Helicopters in EMS

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As preface I want to state that none of what I say refers to military use of helicopters for CASEVAC in combat zones. Or even non combat zones that are very remote from hospitals. A retired military friend of mine would slap me silly if I didn’t make that clear and he’d be right.

Success using helicopters, particularly in the Vietnam War sparked the use of helicopters in civilian EMS. Beyond that, the connection ends as the issues are much different.

On with the post.

Over the past several days there have been two medical helicopter crashes with fatalities.

Let’s go back six months. There have been seven Helicopter EMS (HEMS) crashes with sixteen deaths and eleven injuries. Here’s a list of them, with links where available,

Flagstaff, AZ (6/30/08)
Prescott, AZ (6/27/08)
Huntsville, TX (6/8/08)
Pottsville, PA (5/30/08)
Grand Rapids, MI (5/29/08)
La Cross, WI (5/10-08)
South Padre Island, TX (2/5/08)
DeLand, FL (1/7/08)

HEMS is the most dangerous job in EMS. Take a look at the Honorees page at the National EMS Memorial Service web site. Notice how many are pilots or crew of HEMS ships.

The sudden increase in crashes has sparked concern over the safety of HEMS. The New York Times has an article about the issue.

“The vast majority of patients could have done well in a ground ambulance,” said Dr. Bryan Bledsoe, a former flight paramedic who is a professor at the University of Nevada School of Medicine. “There is pressure to fly because most companies are owned by publicly owned entities.”

I hesitate to disagree with Dr. Bledsoe, because he is as we say in this part of the world “wicked smart”. Still, I have to wonder if this is the sole or even major cause of HEMS crashes. Many services are in fact operated by for profit companies, but many aren’t. I’d like to see a breakdown of crashes sorted by owner to determine the validity of his statement.

I also have to wonder if we are using HEMS resources wisely? Are trauma centers using HEMS to pump up their services? If you read this story and watch the video you’d think there is a critical problem. But, is there? I talked to a couple of people involved in incidents cited in the story and they tell a slightly different story than the media revealed. A quick example. Region 4, includes Boston and the great Boston area. In much, if not most of that area ground transport is as fast as helicopter transport due to the problem with finding a suitable landing area in densely packed urban terrain. To read the story or watch the video you would get the distinct impression that trauma center = helicopter when that isn’t the case.

More generally we in EMS need to ask how and why the decision to call HEMS is made. Do all trauma patients need to go by helicopter? How do we determine what a “trauma patient” is? Do we use mechanism of injury, Chief Complaint, Physical Exam, or some combination? Who decides to call the helicopter and when? Should that decision be made by the medical people at the scene, dispatch, medical control? I know of one hospital that required all patients be transported to it’s Emergency Department for evaluation before a helicopter was called. One could reasonably wonder if that was because the administration was concerned about HEMS over utilization or loss of revenue.

I know of another that used to call the helicopter to transfer patients out when the local orthopedic surgeons didn’t want to come in from home in the middle of the night to do a closed reduction. Why a helicopter and not a ground ambulance? Because the ground ambulance crew couldn’t maintain the pain medication infusion because it required a pump. That would have required sending a nurse on with the ambulance. The HEMS crew could maintain that drip but could only transport to a trauma center, not a closer non trauma center. I’m not sure I’d call that good utilization of resources.

Is a national criteria for calling HEMS even attainable? Probably not because of a variety of factors. Boston has four Level I trauma centers with one more hospital working towards that designation. It has four Level I pediatric trauma centers as well. On the other hand, Alaska has none. For those of you who want to know the difference between the levels of trauma centers, the State of Alaska has a handy site with information. If you need a Level I trauma center and you are in Alaska you have to go to Harborview Medical Center in Seattle Washington. Clearly there are different needs if you are in eastern Massachusetts or Alaska and one size fits all won’t work.

The problem seems to be that we don’t even have a good idea of what the questions are when it comes to HEMS. I do know this though. If EMS in general and HEMS in particular doesn’t figure out the dual issues of when to transport to a trauma center and when to utilize HEMS to do so, we’ll have the answers given to us by judges, juries, and regulators. This is on the verge of becoming a media driven issue and the results aren’t likely to be good for EMS, HEMS, or patients.

