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Can EPs Fix the Helicopter EMS System?
Over at Emergency Physicians Monthly, Dr. Bryan Bledsoe writes Can EPs Fix the Helicopter EMS System?
Dr. Bledsoe, an EP (Emergency Physician), starts with the following paragraph that puts things in a perspective quite a bit different from what we think of, when we think of helicopter EMS -
Imagine that several times a year (approximately every 50,000 procedures) there was a cardiac catheterization lab accident in which the medical team (cardiologist, nurse and technician) perished along with their patient. There would be an immediate outcry to make the procedure safer (technology, practices, safeguards) and reduce risk for the patient and providers. Second, all cath lab procedures would undergo intense scrutiny to assure appropriate utilization. Although such a scenario may seem outrageous, it is essentially the same risks that helicopter EMS (HEMS) crews face on a daily basis. In fact, HEMS transport is the only medical procedure that holds a much higher morbidity and mortality for the providers than it does for the patient.
The only other category of medical personnel that has had a higher fatality rate than their patients is the military medic. That is because the opposing military views killing/disabling the medic as an important way to demoralize the troops served by that medic.
The difference is that nobody is intentionally trying to kill flight crews, are they?
Dr. Bledsoe, an EP (Emergency Physician), starts with the following paragraph that puts things in a perspective quite a bit different from what we think of, when we think of helicopter EMS -
Imagine that several times a year (approximately every 50,000 procedures) there was a cardiac catheterization lab accident in which the medical team (cardiologist, nurse and technician) perished along with their patient. There would be an immediate outcry to make the procedure safer (technology, practices, safeguards) and reduce risk for the patient and providers. Second, all cath lab procedures would undergo intense scrutiny to assure appropriate utilization. Although such a scenario may seem outrageous, it is essentially the same risks that helicopter EMS (HEMS) crews face on a daily basis. In fact, HEMS transport is the only medical procedure that holds a much higher morbidity and mortality for the providers than it does for the patient.
The only other category of medical personnel that has had a higher fatality rate than their patients is the military medic. That is because the opposing military views killing/disabling the medic as an important way to demoralize the troops served by that medic.
The difference is that nobody is intentionally trying to kill flight crews, are they?
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Replies to This Discussion
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Permalink Reply by Rob Theriault on
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I should preface my comments by first saying that I am not a U.S. resident so I can't profess to be intimately knowledgable about the system. I have however attended several aeromedical conferences in the U.S., have flown with numerous medivac crews across the U.S. as an observer and worked on a medivac helicopter for 10 years in Toronto, Ontario, Canada as a Critical Care Flight Paramedic.
Given the U.S.'s for-profit system of health care I am not confident there is a good short term fix. I agree with the premise of the article that helicopter transports must be evidence based, but this is in direct conflict with the profit model. First and foremost the air ambulance industry, in my view, should be regulated at the federal and/or state government level. I also think that it should fall under a state or federal funding model (I assume it's probably state as I am not too familiar with the U.S. funding system). This way, private comapnies could continue to privide the service under government contract, but the profit level would inevitably drop substantially. I am not a big supporter of the concept of physician's signing to approve air transport. I think a better model would be one of implementation of an evidence based consensus, such as the one referred to in the article, and that regular reviews or air transports (audits) would need to be in place for QA. An EBM approach can also be applied to a universally accepted scene response algorithm.
More importantly, the air ambulance industry in the U.S. would be safer if it looked at models that work well in other countries and adopted those best practices.
e.g.
- twin engine aircraft for all medevacs
- two pilots for all medevacs
- IFR rating
- night on-scene response restricted to airports and licensed helipads (in the German model for example there are diesignated helipads along all the major highways)
cheers
Rob
Paramedic Tutor
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Permalink Reply by Skip Kirkwood on -
Rob makes many very valid points.
We seem to have a common theme in EMS in the US. I think it's because we haven't yet decided whether EMS is a hobby or a profession. But we keep seeing the same model or cycle play out.
1. We have a problem.
2. We in EMS know about the problem.
3. We in EMS know the answer to the problem. It usually has to do with human performance and decision-making.
4. We in EMS are not professional enough, concerned enough, or committed enough to solve our own problem.
5. People start looking for somebody outside of EMS to solve the problem, since EMS can't or won't. "Medics can't handle refusals - let's make 'em call the ED before allowing a patient to refuse." "Medics can't triage to helicopters - let's make them call the ED before allowing the helicopter to take off." Mother may I?
