly in every civilian airframe used for HEMS, even the smaller ones. 

Lack of pressurization is actually not an issue for crew or patients except for those few programs that operate at very high altitudes. The much more common stressors are noise and vibration. Noise is easily mitigated and vibration is usually less of a stressor in a helicopter than the bouncing, jarring, and g-forces experienced in ground ambulances. Unless it's a gusty day, then it can be brutal. Bring out the midazolam and promethazine. I actually have a couple pretty good stories about that....

The NG was used in many communities during the 70's and 80's. Many of the problems mentioned here are actually worse with military aircraft, though. They typically take much longer to launch, require more space to land, are more expensive to operate, and still require (if it's done right) facilities, crew training, etc.





Summit said:


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



No, I don't think so. I mean, maybe in some cases they had docs on board, but usually it was Army medics, or sometimes local EMS folks. Just depends how the agreements and system was set up between the MEDEVAC unit and the local EMS system.

It was called the Military Assistance to Safety & Traffic (MAST) program. It started in the early 70's and was officially ended in 2008 or 2009, I think, though most MAST units already hadn't been active for years at that point.





Arovetli said:


> Make them unprofitable and they will largely disappear.
> 
> Money wins.



The necessity of being financial solvent is not limited to HEMS companies. Make any hospital or physician's group unprofitable and they too will go away.

I think a much better strategy than trying to manipulate their profitability is to simply utilize them appropriately.

If we (both EMS and ED docs) would stop calling HEMS for every stubbed toe we come across, the problem would fix itself.


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## Arovetli (May 19, 2013)

Halothane said:


> If helicopters were properly utilized, you would only need a handful in each state, they would be based in the areas where they are most likely to be needed, and their use would be infrequent.....
> 
> ....I think a much better strategy than trying to manipulate their profitability is to simply utilize them appropriately.
> 
> If we (both EMS and ED docs) would stop calling HEMS for every stubbed toe we come across, the problem would fix itself.



If appropriate use decreases the transports it decreases income which is a manipulation of profitability. If changes are to be made to how they operate, changes have to be made to the revenue stream.

Respectfully, its a bit naive, yet endemic to clinicians, to believe that simply practicing medicine real good will always change the world.

There is money and politics in the mix, and unfortunately in the current system, unnecessary medicine provides income to offset the low paying or absent paying. And unnecessary medicine can make one alot of money.

money wins. 
always does.


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## Carlos Danger (May 19, 2013)

Arovetli said:


> If appropriate use decreases the transports it decreases income which is a manipulation of profitability. If changes are to be made to how they operate, changes have to be made to the revenue stream.



No, manipulation requires intent.

Just because something I do affects some variable downstream from my action does not mean that I "manipulated" that variable. 

Why do ED physicians only order CT's for certain patients, rather than simply having one done on everybody who presents with a headache or abdominal pain? Because CT's are expensive and are not always necessary. In order to minimize unnecessary cost and risk, they only order them on patients who meet criteria which indicates that a CT would be helpful. Does that mean those ED physicians are "manipulating" the profitability of GE Healthcare? Of course not. The profitability of GE Healthcare is the last thing on the mind of a physician who is considering whether or not to order a CT.     

When I'm doing a TIVA and I choose to use fentanyl over Ultiva because fentanyl is cheaper and I don't think the pharmacokinetic advantages of remi will offer any advantage in this patient, does that mean I'm "manipulating" Abbot's profits? 

Similarly, if you are a medical director and you put in place HEMS utilization criteria that are intended to minimize unnecessary risk and cost to your patients, you are not manipulating the HEMS program. 




Arovetli said:


> Respectfully, its a bit naive, yet endemic to clinicians, to believe that simply practicing medicine real good will always change the world.



There is nothing at all naive about the idea that more appropriate utilization is a good thing.

I'm pretty sure no one suggested it would change the world. 




Arovetli said:


> There is money and politics in the mix, and unfortunately in the current system, unnecessary medicine provides income to offset the low paying or absent paying. And unnecessary medicine can make one alot of money.
> 
> money wins.
> always does.



Money doesn't always win, and the proof of that is that HEMS bases often close when utilization decreases. If HEMS programs could simply purchase profitability, then they would never close bases. 

A HEMS program can't force EMS agencies to use them inappropriately. They can't force ED doctors to use them inappropriately. They can't force insurance companies to keep paying them for unnecessary services. They can't stop medical directors from implementing sensible protocols that minimize HEMS over utilization. 

