Category Archives: General

Helicopter EMS: The Final Word??

One of my readers left a lengthy comment on the helicopter EMS guidelines from the ACS-COT and NAEMSP on Wednesday. For those of you who don’t dig into the comments, I’m publishing it in its entirety today. It’s that good. Thanks to Mike Abernathy for the time he took to write it! BTW, he is a co-author on several papers with Brian Bledsoe, whose data I quoted. See references below. 

“Great recommendations –they make perfect sense. But..with the current structure of the US HEMS system, they are largely unenforceable . Due to multiple factors, there is a HUGE disparity among the aviation and medical abilities of HEMS programs –yet they are treated and paid as a uniform entity.

An ever growing, profit driven sector of the industry is run by large corporations ( Air Medical Holdings, PHI, AMC) who operate independently and have little connection with health care/hospitals as we know them.

Due to loophole in the the Airline Deregulation act of 1978, there is little meaningful state or federal regulation over the HEMS industry. Several states have tried to create and enforce regulations but have been defeated in court every time. Medical standards, equipment and training are essentially determined by individual programs. The classic fox guarding the henhouse. One program mayfly with almost minimum wage paramedic team with minimal training/experience while another down the street may use a highly trained EM physician- nurse team ( and everything in between) One program may fly a 25 y/o single engine aircraft worth $800k and another program invests in $8M state of the art helicopters. Does the program want to put profits into the pockets of shareholders or back into improving the quality of the program? Right now –there is zero incentive for quality. Everyone gets paid the same per patient mile. There is absolutely no reason why these programs would not want to fly every pt they can –because they get paid very well for it.

Anyone can put a helicopter anywhere and due to lack of real Medicare/Medicaid requirements (currently so vague, any transport can be justified) and get paid damn well for it. Interestingly – the ground EMS industry is highly regulated by comparison.

But – there are many good programs out there who do the right thing – use well trained, experienced medical personnel and pilots along with state of the art equipment but they are slowly being overtaken by the “darkside” of the industry.

BTW – the standard of care for HEMS in almost every other developed country in the world is a physician-medic team using larger dual engine aircraft. Considering these patients should be the most critically ill of all those transported –not a bad idea. The bar in the US has been grossly lowered in the name of profit.

The only way to fix the whole system is that reimbursement must be tied to quality measures and appropriate utilization criteria based on medical research. When Medicare requires precertification and other quality measures, insurance companies will follow. Like every other aspect of medicine quality must be incentivized ( = $$$) When this happens the low end / low quality, profit driven subsection of the HEMS industry will disappear –and so will many of the problems that you have appropriately outlined.”

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References:

  • Helicopter Scene Transport of Trauma Patients with Nonlife-Threatening Injuries: A Meta-Analysis. J Trauma 60:1254-1266, 2006.
  • Helicopter Accidents in the United States: A 10-Year Review. J Trauma 56:1325-1329, 2004.
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When Can Your Trauma Patient Stop Taking Warfarin?

The number of elderly patients needing care at trauma centers is skyrocketing. Many are on anticoagulants for medical conditions, most commonly atrial fibrillation. When one of these patients is seriously injured, anticoagulation can cause serious and life-threatening complications that might otherwise not occur. 

Reflexively, many trauma professionals decide to just stop the medication, especially if they believe that the patient may injure themselves again (and again, sometimes). However, this may not always be a good idea. Remember the good old juice to squeeze ratio. Look a the risks (reinjury) vs the potential benefits (stroke prevention). The easiest way to assess this is to use CHADS2.

CHADS2 is a validated scoring system for predicting stroke risk in people with atrial fibrillation. There are 5 components as follows:

  • C – congestive heart failure – 1 point
  • H – hypertension (treated or untreated) – 1 point
  • A – age >= 75 – 1 point
  • D – diabetes mellitus – 1 point
  • S2 – history of stroke or TIA – 2 points

Stroke risk is directly correlated to the number of points scored. So based on that the recommendations are:

  • Score = 0: low risk, no therapy needed or just take aspirin
  • Score = 1: moderate risk, aspirin or oral anticoagulant
  • Score >= 2: moderate to high risk, take oral anticoagulant

Bottom line: Evaluate every trauma patient on anticoagulation to see if they really need to keep taking it. If it’s for a one-time episode of DVT or PE that happened years ago, they should be able to stop. If it’s for a-fib, check their CHADS2 score and work with their primary care provider to see if they could take aspirin or nothing. Factor in a history of frequent falls or car crashes as well.

