Medic school paper - Appropriate Utilization of Helicopter EMS - Draft

(Please comment! If you want to comment on the paper in Google docs then I will happily share the link! Thank you!)

Helicopter based emergency medical services (HEMS) are an essential part to any EMS system.  The first benefit noted with HEMS is that it gives prehospital providers access to rapid transport without the difficulties of traffic or terrain. HEMS utilizes staff ranging from a critical care paramedic to a physician led team. Working under an expanded scope of practice compared to the traditional ground ambulance. However, HEMS can be misused and abused like the rest of the EMS and emergency response system. According to Taylor, C. B. (2010) annual cost range from $115,777 to $5,571,578.  The LifeFlight Foundation annual report states that in 2013 alone Maine’s very own “Green Angels” had expenses equalling $9,109,732 (2013, p. 22). That cost can be placed with the patients and insurance or absorbed by the government and citizens. No matter where the funding comes from, it is associated with significant cost. The question is are we, as ground based field providers, properly utilizing HEMS as the valuable and equally expensive resource it is? To decide that we are going to look at HEMS response, skills provided by HEMS, and issues or risks associated with HEMS.

The first decision we need to make is when the proper time is to activate HEMS, and when is air transport beneficial over ground transport. The first thought is almost always trauma. From my first day learning the management of trauma as an EMT, I was taught that “bright lights, cold steel” are what save the lives of trauma patients, and that getting them to a trauma center as quickly as possible is the best way to help that patient. It’s easy to assume that calling a helicopter will decrease that time. Helicopters fly faster than we can drive and don’t deal with rush hour traffic; unfortunately life is never that simple. Shepherd, Trethewy, Kennedy, and Davis performed a retrospective study. “To profile a helicopter emergency medical service in rural Australia. To assess patient injury severities and outcomes. To compare missions involving ambulance officers with physicians. To determine any time advantage of the aircraft over ground transfer.” (2008, p. 1). While Maine may not be as interesting as Australia it does have many places that fit into the rural category.

When comparing air transport to the computer calculated ground transport by local ems, Shepard, Trethewy, Kennedy and Davis found that in transports under 50Km (31 Miles) road transport calculated to a mean of 29.44 minutes, while air transport had a mean of 48.11 minutes. This is due partially to pre-flight preparation and increased response distance compared to local ground EMS. It was noted between 50 Km and 100 Km that times were very close with a mean time of 56.34 minutes for ground and 62.63 minutes for air. When looking beyond 100 Km (62 Miles) a significant difference is found; the mean transport time of the helicopter being 93 minutes while ground transport reached a mean of 141 minutes (2008, p. 496-497). Shepherd, Trethewy, Kennedy, and Davis concluded, “we believe that in comparable environments and in the absence of special circumstances, a helicopter response within 100 km from base does not improve time to definitive care” (2008, p. 498).

Take a map of Maine, and draw circles of a 30 mile radius of every trauma center. If your service falls in this circle, than even in trauma without special circumstances (e.g. patient entrapment or airway interventions beyond paramedic scope of practice) strongly consider transporting directly to the trauma center. On the other side of the equation, if your service covers an area 60 plus miles from a trauma center or the call requires prolonged extrications, or advance airway interventions outside of the paramedic scope of practice, then strongly consider HEMS in severe trauma.

LifeFlight has access to multiple tools that are either prohibited by cost or law to ground transport. Tools like rapid sequence intubation protocols, mechanical ventilators, portable lab equipment, invasive blood pressure monitoring, and blood products. Utilizing a paramedic and nurse team gives them the ability to provide the appropriate care to the most critical patients quickly and rapidly transport to the appropriate facility. While HEMS can use more tools than most ground based EMS and possibly use them better due to higher frequency skill use and proficiency.

“...prehospital intubation in patients with severe head injury was associated with worse survival and functional outcome in their overall population, but was associated with improved outcomes when performed by helicopter crews”. (Brown, 2013, p. 282)

It was noted in the article that in a separate study, HEMS crews had a much higher intubation frequency (80%) as compared to their grounded EMS counterparts (10%), and had a lower mortality rate in head trauma patients of 34% (Brown, 2013, p. 282). we have evidence that attributes lower mortality to a specific injury process and we should strongly consider it.

