Helicopter Usage

[vc85]

Just wanted to run this situation by everyone and get their opinions on it.

Our local hospital had a patient with a partial thumb amputation. Replantation center is 45 min to 1 hour away by ground, so they called for a helicopter transfer. Now, the thing is this patient was completely stable...AAOx3, BP 120/70, HR 70, SpO2 = 100% room air, RR = 16/regular. The hospital had bandaged the patient's hand and that was about it. Not even on O2 and wasn't even in the hospital cot when the flight crew arrived.

So what does everyone think? On one hand, a thumb is the most important digit and a successful replant greatly benefits quality of life. On the other hand, $20,000+ bill for what Is essentially a BLS transfer and taking a limited aeromedical resource out of service

 

[Chewy20]

Hey if they can afford the flight with insurance then that was their decision. No one forced a stable guy to fly. If you look at it, a TON of flights are BLS.

 

[redundantbassist]

A thumb is the most important digit and a successful replant greatly benefits quality of life.

There's your answer.

 

[Jim37F]

A thumb is the most important digit and a successful replant greatly benefits quality of life.

If the helicopter can get him to the surgical team in less time than the ground unit, then I think it's completely justified. You have a patient that needs urgent surgery to save a vitally important digit right now, absolutely no sense in saying "Naw bro, sorry but this hypothetical patient that only exists in my mind that may need a choppa in the next hour is more important than you who are physically in front of me ready to go with a waiting surgical team"

patient was completely stable...AAOx3, BP 120/70, HR 70, SpO2 = 100% room air, RR = 16/regular....Not even on O2

Um...why does this guy need O2? And does he really need to be sitting in the cot waiting if he's ambulatory?

 

[vc85]

I mentioned the O2 because I think the flight crew put him on it, and a 4 lead, probably more so they could say they did something

And around here BLS flights are exceedingly rare, in fact that is the only one I have heard of

 

[Akulahawk]

I would suggest that there's a "time" factor that nobody has mentioned so far in this thread. That factor is simply this: how long has it been since the partially amputated thumb last had effective circulation? If the patient had nearly removed his thumb a few minutes earlier and they could arrange for a stat ground transfer, that would be OK. If it's been an hour or two since, then going by ground means at least 3 hours will have passed since injury and figure another 30-60 min for surgery prep and the like. That means 4 hours, and possibly 5, before meaningful circulation is restored to that digit. Significant amounts of tissue in that thumb will not survive past that, meaning they'll simply complete the amputation, close things up, and consider replacing that thumb with a toe. Now what about pain control? Last I heard, that's not something that BLS is allowed to do... so now you're tying up an ALS asset.

Fly the patient and the transport time drops by quite a bit, at least by 30 minutes, and possibly more because of transit time to the sending hospital. Where I work, we sometimes have to wait an hour or so for a local IFT crew to arrive after being requested because of their own availability. We rarely have to wait more than about 30 min for a helicopter unless they're coming from a more distant base than usual. The evaluation by the flight team won't take long and they do have pain management available. They may even be able to work through a pre-op checklist for the receiving hospital (if they're hospital affiliated) and speed up that process. In short, that same patient may be able to go to OR with a replant team in 2-3 hours post injury and have a decent chance to save most of the thumb if they're flown.

Is it emergent to fly the patient? Not necessarily, but definitely urgent as this is fairly time critical.

 

[CALEMT]

I would suggest that there's a "time" factor that nobody has mentioned so far in this thread. That factor is simply this: how long has it been since the partially amputated thumb last had effective circulation?

Ding ding ding. Winner winner chicken dinner. As Akulahawk explains, time is everything when it comes to an amputation. The sooner the pt is in the OR the better the chance of a successful replant.

 

[redundantbassist]

I mentioned the O2 because I think the flight crew put him on it, and a 4 lead, probably more so they could say they did something

And around here BLS flights are exceedingly rare, in fact that is the only one I have heard of

They put him on O2 with an spo2 of 100% on room air? That's just dumb.

