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Another chopper down

Discussion in 'Emergency Medicine' started by jbar, May 29, 2008.

  1. jbar

    jbar Senior Member
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  3. Blue Dog

    Blue Dog Fides et ratio.
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    Well, it could've been worse... ;)

    [YOUTUBE]fksjgg11qXQ[/YOUTUBE]
     
  4. EM2BE

    EM2BE Elf
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    Are these things happening more now, or did it happen just as often in the past? Maybe I didn't pay as much attention then.
     
  5. jbar

    jbar Senior Member
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    That chopper was going back for the rest of Romano. Once you get a piece, I guess you want the whole thing.
     
  6. southerndoc

    southerndoc life is good
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    Helicopter EMS is one of the most dangerous jobs. Helicopter crashes occur very frequently in HEMS.
     
  7. iatrosB

    iatrosB trying not to kill anyone
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    Do they occur more frequently than other helicopter jobs...ie, news helicopters?
     
  8. jbar

    jbar Senior Member
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    my understanding is that medical aviation has a higher accident rate, mainly because they are landing at improvised LZs so much higher chance of tangling with things like telephone poles than choppers that only go in and out of heliports. Also I think there is some pressure to fly in weather that may be somewhat marginal when commercial flights wouldn't fly. I know the pilot has safely first, and can decide not to fly because of weather, but I think they push it a little further when they know someone is hurt. (This is just my impression from working EMS and calling in choppers, someone who has worked in aviation medicine would know better)
     
  9. notdeadyet

    notdeadyet Still in California
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    Makes sense. Though the pilot's going to have a tough time pitching that one when the crash occurs on his hospital's own roof. This is the equivalent of crashing in your own garage.
     
  10. EM2BE

    EM2BE Elf
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    I figured the news may have a bias in the news. Health flights are big news and therefore are talked about more. I definitely don't see them talking about their own helicopters, but I could see the other stations talking about them. I thought the largest difference would be the money spent on the helicopters and their maintenance. More than likely more is spent on the news and maybe the police helicopters.
     
  11. chuck deli

    chuck deli Senior Member
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    From 1998 to 2005, according to the NTSB, 89 medical helicopter crashes killed 75 people; 47 of the incidents were at night.

    In 2006, after an apparent increase in crashes in previous years drew considerable public attention, researchers from Johns Hopkins University reported on an analysis of medical helicopter crashes since 1983.

    The researchers said 56 percent of the fatal crashes were at night, and 77 percent occurred when weather conditions required pilots to fly primarily by instruments instead of using visual cues.

    Source:

    http://www.madison.com/archives/read.php?ref=/wsj/2008/05/12/0805120161.php
     
  12. pseudoknot

    Physician PhD Faculty Lifetime Donor Classifieds Approved 10+ Year Member

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    No, HEMS definitely has a high crash rate. News and police helicopters rarely land in the field, which is probably a big part of it. As far as money, police aviation doesn't generate any revenue and EMS does, so it's hard to say.

    I know some people are very passionate in their opposition to HEMS. I'm not too familiar with the literature, but it seems to me like something that would be hard to study and get definitive answers. Is there (can there be?) really good evidence that it doesn't help, even in critical trauma patients who are far from the hospital?
     
  13. emtcsmith

    emtcsmith Paramedic
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    You tell me a patient thats 90 min or more from a trauma center wouldn't benifit from a flight service....

    This "hard landing" is close to home so I hope everyone is alright and we will all continue to support the strong care and service all the fight services provide us on the ground.
     
  14. AmoryBlaine

    AmoryBlaine the last tycoon
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    Well, that's sort of the point of suggesting that the question be studied isn't it? 20 years ago everyone would have said, "you tell me that witholding pain meds from undifferentiated abdominal pain isn't a good idea..."

    There are questions here that might not come to an intuitive conclusion if studied.

    Do patients transported via helicopter do better than ground? What is the cost/benefit of the helicopter maintainance/occasional crash? How much faster is helicopter transport than ground? How many chopper hours are required to save one life (NNT)?
     
  15. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner
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    It came about because yes, in rural areas it does help. Places like Korea and Vietnam. Rural areas in the US are similar, in that there aren't easy ways to get from place A to place B. Islands also work. You've never had a pucker factor like someone bleeding on a ferry after the cars shift. You just ain't getting there any faster, and the Coast Guard isn't going to pluck someone from the boat (usually).
    I don't have the papers right at the moment, but there are arguments for both.
     
