Helicopter or Ambulance?

[MrBrown]

As much as I love the guys in there oh so delicious orange jumpsuits rocking up we must consider the pro HEMS evidence is quite poor and that they are horrendously overutilised.

For this particular patient no unless he was severely traumatically injured with substantial physiologic abnormalities and/or significantly isolated from hospital.

The helicopter usually does not offer a higher level of clinical skill than is avaliable from a ground ambulance unless you use an RN or MD based system.

Example 45 minutes ground to the hospital well lets see, 10-15 minutes for the helicopter to get ready and go, say 1o minutes flying time each way, 10 minutes or longer for a handover and loading means its probably just as fast if not faster to take him by road.

Lets see

- Doors, closed
- Beacon, on
- Strobes, on
- Nav, not using
- GPS, checked
- Winch, stowed
- Rotor, well clear
- Radios, tuned

Lil' cyclic ... and away we go ... Auckland morning, it's Westpac Rescue, helicopter hotel lima november, just getting airbrone off Mechanics Bay uh, 1500 or below through the TMA be tracking eh, southbound.

Mmm Westpac Rescue calls Ambulance Control airborne, four POB in awesome looking orange jumpsuits, 120 fuel, ten imutes to scene

 

[Veneficus]

In my local area at least, our helicopter services carry blood, can do RSI, central access, chest tubes, etc. and our ground services can not.

Not saying that these tools can't be helpful, but they are not magic. Here are a few of the drawbacks.

While they can be useful, the situations in which they maybe useful are extremely rare.

In Trauma, thanks mostly to recent wars, EDs and especially Trauma centers have moved to massive blood transfusion for its effectiveness. That is usually a ratio of 1:1:1 or 3:3:1 depending on the center. (packed red, fresh plasma, platelets respectively) It is also expected between the ED and final surguries this may need to be repeated a few if not several times. (12 is the record I have seen on a ruptured esophagus. With another 6 standing by) Most Helos I am aware of carry 2 units of O neg. Which in all likelyhood will only be useful for the flight time if the patient requires surgical intervention and will be used up quickly prior to extrication.

RSI is useful, but extremely risky when the patient cannot be positioned for maximum ease of intubation. RSI in a patient in a sitting position is asking for trouble.

Chest tubes were removed from STAT Medivac years ago, I am told from employees they concluded through in house QA that it is more effective to put in multiple needles than to take the time putting in a chest tube. As well, one of the benefits of a chest tube is autotransfusion from hemothorax, so if you didn't bring that gear and have that injury, a chest tube is just a "cool" procedure. Not to mention they are probably going to be opened completely in surgery if it is massive. So it becomes a waste of time also.

 

[MrBrown]

RSI in a patient in a sitting position is asking for trouble.

Now I have heard of this being done here at least once ... don't ask me how I an not a thisproceduremightmakemeloosemyjobologist

Chest tubes were removed from STAT Medivac years ago, I am told from employees they concluded through in house QA that it is more effective to put in multiple needles than to take the time putting in a chest tube.

What about in a haemothorax or ha..he...haemop...um, *looks in dictionary, heamopneumothorax? ... and did you know the Zebra did it?

Ambulance Control, Westpac Rescue locating ... orange jumpsuits away!

 

[FlightMedicHunter]

Why not get them to a closer, but perhaps less well equipped hospital that would be able to do all those things instead of waiting on scene? The helicopter can always come pick up the patient at that hospital for transfer to a tertiary care center, should they actually need to be transferred out.

If only this method was as easy to utilize as you write. My base has a 90 minute flight time for all definitive care whether it be cardiac, neuro, or trauma. There are around 8 or 9 small (and boy do I mean small) hospitals within our coverage area. If the ground service finds that it would be quicker to transport the patient to a local "level 5" hospital they can always do that. Here's the problem: first and foremost, once that patient is delivered to that tiny ER they cannot leave until there is an accepting physician at the higher-level-of-care facility. Now, we have just added some serious time for this patient to get to definitive care (should they actually need it). Second, many of the hospitals around here have a very poor level of emergency care. Many of them cannot control an airway or manage a tension pneumo. That's just the norm for these extremely rural hospitals.

So, it would be great if the ground crews could call us and have us headed to the hospital where we could transport, but if the patient goes through the ER doors we simply cannot do that. These scenarios I speak of are assuming that patient actually needs a higher level of care. I think the biggest change needs to be made on the ground level and to educate ground crew better on what might need to be flown. For instance, I always tell my students,,,,when determining if this patient is a "trauma alert" try to disregard the standard trauma triage criteria and focus more on whether or not you think the patient needs to have immediate surgery. Always think, "Does this patient need to go straight to OR for immediate, rapid life-saving surgery?" If not and they have a good airway,,,transport by ground.

 

[Veneficus]

Now I have heard of this being done here at least once ... don't ask me how I an not a thisproceduremightmakemeloosemyjobologist

Not saying it can't be done or that doing it should make a person lose their job, just pointing out that there is just a whole lot that can go wrong.