The blame for inappropriate utilization (and thus, proliferation of unneeded bases and the problems that follow that) rests solely on the shoulders of those who keep demanding inappropriate service. If you stop demanding it, it will go away. 

No one forces it on you.


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## Eli (May 19, 2013)

Halothane said:


> No, I don't think so. I mean, maybe in some cases they had docs on board, but usually it was Army medics



Army medic in those days was a guy with some battlefield training who could start in IV. Not much else


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## VFlutter (May 19, 2013)

Halothane said:


> The blame for inappropriate utilization (and thus, proliferation of unneeded bases and the problems that follow that) rests solely on the shoulders of those who keep demanding inappropriate service. If you stop demanding it, it will go away.
> 
> No one forces it on you.



My work is a non-trauma stroke and cardiac hospital. We are the definitive care hospital for a handful of rural facilities 1-4 hours away. I was amazed at how many fly ins we get that are IMO non critical. We usually get a a couple fly ins a day. A typical occurrence is "patient has chest pain and a positive troponin of 0.09!, we are flying him to you" only to have the patient get a scheduled cath the next day and then d/c'd home. Total waste of resources. 

One of the HEMS programs sells "insurance" so all these people who have the ensurance request a helicopter. I am guessing that is a big part of the problem.


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## Arovetli (May 19, 2013)

Halothane, you have a very myopic view of the healthcare system.

I do, however, admire your nobility.


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## Carlos Danger (May 20, 2013)

Arovetli said:


> Halothane, you have a very myopic view of the healthcare system.



It is always very easy to accuse someone of being wrong, without providing justification. I'll take the fact that you've not provided a rebuttal to mean that you are unable to.

The HEMS industry would not be nearly as volatile as it is, if they had as much power and influence as you seem the think they have. Many bases operate at such a narrow margin that that they are no more than a 15 or 25 lost transports away (over 3-6 months) from the base closing permanently. 

I have been involved in HEMS for quite a while now, for several programs, in multiple states, in different capacities. I have some idea what I'm talking about.


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## Tigger (May 20, 2013)

We lost our MAST unit at Fort Carson, CO after 9/11. I guess they used to come out if Flight for Life was unavailable. They didn't bring a medical crew with them, the ambulance crew flew in with the patient.


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## Arovetli (May 20, 2013)

Halothane said:


> It is always very easy to accuse someone of being wrong, without providing justification. I'll take the fact that you've not provided a rebuttal to mean that you are unable to.
> 
> The HEMS industry would not be nearly as volatile as it is, if they had as much power and influence as you seem the think they have. Many bases operate at such a narrow margin that that they are no more than a 15 or 25 lost transports away (over 3-6 months) from the base closing permanently.
> 
> I have been involved in HEMS for quite a while now, for several programs, in multiple states, in different capacities. I have some idea what I'm talking about.



Thats presumptuous.

I didn't respond because we both expressed our opinions. You can reread what I already wrote, Ive already addressed the issue you have raised here. Im not interested in hijacking a thread to slug it out back and forth with someone on the internet over who is right and who is wrong, we have different views and experiences and are unable to come to an agreement on an anonymous internet forum.

Whoopdefreakindoo.

We can be mature and leave it at a gentlemen's disagreement, yes? Mutual respect for opposing opinions?

Or if you want to continue the debate feel free to PM me and we can discuss privately.


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## Handsome Robb (May 20, 2013)

Tigger said:


> We lost our MAST unit at Fort Carson, CO after 9/11. I guess they used to come out if Flight for Life was unavailable. They didn't bring a medical crew with them, the ambulance crew flew in with the patient.



While awesome my only question is how much does your standard ground crew know about flight physiology, gas laws and how the patient is affect by them? Especially at the altitude you're at.


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## Tigger (May 20, 2013)

Robb said:


> While awesome my only question is how much does your standard ground crew know about flight physiology, gas laws and how the patient is affect by them? Especially at the altitude you're at.



Probably not a lot. Most of our fulltime medics are CCEMTPs, but I don't think there is much in the way of flight specific curriculum in them. Our paramedics do receive a fair bit of education from our medical director about how altitude can affect various disease processes. Our district goes from 7 to 9000 feet plus so it is consideration on many transports.

It was also my understanding that the MAST helos only flew on very extenuating circumstances. We have five or six civilian helicopters that could arrive in reasonable time provided there is good weather at their base (far from a guarantee). One partner of mine flew two arrests in back in the 1990s before calling the field was allowed. The only other time it was used was for strokes where the transport time was well over an hour.


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