  16. Jarabacoa

    Jarabacoa non carborundum ilegitemi
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    In my opinion, this topic is similar to so many in Emergency Medicine in that it is extremely difficult to study. It is not a like studying a certain type of cancer, where we can do a double blind, placebo controlled trial and come up with a relatively indisputable answer. Most Emergencies don’t easily lend themselves to easy research. When all is said and done, people tend to form an opinion and the only thing that can make them stop expressing that opinion is their own death.

    The best argument that I have heard is that with a helicopter crew, you can recruit, heavily train, and devote a lot of resources to a few dozen individuals. This results in paramedics that are highly trained, and much more able to handle severely sick individuals. The flight paramedics where I work put in chest tubes, run drips, and are experts in RSI. The helicopter gives them a much greater mobility and improves the patient care over a huge geographic area. The amount of resources that you would have to devote to the entire ground EMS system to achieve the same paramedic expertise would be astronomical.

    There are a plethora of articles on Pubmed regarding cost and impact on mortality and morbidity. I included a few of the articles with their conclusions. In my opinion, most inter-city transfers and MVA scenes don’t need helicopter. However, it is a resource that we all have. The more we use them, the more expertise we create, and the more useful they are. The less we use them, the less patient care they experience and the quality of care will decrease.

    Can J Surg. 2007 Apr;50(2):129-33. Air versus ground transport of major trauma patients to a tertiary trauma centre: a province-wide comparison using TRISS analysis.
    CONCLUSION: The transport of trauma patients with an ISS = 12 by a provincially dedicated rotor wing air medical service was associated with statistically significantly better outcomes than those transported by standard ground ambulance. This is the first large Canadian study to specifically compare the outcome of patients transported by ground with those transported by air.

    J Trauma. 1997 Dec;43(6):940-6.
    A comparison of the association of helicopter and ground ambulance transport with the outcome of injury in trauma patients transported from the scene.
    CONCLUSION: The large majority of trauma patients transported by both helicopter and ground ambulance have low injury severity measures. Outcomes were not uniformly better among patients transported by helicopter. Only a very small subset of patients transported by helicopter appear to have any chance of improved survival based on their helicopter transport. This study suggests that further effort should be expended to try to better identify patients who may benefit from this expensive and risky mode of transport.

    Prehosp Disaster Med. 1999 Jul-Sep;14(3):159-64. Differences in mortality rates among trauma patients transported by helicopter and ambulance in Maryland.
    CONCLUSION: The State of Maryland has demonstrated a commitment to its citizenry and invested heavily in its public safety air medical service. This study suggests the rapid air transport of victims of traumatic events by specialized personnel in Maryland has a positive effect on the outcome of severely injured patients. Further research is necessary to clarify the causal relationships in order to more fully elucidate the value of this resource.

    J Emerg Med. 2000 Apr;18(3):349-54. Scene disposition and mode of transport following rural trauma: a prospective cohort study comparing patient costs.
    The prehospital transport costs were significantly more for patients transported to a rural hospital first. The costs incurred at the trauma center were highest for those patients transported directly from the scene. Many severely injured patients were initially transported to a rural hospital rather than directly to the trauma center. At both the scene and rural hospital, consistent use of triage criteria appeared to be lacking in determining the severity of injury, appropriate destination, and mode of transport for trauma patients. Since no significant difference in prehospital helicopter and ground transport costs was demonstrated, the decision on mode of transport should be in the best interest of patient care.

    J Trauma. 2006 Jun;60(6):1257-65; discussion 1265-6. Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis.
    CONCLUSIONS: The majority of trauma patients transported from the scene by helicopter have nonlife-threatening injuries. Efforts to more accurately identify those patients who would benefit most from helicopter transport from the accident scene to the trauma center are needed to reduce helicopter overutilization.

    BMJ. 1995 Jul 22;311(6999):217-22. Effects of London helicopter emergency medical service on survival after trauma.
    CONCLUSION--Any benefit in survival is restricted to patients with very severe injuries and amounts to an estimated one additional survivor of major trauma each month. Over all the helicopter caseload, however, there is no evidence that it improves the chance of survival in trauma.

    J Trauma. 2007 Aug;63(2):258-62.Helicopter emergency medical services (HEMS): impact on on-scene times.
    CONCLUSIONS: Combined EMS/HEMS assistance at an injury scene is associated with longer OST. When corrected for severity of injury and patient characteristics, no influence of longer OST on mortality could be demonstrated.

    Unfallchirurg. 2007 Apr;110(4):334-40. [The influence of transportation mode on mortality in polytraumatized patients. An analysis based on the German Trauma Registry]
    CONCLUSIONS: Only minor differences in age and ISS were found between the groups. The time between the accident and arrival of the physician was longer in the HEMS group. The HEMS group also remained on the scene for longer, but had a higher rate of intervention. According to our analysis of the German Trauma Registry, patients with multiple injuries benefit from HEMS transportation.