 

[chaz90]

They put him on O2 with an spo2 of 100% on room air? That's just dumb.

Very likely they put him on nasal prong EtCO2 to monitor ventilators status during analgesic administration mid flight.

 

[epipusher]

Is the thumb worth $30k+

 

[redundantbassist]

Is the thumb worth $30k+

You would seriously rather have a guy lose his thumb instead of getting treatment quickly? Because that's what your post is implying.

 

[epipusher]

You would seriously rather have a guy lose his thumb instead of getting treatment quickly? Because that's what your post is implying.

Its a hypothetical question in a hypothetical thread.

1. hypothetical question - Legal Definition. n. A question, based on assumptions rather than facts, directed to an expert witness intended to elicit an opinion.

 

[Akulahawk]

Is the thumb worth $30k+

It might be better personalized here... is your thumb worth $30k? Put yourself in the place of that patient and ask yourself that question. Remember that while loss of a digit may not be exactly life threatening, if it's on the dominant hand, that could have some pretty severe quality of life consequences.

Something to consider.

 

[chaz90]

Is the thumb worth $30k+

Yup.

An opposable thumb on each hand affects absolutely everything I do in life. Work, writing, dexterity, carrying things, driving, grip...The list goes on. If I were far enough away from a vascular/hand surgery center that potentially had the ability to reattach a digit that there was a significant time saving in flying versus ground, I would absolutely take that time saving into account. If the receiving facility recognizes quickly that there is a need to transfer this patient and calls for a flight immediately, there is the potential for a 2 or more hour difference in time to reattachment in many cases. I'm no expert in this field, but I know that can have a real impact depending on time of injury and reperfusion of the missing digit.

 

[DesertMedic66]

During my clinical time at a trauma center we flew a patient to a hospital about 2 hours away for an amputated penis.

 

[redundantbassist]

During my clinical time at a trauma center we flew a patient to a hospital about 2 hours away for an amputated penis.

Ouch...

 

[Tigger]

Hey if they can afford the flight with insurance then that was their decision. No one forced a stable guy to fly. If you look at it, a TON of flights are BLS.

Maybe not forced but many smaller facilities are not very good at discussing the various transportation options with a patient. Here it's "the ambulance/helicopter is here to take you to the trauma center, good luck. No one talks about billing, just that the doctor thinks it's "necessary." Many patients complain to both us and the local helicopter services about how much their transfer costs. To a certain extent the providers have a responsibility to either not suggest medically unnecessary procedures or at least educate about their costs.

I don't think this was a waste. Sometimes speed does matter. But then again we don't have quite all the info.

 

[DesertMedic66]

Ouch...

Meth is a hell of a drug. Smoked it and heard voices that told him to cut it off and we'll he obeyed the voices.

 

[Akulahawk]

Maybe not forced but many smaller facilities are not very good at discussing the various transportation options with a patient. Here it's "the ambulance/helicopter is here to take you to the trauma center, good luck. No one talks about billing, just that the doctor thinks it's "necessary." Many patients complain to both us and the local helicopter services about how much their transfer costs. To a certain extent the providers have a responsibility to either not suggest medically unnecessary procedures or at least educate about their costs.

I don't think this was a waste. Sometimes speed does matter. But then again we don't have quite all the info.

Exactly correct, Tigger. The trick is knowing when it does and when it does not. If there will be no clinical difference going by ground, I'd choose that mode of transport as it'll be cheaper. Partial amputation of a thumb shows up minutes after it occurs, replant team is 70 miles away, ground ALS (not CCT) IFT unit is right at my doorstep... Quick eval, xrays, IV pain management, and out the door could happen within 30 minutes. Patient arrives at replant facility right about 2 hours post injury and likely would be in OR within 30 minutes. Plenty of time to attempt revascularization and then reattachment. That should = thumb saved.

 

[CALEMT]

During my clinical time at a trauma center we flew a patient to a hospital about 2 hours away for an amputated penis.

Now that is extremely vital to quality of life right there...