This is the opposite of a profession, where self-regulation is paramount. We EMSers don't need non-EMS physicians, the FAA, the NTSB or anybody else to solve this problem, which we've known about for too long. Same thing with crew fatigue, skill proficiency, etc., etc.
We just won't do it.
I guess that means that it's a hobby?
Sure hope not!
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Permalink Reply by Rogue Medic on -
Rob,
One of the strange things about the helicopter EMS industry is that possibly the most egregious abuser of the system is the State of Maryland with their completely state operated "not-for-profit" system. As I have stated before, I think that eventually someone in the administration will end up doing some jail time for the way things are run.
Money is not the only conflict of interest. Almost all of the for-profit flight services do a much better job of providing medical care. The Maryland State Police Aviation unit helicopters have one solo medic, cross-trained as a state trooper apparently as a way to distract the medics from medical skills (as Thom Dick wrote in his 30 Tricks of the Trade earlier this month - 10. There’s a very good reason why you’ve never met a dual-role surgeon. 11. The genius who first presumed that one person could do two full-time jobs at once was an administrator who meant some other person, but that is a whole different topic).
We would expect that the helicopter service providing this cut rate service would be some private cut the costs as low as possible and then change the name and address when the authorities catch on kind of scary business.
Nobody expects that kind of flagrant abuse of responsibility from the people who are supposed to enforce the laws, but this inexcusable unethical arrangement is what Maryland State Police Aviation brags about as the best in the country. Only one medic in the back - and that medic is cross-trained as a trooper.
The only way they get away with this is that they have a lot of people willing to come out and protest when they call for a protest. Their role model seems to be the Teamsters. How bad is it when the police are imitating the people who were taken over by the government because they were run gangsters? Maybe they figure they have a head start, since they are already in the government.
The private helicopter services in the area all have a medic and a nurse in the back with the patient. Maryland State Police Aviation claims to be too good for that. It isn't about patient care in Maryland.
It isn't as simple as privates vs. public.
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Permalink Reply by Rogue Medic on
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Skip,
You make some great points.
One of the problems is that we do not generally get training in paramedic-initiated refusals, but people think that it is an answer to EMS abuse. Why would we expect to be good at something with no real training?
We have a broken EMS education system. National Registry is just a mechanism that allows us to slap a patch on a bunch of scrapings off the bottom of the barrel. We aren't concerned with making EMS better, but with how bad of a system we can get away with. As long as we continue to do that, you are right - EMS is a hobby.
We need to change.
We need educational standards that are concerned more with getting students to understand patient care, than with being politically correct, because somebody might discriminate. Evaluation of students is all about discrimination. Discriminating between those who understand and everyone else.
We need to promote aggressive critical decision making by EMS and hold ourselves accountable afterward. Not holding ourselves accountable by punishment, but by remediation, and if we cannot be remediated, we need to seek out adventure in the wild world of fast food service. It isn't as if there is much of a difference in pay.
We have too many people in EMS fighting to keep the standards so low that the cockroaches are able to get in and move up to management, where they protect their own.
There are places that do things the right way. Rather than encourage others to do things the right way, we make excuses for keeping the staus quo as low as possible.
This needs to end.
A medic who left EMS used to describe it bluntly as -
EMS - Your life is our hobby.
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Permalink Reply by Ben Waller on -
Rogue,
"10. There’s a very good reason why you’ve never met a dual-role surgeon. 11. The genius who first presumed that one person could do two full-time jobs at once was an administrator who meant some other person." So now we need the same qualifications as a surgeon to decide when to fly a patient? That's ridiculous.
I have met a dual-role surgeon - in fact, I used to respond to calls with him. He was one of the co-authors of the original "orange" AAOS EMT texts. He actually was a triple-role surgeon, as he was a terrific orthopedist, a military officer, and a long-time member of his local rescue service where he performed extrication, did wilderness searches, responded to floods, responded to rope and cave rescues, and did some firefighting. He was actually recalled to duty to command a U.S. military base during Desert Storm, a role for which he was commended by the military. I know another surgeon who was also a firefighter, and their are any number of physicians who are firefighters and rescue squad members in the Mid-Atlantic and New England states. Thom might just need to widen his horizons.