    J Trauma. 1997 Jul;43(1):83-6; discussion 86-8. Are scene flights for penetrating trauma justified?
    CONCLUSIONS: Scene flights in this metropolitan area for patients who suffered noncranial penetrating injuries demonstrated that these flights were not medically efficacious. This conclusion rests on the findings that arrival at a trauma center was not hastened by scene flights and that only 4.9% of patients required prehospital care by the medical flight crew beyond the capabilities of the first-responding EMS personnel (2.5 and 6.7% for ALS and BLS responders, respectively). Based on this experience, we believe that in metropolitan areas, scene flights for victims of noncranial penetrating injuries should be restricted to critically injured patients likely to require prehospital care by the medical flight crew that is beyond the capabilities of the first responders or when the scene flight is likely to significantly hasten the arrival of the injured patient to an appropriate trauma center.
     
  17. nymbarra

    nymbarra In flux
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    Jarabacoa, thanks for the citations. Seems like the results are mixed.

    I have never worked in EMS and know little about how resources are allocated based on the initial call for assistance.

    In real life, if an institution has both forms of transport available, what criteria are used to mobilize air vs. ground transport?

    The patient-based criteria used in the studies--like the ISS and GCS--depend on an initial eval of the pt, and I assume that is done by the EMT. If that's the case, the decision of air vs. ground has already been made, and it's a little odd that these variables are studied if the question is how to choose air vs. ground transport in real time...:confused:
     
  18. pseudoknot

    Physician PhD Faculty Lifetime Donor Classifieds Approved 10+ Year Member

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    nymbarra, typically ground units respond first and then decide whether to transport by air. I think in some areas police might be able to request a helicopter directly if they are the only ones on scene. I haven't heard of any system where the helicopter is first on scene (and it's hard to imagine since someone needs to be there to secure the landing site and assess the patient).
     
  19. EM2BE

    EM2BE Elf
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    I think what they do is if there is a call that sounds like air may be needed, they tell them to be on stand-by and ready to go when they get the official call. Esp if something sounds bad at least an hour by land from the hospital. Just my thoughts of course...may not work this way everywhere or nowhere.
     
  20. Squad51

    Squad51 Paracelsus'es Love Child
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    There are "auto launch" programs where a helicopter is launched for all calls of a certain type in an area. A friend of mine works for one. They do occasionally beat the volunteer EMS folks to the wrecks.
     
  21. Squad51

    Squad51 Paracelsus'es Love Child
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    In case you think I'm F.O.S.

    http://www.aams.org/Content/NavigationMenu/PublicationsProducts/ResourceDocuments/EarlyActivationFINAL.pdf

    and

    Berns KS, Caniglia JJ, Hankins DG, Zietlow SP. Use of auto launch method of
    dispatching a helicopter. Air Med J 2003; 22:35-41.
     
  22. pseudoknot

    Physician PhD Faculty Lifetime Donor Classifieds Approved 10+ Year Member

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    Nah, I trust you, but I appreciate the ref.
     
  23. pseudoknot

    Physician PhD Faculty Lifetime Donor Classifieds Approved 10+ Year Member

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    This is very true, and what I was trying to get at earlier. One thing I took from your citations was that we really have to be skeptical of taking studies that look at all flights and don't find a significant difference between ground and air transport. That doesn't tell us anything about the subset of patients for whom time is a real factor.

    Well, the emergency physician at the hospital will always be better trained than the EMS people, so I do think that ultimately it comes down to who can get the patient to the ED fast enough. (Not necessarily "faster.")

    There are two drawbacks to this approach:

    1. The more flights you have, medically necessary or not, the more crashes and LOD deaths you will have.
    2. The more you use the helicopter for patients who don't really need it, the worse the statistics look for outcomes.

    However, it may not matter much in the real world as there are some services that are heavily trying to market the use of helicopters, even to the point of telling people to call them instead of 911. If there is a financial incentive to overuse HEMS then it will happen, and I suspect these are often the same services that cut corners on maintenance and safety, leading to crashes.
     
  24. nymbarra

    nymbarra In flux
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    Hey guys,

    Thanks for the clarification. I know I am a newbie, thanks for your patience. Just a few more ?'s and thoughts...

    1) It seems from the studies that even within the subsets of patients (cranial vs. non-cranial injuries, penetrating vs. blunt trauma) there are still mixed results.

