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,
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.