I've met other physicians who respond to calls and who have their own turnout gear in a number of states, and who are good at both roles. Just because it's not common doesn't mean that it can't be done or that the people that do it are subpar performers at both.
One paramedic in the back is good enough for ground EMS but not for a helicopter system with some of the shortest flight times in the industry? That's also ridiculous. For one thing, Maryland's system allows the ground medics to fly with them when a second set of hands in the back is needed. For another, Maryland has had exactly two fatal crashes in the 35 years or so they've been flying helicopters. That's not a perfect system, but considering that they fly law enforcement and search & rescue missions that most for-private medievacs don't, it's surprisingly low. Comparing Maryland's all-hazards helicopter system to a for-profit, medical-only system is a serious cases of apples to oranges.
There are for-profit medevac companies with much shorter corporate lives that have much worse safety records. That doesn't make MSP perfect - they're not, but it certainly doesn't make the way the system is run criminal.
Having one provider in the back is "unethical". I call B.S.
"The Maryland State Police Aviation unit helicopters have one solo medic, cross-trained as a state trooper apparently as a way to distract the medics from medical skills." I call B.S. on that statement. The reason that the medics have to be troopers is that those helicopters fly law enforcement missions and the flight medics must be law enforcement officers in order to carry out that part of their mission.
As for administrators doing jail time for the way MSP runs their helicopters, that is very, very unlikely.
In fact, if that were the case, it would likely have already occurred. It has not, for the simple reason that there's nothing criminal in the way that system is operated. Accusing a law-enforcement system of criminal activity is something that you should be able to prove. Otherwise, that statement falls into the "slander" category. If you're going to post something that can be perceived as slander, you need to have very strong evidence to back it up - evidence that will withstand being the defendant in a slander suit.
Your post is full of unproven perjoratives without a shred of evidence to back them, because that evidence doesn't exist. If you have actual evidence to prove that the MSP's air wing administration is criminal, I'll believe it when I see it.
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Permalink Reply by Ben Waller on
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Chance, the MSP medevac system primarily does trauma/scene flights, not interfacility/medical. When they do interfacility flights, they have the capability to take any additional specialty care providers and equipment they need with them. There is no rule that says that a state police agency must provide those resources.
Maryland classifies their medevacs as State Police Helicopters, not as specialty care resources. They have done so since their inception in the 1970's. They've had that classification prior to the existance of the model and classification your particular service uses. They fly the vast majority of their patients to one of three trauma centers - ShockTrauma in Baltimore, Washington County Hospital in Hagerstown, and Suburban Hospital in Bethesda. For a helicopter system that flies primarily law enforcement and scene medevac missions, classifying them as a specialty care resource that being the private, for profit model is apples to oranges.
The vast majority of Maryland's population and transportation infrastructure - and thus, most of their scene calls - is within a short air transport time of one of those three hospitals.
The vast majority of those patients are trauma patients from scene flights. Most of their flights are very short - the last time I checked, their 90% loaded flight time was something like 10 or 12 minutes.
Further, unlike most hospital-based, for-profit medevacs, the MSP helicopters spend a lot of time in the air on law enforcement missions, fly directly to the scene, transport a patient, fly to a refuel point, and then return to their traffic patrol, SAR, or other law enforcement flight duties. They're not going to take a RN, a RT, or a pedi critical care team while they use their FLIR to help with a ground-based foot pursuit or while they fly traffic observation on the interstate.
Or...do we now need to put nurses, RTs, and neonate critical care teams on patrol in police cars?
I don't think we do. We just need to recognize that their are different system models with different rules, and there is nothing unethical or criminal about having different system models.
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Permalink Reply by Rogue Medic on
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Ben,
I was only quoting Thom Dick on the you’ve never met a dual-role surgeon. I would have stated it differently. I would state that you rarely meet cross-trained people who are excellent at both jobs, but I suspect that this was written the way it was for brevity and memorability. The only time we should even consider cross-training people is when they can demonstrate excellence at the primary job. But why would we want to cross-train people? Are they so good at their job, so we need to decrease their competence?