What about in a haemothorax or ha..he...haemop...um, *looks in dictionary, heamopneumothorax? ... and did you know the Zebra did it?

might help with that, of course as you said, not very common. Also most likely open already. There is also the issue that the pressure being creating might be tamponading the bleeding. So without a knife, a clamp and some thread, what would stop the bleeding with if you reopen the wound?

 

[redcrossemt]

OK, so you're willing to wait the 15-20 minutes (and that's a national average I heard quoted in a presentation at a conference recently; assuming you're on a scene that allows for the helicopter to easily find you, land quickly at the scene, the weather is cooperating, etc) for RSI?

OK, so you're willing to wait the 15-20 minutes (and that's a national average I heard quoted in a presentation at a conference recently; assuming you're on a scene that allows for the helicopter to easily find you, land quickly at the scene, the weather is cooperating, etc) for RSI? Why not get them to a closer, but perhaps less well equipped hospital that would be able to do all those things instead of waiting on scene? The helicopter can always come pick up the patient at that hospital for transfer to a tertiary care center.

No, no... Sorry maybe I wasn't clear. I would never advocate sitting on scene with a patient. I am saying that if you are sitting next to the critical patient who's entrapped and will be entrapped for an extended extrication period, then it may be worth having the helicopter fly.

In our area (SE Michigan as you mention), there is no reason to call HEMS for a scene flight unless there is an extended extrication time involved. I personally have no problem transporting to a community hospital if the patient needs an airway or blood or immediate basic surgical intervention and transporting to a trauma center will be detrimental to them. The helicopter can always pick up at the local ER if needed.

Basically, if the helicopter can land before you can access the patient to transport, then consider them based on patient condition and immediate treatment needs.

 

[usafmedic45]

Basically, if the helicopter can land before you can access the patient to transport, then consider them based on patient condition and immediate treatment needs.

OK...thanks for clarifying. I pretty much agree with that, although I will argue that even that will lead to overtriage of patients in a lot of circumstances.

 

[1badassEMT-I]

Put the bird on alert......size up pt and make your call either by ground or by air......If you feel the pt needs a level one trauma center launch the bird... Depends on the Pts needs.....and what your closest hospital can provide for your pt.

 

[puttnum1]

In my humble opinion

If you even have to consider calling for aeromedical support, just call for it. The worst that's gonna happen is you cancel the bird and transport by ground. No sense in wasting time inside the golden hour. In my experience, putting a helicopter on "standby" does nothing. If they get another request in the meantime while your figuring out if you need them or not, they're gonna take the confirmed call. Standby doesn't secure you the fly. But like I said, that's just my opinion from the places I work.

 

[usafmedic45]

If you even have to consider calling for aeromedical support, just call for it.

Do you have any evidence to back that suggestion up?

The worst that's gonna happen is you cancel the bird and transport by ground.

No, the worst that could happen is that the flight crew ends up on the soon-to-be built Air Medical Memorial. Calling for the helicopter simply because the thought crosses your mind does nothing but increase the exposure of crews to obscenely high risk flights. Standby might be one option to consider, but calling for the launch of the helicopter outside of extreme distance or other major (>1 hour) delays in transport should be viewed with the same hesitance a lot of people wrongly associate with doing surgical airways.

Calling for a helicopter without justification would be grounds for me (as your supervisor) calling the medical director who would in turn call you to inform you that you're practice privileges are suspended pending an investigation that could result in your credentials being revoked. I have seen it happen several times and was responsible for filing the initial reports on three of them. One of them was simply a paramedic who wanted to show his girlfriend (an EMT student) "how cool" a scene landing of the helicopter was. He is no longer a paramedic, needless to say. I wonder how cool she thought that was.

No sense in wasting time inside the golden hour.

You do realize the "golden hour" concept was admittedly (by R. Adams Cowley himself) a marketing concept more than anything else right? True, there is no sense in wasting time (of which calling for the helicopter is a great example), but there is nothing magical or special about the first hour after trauma. It just sounds better than the "platinum five minutes" or the "diamond thirty minutes". It realy irks me that we still utilize that outdated concept to explain the need to move our butts when things are going badly.

 

[MrBrown]

A helicopter response must add value to whatever resources and modalities you have at your disposal as land based Paramedics.

It is often faster to take the patient by road than it is to sit and wait for the helicopter to come to you.

Currently the evidence base for helicopter responses is poor and it is clear disporoprtinate disparity exists between the rate of utlisation and actual need.

The more I think about it, the more sense it makes to have a Doctor on the helicopter.

Maybe I have been listening to Gareth Davies too much?

 

[Aidey]

I agree with much of what everyone else has said. HEMS have their place in rural areas and may significantly decrease transport times, but are of little use in urban areas. We have a HEMS available to us where I work and I won't use them unless they will get to the scene before we leave with the patient. So basically either they have to be launched at the same time we are dispatched, or it has to be an extended extrication.

I will not wait on scene for them, I can't justify it from a patient care perspective. The HEMS can't really provide much more advanced care than we can pre-hospital except on planned CCT trips.