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Reference: Selecting patients with atrial fibrillation for anticoagulation: stroke risk stratification in patients taking aspirin. Circulation 110 (16): 2287–92, 2004.

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Helicopter EMS: The Recommendations

So after two days of pros and cons about helicopter EMS (HEMS), we lead up to this. The American College of Surgeons Committee on Trauma, Emergency Medical System subcommittee, has released a set of guidelines on appropriate use of HEMS. It’s been endorsed by the National Association of EMS Physicians and looks like a lot of thought has gone into it.

Here are the factoids about the HEMS guidelines:

  • Must be integrated with your trauma system
  • Must utilize standardized field triage guidelines that should be applied consistently throughout your trauma system
  • Is blind to the insurance status of the patient
  • Uses a regional dispatch system. Self-launch should never happen.
  • Referring physician to receiving physician conversations must occur when considering transportation mode (air vs ground) for interfacility transfers
  • There must be good online medical direction from a physician
  • Offline medical direction must be based on protocols and policies developed by the trauma system
  • There must be regular PI review of all HEMS transports to ensure compliance
  • HEMS crews must have regular training opportunities
  • A culture of safety must be maintained

Bottom line: We absolutely must take a critical look at our patient transport practices and procedures. To ensure even-handed application of best practices, our state trauma systems are going to have to step up and address this issue so the right patient will get to the right hospital at the right time, safely and cost effectively.

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Reference: Appropriate use of Helicopter Emergency Medical Services for transport of trauma patients: Guidelines from the Emergency Medical System Subcommittee, Committee on Trauma, American College of Surgeons. J Trauma 75(4):734-741, 2013.

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Helicopter EMS: The Risks

Yesterday, I wrote about the (unclear) benefits of helicopter EMS transports. Today, I’ll cover the risks. The number of medical helicopters in the US has grown dramatically since 2002.

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As can be expected, the number of mishaps should go up as well. 

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Although it looks like the fatal and injury accidents peaked and then declined, it does not look as good when compared to the rest of the aviation industry. Consequently, being on a helicopter EMS (HEMS) crew has become one of the more dangerous professions.

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And unfortunately, the numbers have not improved much during the past five years. So what to do? Make it a big PI project. Approach it systematically, analyze the issues, and create some guidelines and protocols for all to follow.

Tomorrow, I’ll review new guidelines for HEMS released by the American College of Surgeons Committee on Trauma.

Related posts:

Reference: Medical helicopter accidents in the United States: a 10 year review. J Trauma 56:1325-1329, 2004.

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Helicopter EMS: The Benefits?

The use of medical helicopters has grown at an astonishing rate in the 10+ years since Medicare got involved with payment for this service. All high level trauma centers have helicopter landing facilities, and many either own or are a part owner in at least one helicopter EMS service (HEMS).

Here’s a state by state breakdown of the number of medical helicopters:

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It’s gotten to the point where the indication for summoning a HEMS service seems to be the presence of a patient to ride on it! 

A lot of papers have been published in the past 20 years trying to justify the benefits of using these services. As is the usually case when a lot of papers are published on one subject, most of them are not very good. Lots of studies have been performed to try to justify their use, and most were not successful. The following items have been scrutinized:

  • Interfacility transfers
  • Trauma
  • Pediatric transfers 
  • Pediatric trauma
  • Burns
  • OB
  • Neonatal
  • Rural trauma

Most of these papers found little, if any, benefit. The ones that did tended to be published by institutions that owned these services, raising the question of bias. The one thing that was always significantly different was the cost. HEMS costs at least 10 times more that ground EMS transport.

So the benefits are not very clear. What about the risks? I’ll talk about those tomorrow.

Click here to view the interactive state map of medical helicopters. See where your state is with respect to number of ships and services, and how busy they are.

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