    2) Assuming that HEMS OST includes the initial EMS OST (ie, HEMS OST= HEMS OST + EMS OST), I think there are at least three ways to spin the conclusion:

    Controlling for injury severity, 1) shorter OSTs via ground transport increase survival---maybe supporting the notion of the 'golden hour' in trauma; or 2) HEMS crews may be better trained (no flame wars please) and somehow provide better care than ground crews, thereby negating the longer OST effects; or 3) the total transit time from first call to hospital is shorter w/ HEMS, again supporting the 'golden hour'...

    BTW, when I was on trauma surgery, my attending showed me this website.


    3) Even with first responders and appropriate eval/triaging, why is it that most HEMS transports are for non-critical patients?

    Thanks for any comments.
     
    #23 nymbarra, Jun 1, 2008
    Last edited: Jun 1, 2008
  25. Jarabacoa

    Jarabacoa non carborundum ilegitemi
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    WHen I was on EMS month, most of the flights weren't scene flights. Most were transfers of critically ill patients (Subarachnoid bleeds being transferred to a facility with a neurosurgeon who can coil an aneurysm. Strokes or STEMIs who have been lysed, hypoplastic left ventricle infants being transferred, intubated, on prostin drips, multiple trauma victims who are are actively bleeding in their chest, or who have massive head trauma). These kinds of patients aren't patients who the average paramedic would love to take care of. In my opinion, these are where flight paramedics are especially helpful.
     
  26. emtcsmith

    emtcsmith Paramedic
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    If we are going to ride flight services so hard for crashes lets not forget fire units and ambulances crash probaby twice as often. Add to that the amount of emergency service personal killed when struck by other cars during operations on the roadway.
     
  27. Apollyon

    Apollyon Screw the GST
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    Umm...get some stats first. Also, most fire department and ambulance collisions are "PDO"/no injuries, and that unit can go back into service almost immediately. When a helicopter crashes, it's out of service for an unknown amount of time. Also, just anecdotally, whenever I've heard about one person dying in a HEMS crash, everyone (pilot, provider, patient) has died. That's scary.
     
  28. leviathan

    leviathan Drinking from the hydrant
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    Just wanted to mention that the EMS service I work for has an annual call volume of 530,000, and we do use helicopters quite routinely. As of this date, our air evacuation program has only had 1 incident with a Learjet back in 1995, and none with our helicopters (*knock on wood*).

    Our helicopters only fly when the time to transfer to a trauma receiving / tertiary hospital by ground would be longer than the time for a helicopter to fly out, land, get the patient, and fly back. We also do not call helicopters for mechanism only: there must be specific physical findings (either physiological or anatomical) to suggest major trauma has occurred before a call for airevac is warranted.
     
  29. southerndoc

    southerndoc life is good
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    When one looks at miles traveled and calls received, HEMS has an enormously higher rate of incidents as compared to ambulances and fire unit incidents.

    It appears that a lot of helicopter junkies on here seem to ignore or discredit risks associated with the profession for fear it will increase the chances that HEMS will lose funding. However, this is unlikely to happen. I am probably one of the biggest helicopter junkies you could find, and I acknowledge that the risks associated with HEMS are astronomical when compared to traditional EMS. The fact is that HEMS is an inherently risky and dangerous profession and there are few things that can be done that will change this.
     
  30. jbar

    jbar Senior Member
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    I just wish that people thought a little more about calling a chopper. In EMS I ran across people who seemed to think "oh, it's easier to call the chopper and our ambulance won't be out of service for an hour." This was especially true on search and rescue when there was the temptation to call a chopper for minor injuries rather than carry someone out for three hours. I also saw choppers being called a fair amount based on mechanism, ie fallen climber, rather than looking at the patient and saying that they seem stable with non life threatening injuries. Also it is a waste to use choppers for people who are too far gone to help. The survival of blunt force cardiac arrests is about 0%. So does it really make sense to use a chopper when CPR is in progress. (I know many flights don't take full arrests, but I heard choppers called for them a fair amount out in CO.)
    There are definately patients that benefit from helicopter transport, but I think field providers have the obligation to weigh the benefits and the risks before putting the crew and patient in harms way. Also worth thinking a little about the money involved. I know that cost shouldn't matter if the patient is critical, but it's worth thinking about if the patient is going to say "why the hell did you cost me $5000 when it was just a broken ankle."
     
  31. leviathan

    leviathan Drinking from the hydrant
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    It isn't that way everywhere...and it shouldn't be!
     
  32. Baditude

    Baditude Senior Member
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    This crash took place close to where I live. Everyone got out ok as far as I have heard. I can't remember any other crashes for this particular company and I have lived here all 38 years of my life (UGH I feel old). I know we sure rely on them as we have no level 1 centers on the lake shore area so anything serious gets a helicopter ride.
     

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