EMS is not a job for cross-trained people. Just look at how badly EMS does in the research on intubation. The second part points out the benefit of being cross-trained - 11. The genius who first presumed that one person could do two full-time jobs at once was an administrator who meant some other person. There is nothing inaccurate in that statement.
"The Maryland State Police Aviation unit helicopters have one solo medic, cross-trained as a state trooper apparently as a way to distract the medics from medical skills." I call B.S. on that statement.
There is no good reason for them to be dual role. BS? What other childhood games do you want to play?
There was an attempt to split MSP Aviation into EMS-only and law enforcement/SAR, but the MSP came out against it. That doesn't demonstrate any kind of interest in what is best for the patients. It appears to be all about control.
If you're going to post something that can be perceived as slander, you need to have very strong evidence to back it up - evidence that will withstand being the defendant in a slander suit.
You can perceive what you want to perceive. This is the problem with the National Registry. They are more concerned with perception and with appearances, than with reality, but EMS is a reality business.
Now you are giving legal advice. Thank you for making my point. Are you cross-trained as a lawyer, or just pretending to be cross-trained as a lawyer?
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Permalink Reply by Ben Waller on
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"Imagine that several times a year (approximately every 50,000 procedures) there was a cardiac catheterization lab in which the medical team (cardiologist, nurse and technician) perished along with their patient. There would be an immediate outcry to make the procedure safer (technology, practices, safeguards) and reduce risk for the patient and providers. Second, all cath lab procedures would undergo intense scrutiny to assure appropriate utilization. Although such a scenario may seem outrageous, it is essentially the same risks that helicopter EMS (HEMS) crews face on a daily basis. In fact, HEMS transport is the only medical procedure that holds a much higher morbidity and mortality for the providers than it does for the patient."
Imagine that we had to transport the cardiac cath lab, the physician, the nurse, and the technician to the patient, rather than the other way around. Imagine that the cardiologist had to monitor the Weather Channel to see if fog, rain, snow, or high winds were going to blow through the cath lab in the next 45 minutes prior to making the determination of whether or not to begin the cath procedure. Imaging that the cath lab operated on JP-5 aviation fuel. Imagine that the cardiologist had to reach over large bodies of water, over mountain ranges, and over tall buildings and communications towers in order to perform the catheterization.
Does this put Dr. Bledsoe's hypothesis in a different light? I think it does. The environments are completely different. We don't judge EMS system performance by ED standards, and we shouldn't judge EMS aviation by cath lab standards.
Can we make better decisions about when to use EMS aviation? Clearly, we can. Can we tighten the weather rules under which aviation EMS can be used? Not only can we, many individual systems have already done so.
Are there aviation EMS systems that have operated accident-free for decades? Yes, there are.
I think this puts things in a different light.
Now let's compare the Maryland State Police EMS aviation system to the NASA Space Shuttle system. In terms of missions flown, MSP flies more missions per year than the total number of NASA shuttle missions - 167 or so, at last count. Both MSP and NASA have had two mission failures with fatal results. By those standards, NASA has a much higher fatality-per-mission rate than does MSP, yet no one is calling for NASA administrators to face criminal charges or calling them unethical.
The choices in running space shuttle missions - and aviation EMS - are about managing risks. Risk management is not an exact science. We can improve risk management with better choices and with good reviews of the common elements in mission failure. However, a mistake in risk assessment isn't unethical or criminal, it's just a mistake. Both NASA and aviation EMS operate in uncontrolled environments. As long as they do, there will be accidents and fatalities. We can minimize them with good risk management. We can't eliminate them without eliminating the system.
I don't think anyone is ready to eliminate either NASA or aviation EMS completely in order to have zero risk. If we're going to use that approach, it's time to shut down every surgical suite in the world - after all, some surgical patients die, and the only way to have zero risk is to shut down the system.
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Permalink Reply by Ben Waller on
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Rogue,
Thank you for your convincing arguments that your opinion is indeed just your opinion, and that you can provide no evidence to back it up. We both know that evidence does not exist.