Currently, LifeFlight uses two helicopters. One is located at Central Maine Medical Center in Lewiston and the other is, located at Eastern Maine Medical Center in Bangor. These two HEMS units cover the entire state of Maine which leaves some obvious access limitations. I personally have called for LifeFlight for a severe trauma and was told that the closest unit was over an hour away in New Hampshire. The reason? Both helicopters were transporting critically ill patients from smaller, community hospitals to large, tertiary hospitals. LifeFlight provides critical care interfacility transport to all the hospitals of Maine, taking an already limited resource and stretching it further. However, this is an essential task to providing good care to the population of Maine. Unfortunately, HEMS units may be available but unable to fly as well.

In EMS we have the difficult job of actually finding and retrieving the patient, no matter where they are. When the EMS system is activated we are obligated to respond in worse conditions than the Mailman. Rain, snow, and ice are all too frequent response conditions in Maine. I do not have the option of saying no to a 911 call. When winter comes and I have to respond to one of the many crashes, caused by snow and poor decisions, I will slowly and safely respond.

Most HEMS on the other hand can refuse a call for any reason, due to the increased dangers of flight and helicopters. The most common one being weather. With the dangers of operating a helicopter in inclement weather it is reasonable for a crew of three people to refuse a dangerous mission. They are not only responsible for their own safety like every EMS provider on the ground, but they also have to think of the patient and the risk over benefits of air transport in poor flight conditions.

It is not only the HEMS medical team that has to consider risk and benefits to the patient, the ground system requesting HEMS also has to consider it. Cost should never be a major factor in directing patient care, but we should always advocate for our patients. With air transport cost being substantially higher than ground, we have to use good critical thinking and medical decision making in deciding “should this patients be flown”? Does the benefit outweigh the cost and risk? Is it reasonable to saddle the patient with transport bill in the tens of thousands of dollars range for injuries or illness that is affecting them? As an EMS provider it is very easy to be afraid for your patient and want to give them the best possible chance by flying them. With any high index of suspicion due to apparent injury, clinical presentation, or mechanism of injury it is reasonable to activate HEMS. It is a different story if do not want to sit with the patient. If you are afraid of treating a patient for the time it will take to get to a trauma center then consider additional help in the back the ambulance instead of having HEMS transport. If for some reason a provider did not feel like giving the effort or the time to treat and transport a sick or injured patient this would be an obvious misuse of resources. It would be unethical for a provider to hand off a patient to a valuable resource as HEMS for personal convenience.

As much as I wish we had a scanner like “The Doctor” has in Star Trek: Voyager, we do not. We have to rely on a solid clinical assessment and factors like the mechanism of injury when it comes to requesting HEMS transport. The choice should never be made lightly, but if a provider has a strong feeling that the patient would benefit from HEMS for any of the reasons that have been discussed, like trauma with distances over 100Km, prolonged extrication, head injury with or without need of airway management. Patients who would benefit from medication assisted intubation, blood products, or invasive monitoring. It is important to recognize however, that HEMS is not always available or could have a significant response time. HEMS crews can refuse to respond for their own and the patients safety. In the critically injured or ill patient we as prehospital providers should always advocate for our patients and consider the risk and benefits of all of our interventions, that includes “calling the bird”.

References

Mommsen, P., Bradt, N., Zeckey, C., Andruszkow, H., Petri, M., Frink, M., & ... Probst, C. (2012). Comparison of helicopter and ground Emergency Medical Service: A retrospective analysis of a German rescue helicopter base. Technology & Health Care, 20(1), 49-56.

Shepherd, M., Trethewy, C., Kennedy, J., & Davis, L. (2008). Helicopter use in rural trauma. Emergency Medicine Australasia, 20(6), 494-499. doi:10.1111/j.1742-6723.2008.01135.x

Brown, J., & Gestring, M. (2013). Does helicopter transport impact outcome following trauma?. Trauma, 15(4), 279-288. doi:10.1177/1460408613497153

Taylor, C. B., Stevenson, M., Jan, S., Middleton, P. M., Fitzharris, M., & Myburgh, J. A. (2010). A systematic review of the costs and benefits of helicopter emergency medical services. Injury, 41(1), 10-20. doi:10.1016/j.injury.2009.09.030

LifeFlight Foundation. (2013). Annual reports [PDF]. Retrieved from   http://www.lifeflightmaine.org/getattachment/About-Us/Publications/ Annual-Reports/Annual-Report-FY13-FINAL.pdf.aspx