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.

10 COMMENTS

  1. I completely agree and was writing about this in my own particular idiom. Helicopter EMS – The Starbucks Effect.. Where I am, we have over half a dozen trauma centers within a reasonably short drive. The expansion of helicopter services seems to have no end in sight.The expansion of competence of the medics is not even considered. Not an expansion of the scope of practice, but basic competence. Nobody seems interested, just fly everyone, because medics can’t tell what is serious.

  2. Good work Sir LAUNCELOT! By the way, Starbucks is closing 600 shops across the country. Oh, the humanity! Think of all those pretentious Baristas who now will have to put those liberal arts degrees to good use!

  3. Thank you, Um, I think when I’m in this idiom, I sometimes get a bit, uh, sort of carried away.You make it seem as if remembering the incantation of the particular order, which is typically much longer than a psalm, then bringing it to life, is somehow inferior to a quest for the grail. Now, if Baristas delivered their Creations by Holy Helicopter, dressed as the Starbucks logo suggests, or in the attire of maidens of the Castle Anthrax,. . . . 🙂

  4. And as you mentioned…it isn’t the same everywhere. Here is rural america, the closest trauma center is at least an hour away. Often times, the HEMS is needed to get a patient where they need to be for definitive care. Unfortunately, two things also exist….one is the reason to fly them out quickly, is a misguided “golden hour” premise…which isn’t valid because it takes 28 minutes for the Helo to get to the hospital or scene (in most cases) and another 28 minutes to fly them back…so..math not being my strong point, it still stands to reason the “golden hours” is blown.the other thing is this…most of the time they can’t fly. The one we use, the pilot has complete control over whether they come or not. If the ceiling is low there, NO, if the ceiling “might” be low here, No…if it’s winter? Most of the time NO…I think we need to address the “critical care transport” issue for ground and you’d see alot less HEMS utilization…when they CAN fly.

  5. Jules, RE: The Golden Hour, it’s a conceptual tool, not a hard and fast rule. In trauma, serious trauma, not the mechanism kind, time is important. The problem is that as a group we don’t seem to get that. The pilot having complete control is vital for crew safety. If the pilot can be coerced into flying in marginal conditions, the risk of a crash goes way up.

  6. TOTWTYTR,I agree with both statements and apparently didn’t say it well. The pilot SHOULD have control and we understand that. When I said “misguided” I as alluding to the fact the golden hour was a marketing concept and not based in fact.Point of interest (or not) to this discussion…we had a major trauma last night. HEMS was diverted directly to the scene as there was an extended extrication. Man flown from scene…ended up NOT having a pneumo as the crews on scene all thought. Second most serious “kid” was taken to local hospital…where she was later transported by ground to the same trauma center…75 minutes away. Good outcomes for both. Man had mangled limb, and was in surgery when we arrived with the “kid”. My point about CCT was that in my world, and I know others, when the HEMS can’t fly, they will send a nurse in teh back of the rig for that critical care transport….usually a new grad, or OB nurse, who has never been in the back of an ambulance..doesn’t have a CLUE what to do for the patient, and spends the majority of the trip puking….perhaps that would be a good thing to discuss as we’re discussing the need/purpose/criteria for HEMS. What is best for the patient.

  7. Jules,A couple of large doses of midazolam, a little airway positioning, and the nurse should be just fine. :-)Yes, the care of the patient should be our primary concern. Unfortunately, when helicopters are involved the spinning of the blades seems to hypnotize the people who are supposed to make the rules. They can be heard answering, “Y e s, M a s t e r,” when the helicopter rules are drawn up and the flight criteria include almost anything that would justify an IV start.What is appropriate for where you are is one thing. Here in helicopter heaven, if we don’t fly everything they do not have the money to pay the flight crews and they will have to cut back on the drug rep type of give-aways.

  8. How about all the ground crashes we dont see on line? Many in the Midwest involve the avoidance of DEER! I think a nice sized push bar welded to the frame like I have on my explorer is a wonderful thing! The driver swerves to miss the deer that is right in front of him and kills everyone in the back!

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