However, your continued use of your own skewed perception does not make the facts fit those perceptions. One of those skewed perceptions is that being good at more than one thing necessarily decreases competence at one or both. It does not. Your statement is just an opinion that you state in a perjorative way in an attempt to present it as fact. It would (hypothetically) be equally valid to state that EMS systems that do not cross-train their paramedics as firefighters or police officers are intentionally defrauding their community by refusing to be flexible.
The bottom line is that if you want to be good at EMS, be good at it. If you want to be good at EMS and something else, be good at both. If you're not capable of being good at both or don't want to do both, then your limitations or wishes are not valid for everyone else.
People who are smart, motivated, and capable can be very good indeed at many different things.
Your opinion that MSP uses the law enforcement/paramedics in a dual role "to distract them..." is what I call B.S. on, and it flatly is B.S., no matter how else you want to characterize it. MSP uses cross-trained trooper/paramedics because it would compromise two missions of varying priority to use EMS-only and LEO-only helicopters. For starters, it would increase costs. The MSP paramedics do just fine in providing care at the level that their system chooses to provide. Just because you prefer some other model doesn't make MSP's choices an intentional distraction, as you stated it is. Thus, it's B.S.
The childhood game being played here is the one you're playing. Children assume that the entire world fits their assumptions and perceptions, when in fact, the world is much larger and more diverse than the children's false assumptions. The world - or MSP's world - doesn't fit your assumptions as posted here.
You also stated that I proved your point and that I gave legal advice. I did neither.
Are you a District Attorney? If not, then why are you making statements that imply criminality on the part of MSP's administration? If it doesn't take a D.A. to make statements that, if disproven, are defamatory in nature, then it certainly doesn't take a lawyer to point out something that is common knowledge in the publishing world. And after all, your statements were made on a publisher's web site.
Back on topic, the question here is the mission profile that results in fatal crashes. MSP has had two in their entire history - Trooper 2 and Trooper 3 have each had one fatal crash. The crew configuration had nothing to do with either crash. The mission profile did. Your bringing crew configuration into this discussion is a diversion from the topic, or to put it into your own words, a childhood game.
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Permalink Reply by Ben Waller on
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Rogue,
"11. The genius who first presumed that one person could do two full-time jobs at once was an administrator who meant some other person." There is nothing inaccurate in that statement.
How do you know that? Can you prove it? If you don't know that "genius" or don't have documentation of who that person was and the situation, then you have no idea whether that statement was accurate or not.
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Permalink Reply by Rogue Medic on
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Does this put Dr. Bledsoe's hypothesis in a different light? I think it does. The environments are completely different. We don't judge EMS system performance by ED standards, and we shouldn't judge EMS aviation by cath lab standards.
Dr. Bledsoe is pointing out the risk. You are claiming that the risks are not relevant.
Imagine if we were to do what is best for the patient.
However, a mistake in risk assessment isn't unethical or criminal, it's just a mistake.
It took a mistake that killed a pilot, trooper/medic, basic EMT borrowed from the ambulance, and one patient (although it did result in amputation and many other serious injuries to the other patient) to get the Maryland flight rules to start resembling anything responsible. Not for any serious injuries. One of the patients was able to survive a helicopter crash and then survive for hours in the woods with no care and no protection from the elements. Clearly Maryland has been sending the right patients by helicopter to the hospital.
Not only was that not just a mistake, it was aggressively opposed by those in charge. Dr. Scalea and Dr. Bass opposed scaling back the flights. They predicted that there would be fatalities due to the lack of flights on the magic helicopter. The approach of these two doctors was nothing but - You can't be too safe.
To critics of our system, I ask: What if the injured patient was your child or your loved one? Which risk would you rather we take: send too many to the trauma center within the recommended time limit, or send too few? A letter from Dr. Scalea, Physician-in-Chief, R. Adams Cowley Shock Trauma Center By Thomas M. Scalea, MD, F.A.C. S. Physician-in-Chief R Adams Cowley Shock Trauma Center Link to Free PDF at Emergency Education Council of Region 5, Inc.
Dr. Scalea asks - What if the injured patient were my child?
Then do not put my child at unnecessary risk for some imaginary benefit. be better
Where is the benefit?
