I think I am done with helicopters

[the_negro_puppy]

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.

 

[Carlos Danger]

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.

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.

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.

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.

 

[Arovetli]

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.

 

[Carlos Danger]

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.

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.

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.

 

[Eli]

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

 

[VFlutter]

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.

 

[Arovetli]

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

I do, however, admire your nobility.

 

[Carlos Danger]

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.

 

[Tigger]

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.

 

[Arovetli]

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.

 

[Handsome Robb]

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.

 

[Tigger]

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.