In defending the quality of our system against those who would seek to diminish it, I know I speak for all trauma physicians in Maryland. I have received many emails and calls from EMS providers throughout the state who share this same concern. Most important, I know I speak for the tens of thousands of patients, and their families, whose lives have been shattered by injury, and whose recovery would not have been possible without Maryland’s vaunted trauma response system.
In other words, the comments about looking for evidence of benefit of the flight program in Maryland - don't hold your breath. We have the tens of thousands of patients, and their families, whose lives have been shattered by injury, and whose recovery would not have been possible without Maryland’s vaunted trauma response system. Of course, there is absolutely nothing to support that statement. It has as much evidence to support it as Tony The Tiger has for saying of Frosted Flakes - They're great!
Where is the evidence that there is any reason to fly any mechanism-only patient?
That is what they defended after the crash.
You correctly state that we cannot eliminate risk without eliminating the system. What we need to do is eliminate the unnecessary risk. Mechanism-only flights are completely unnecessary and need to be opposed. Dr. Scalea and Dr. Bass have continued to defend mechanism-only flight criteria.
They even use the EMS version of the Easter Bunny - The Golden Hour to defend their abuse of the system. A concept dreamed up in a bar to convince people to send patients to Shock Trauma. No science to support this.
The golden hour: scientific fact or medical "urban legend"?
Lerner EB, Moscati RM.
Acad Emerg Med. 2001 Jul;8(7):758-60. Review.
PMID: 11435197 [PubMed - indexed for MEDLINE]
What about cutting down on transport times, response times, scene times, and all of the rest of the stuff drilled into our heads?
Emergency Medical Services Intervals and Survival in Trauma: Assessment of the "Golden Hour" in a North American Prospective Cohort.
Newgard CD, Schmicker RH, Hedges JR. at al.
Ann Emerg Med. 2009;(in press, may end up with a 2010 publication date)
PMID: 19783323 [PubMed - as supplied by publisher]
Injured patients with one or more of the following criteria were included: systolic blood pressure (SBP) less than or equal to 90 mmHg, Glasgow Coma Scale (GCS) score less than or equal to 12, respiratory rate less than 10 or greater than 29 breaths/min, or advanced airway intervention (tracheal intubation, supraglottic airway, or cricothyrotomy). “Injury” was broadly defined as any blunt, penetrating, or burn mechanism for which the EMS provider(s) believed trauma to be the primary clinical insult.
In other words, only the most unstable of the trauma patients - the ones nobody would argue are most likely to die.
In the multivariable logistic regression model, total EMS time was not associated with mortality (odds ratio [OR] for every minute of total time 1.00; 95% confidence interval [CI] 0.99 to 1.01) (Table3). When the sample was assessed with 10-minute increments for total EMS time, there was no evidence of increased mortality with increasing field times (OR 0.90; 95% CI 0.80 to 1.02). Similar results were obtained when total times were grouped by quartile (OR 0.95; 95% CI 0.83 to 1.08). We were also unable to demonstrate independent associations between mortality and any other EMS interval for the overall sample (Table 4).
In multivariable logistic regression models, there was no demonstrable association between time and mortality for any subgroup.
There are problems with the way NASA handled the Space Shuttles that led to the Challenger and Columbia accidents. They did not have to happen, but not by eliminating the program - by using intelligent risk management. NASA did not do that. MSP Aviation, Dr. Bass, and Dr. Scalea are just following NASA's example.
Claiming that decreasing risk is the same as eliminating risk, and therefore impossible, just demonstrates a lack of understanding of risk management.
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Permalink Reply by Bob Sullivan on -
Back to the helicopters.
I suspect that overuse of helicopters will soon be fixed by the insurance industry. Not because of they are good or bad for patients and providers, but because they will stop paying for flying people with silly problems. They will go away and none will be left for the people who could benefit from them. It's a shame that we don't fix this ourselves, but add it to the list.
One problem is that in most areas, HEMS is the holy grail for paramedic career advancement. Besides the cool factor of flying, few ground paramedics acheive that level of training or see as many critical patients. Now how about putting these paramedics on the ground?
The other problem is our educational system. Most EMT's out there still believe everyone who walks away from rollever wreck could have a hidden life-threatening injury, that their chances of survival from that injury go down each minute that passes, and should be flown. This gets reinforced at the Con-ed case study about one patient who looked fine on scene but died. So we overtriage.
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