Dr. J?

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FoughtFyr

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Dr. J? said:
Interesting article about med evac flights. Thought I might use it to stimulate a little discussion.

http://www.nytimes.com/2005/02/28/national/28copter.html?hp&ex=1109653200&en=bdb069ae55b161f1&ei=5094&partner=homepage

Would any EM physicians out in SDN-land care to comment on the notion that med flights are currently overused?

Does anyone know of any studies out there that have looked at transport times and patient outcomes for various conditions?
From: Helicopter air medical transport: ten-year outcomes for trauma patients in a New England program. Jacobs LM, Gabram SG, Sztajnkrycer MD, Robinson KJ, Libby MC. Conn Med. 1999 Nov;63(11):677-82

UConn found an overall 13% reduction in mortality for trauma patients. In patients with a trauma score of 4 - 13, the mortality decrease was 35%. The problem was that these patients only accounted for 5 - 10% of flights.

However, this study also only looked at mortality, not morbidity, LOS, etc. And it did not look at sick medical patients. Morover, UConn serves a rather rural area, where there are a lot of volunteer BLS squads, and one could suppose that this would result in an even greater survival benefit from Helicoptor EMS than would be shown in areas served by ALS.

Does the benefit justify the cost? Probably not, but neither 90% of the routine tests and x-rays that we do.

- H
 

flighterdoc

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FoughtFyr said:
From: Helicopter air medical transport: ten-year outcomes for trauma patients in a New England program. Jacobs LM, Gabram SG, Sztajnkrycer MD, Robinson KJ, Libby MC. Conn Med. 1999 Nov;63(11):677-82

UConn found an overall 13% reduction in mortality for trauma patients. In patients with a trauma score of 4 - 13, the mortality decrease was 35%. The problem was that these patients only accounted for 5 - 10% of flights.

However, this study also only looked at mortality, not morbidity, LOS, etc. And it did not look at sick medical patients. Morover, UConn serves a rather rural area, where there are a lot of volunteer BLS squads, and one could suppose that this would result in an even greater survival benefit from Helicoptor EMS than would be shown in areas served by ALS.

Does the benefit justify the cost? Probably not, but neither 90% of the routine tests and x-rays that we do.

- H
A GCS range of 4-13 is essentially meaningless: You can be dead and score a 3 (no eye opening, no motor response, no verbal response), and everything fully functioning is 15 so a 13 is not necessarily a particularly dangerous score - Guarding a broken arm and slightly confused responses (from EtOH) will get you a 13.

Once again crappy research delivers meaningless "evidence".
 

FoughtFyr

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flighterdoc said:
A GCS range of 4-13 is essentially meaningless: You can be dead and score a 3 (no eye opening, no motor response, no verbal response), and everything fully functioning is 15 so a 13 is not necessarily a particularly dangerous score - Guarding a broken arm and slightly confused responses (from EtOH) will get you a 13.

Once again crappy research delivers meaningless "evidence".
Did you actually read the paper or are you just making as general comment overall?

Here is the abstract:
Authors
Jacobs LM. Gabram SG. Sztajnkrycer MD. Robinson KJ. Libby MC.

Institution
Department of Traumatology and Emergency Medicine, University of Connecticut School of Medicine, Farmington, USA.

Title
Helicopter air medical transport: ten-year outcomes for trauma patients in a New England program.

Source
Connecticut Medicine. 63(11):677-82, 1999 Nov.

Abstract
BACKGROUND: Twenty-five years have passed since the introduction of the first civilian hospital-based air medical helicopter service. This study reviews the impact of a single air medical service during a decade of service on the survival of severely injured trauma patients. METHODS: A retrospective database analysis was performed to determine program demographics and obtain outcome data. The outcomes of trauma patients were compared to mortality derived from a national database utilizing physiologic indices of severity. RESULTS: Outcome analysis demonstrated an overall 13% reduction in mortality for air transported patients when compared to controls. Stratification based upon Trauma Score demonstrated a 35% reduction in mortality for victims transported directly from the scene with scene scores between four and 13, and essentially no difference in outcome for patients at Trauma Score extremes. CONCLUSIONS: Rapid utilization of helicopter air medical transport can have a dramatic impact upon patient outcome, especially within a select group of scene transported trauma patients with Trauma Scores ranging from four to 13.​

Notice they agree with you, finding "essentially no difference in outcome for patients at Trauma Score extremes". So where is the poor research? Or is it merely poor lit review prior to comment?

Other abstracts of note:
Gearhart PA. Wuerz R. Localio AR.

Cost-effectiveness analysis of helicopter EMS for trauma patients.
Annals of Emergency Medicine. 30(4):500-6, 1997 Oct.

College of Medicine, Pennsylvania State University College of Medicine, Hershey, USA.

Abstract
STUDY OBJECTIVE: To evaluate the cost-effectiveness of helicopter EMS for trauma patients. METHODS: We applied a cost-effectiveness analysis from the service provider's perspective to cost and effectiveness estimates. The cost estimates comprise direct operating costs and additional survivors' hospital costs. The effectiveness estimates were calculated with the TRISS methodology from literature sources and data from a cohort of patients transported by helicopter during 1994 and 1995. Sensitivity analysis and discounting were used. Cost per life saved and discounted cost per year of life in 1995 US dollars were the main outcome measures. RESULTS: The reported literature survival benefit ranges from 1 to 12 additional survivors per 100 patients flown. Transport costs were $2,214 per patient, and each additional survivor's hospitalization averaged $15,883. For the base case (5 additional survivors per 100 patients flown), cost per life was $60,163 and discounted cost per year of life $2,454. Sensitivity analysis revealed that discounted cost per year of life could be as high as $9,677 or as low as $1,400 and that it was most dependent on the surviving benefit. These results are comparable to a reported median discounted cost per year of life of %19,000 for other commonly used lifesaving medical interventions. CONCLUSION: Assuming that helicopter air medical transport provides a substantial survival benefit for trauma patients, our findings suggest that this service is a cost-effective option for the treatment of trauma patients. The magnitude of the survival benefit is the most important factor determining cost-effectiveness.​

and

Diaz, Marco A. MD; Hendey, Gregory W. MD; Bivins, Herbert G. MD

When Is the Helicopter Faster? A Comparison of Helicopter and Ground Ambulance Transport Times. Journal of Trauma-Injury Infection & Critical Care. 58(1):148-153, January 2005.

Department of Emergency Medicine, St. Mary Medical Center (M.A.D.), Long Beach, and Department of Emergency Medicine, UCSF Fresno, University Medical Center (G.W.H., H.G.B.), Fresno, California.

Abstract
Background: A retrospective analysis of 7,854 ground ambulance and 1,075 helicopter transports was conducted.

Methods: The 911-hospital arrival intervals for three transport methods were compared: ground, helicopter dispatched simultaneously with ground unit, and helicopter dispatched nonsimultaneously after ground unit response.

Results: Compared with ground transports, simultaneously dispatched helicopter transports had significantly shorter 911-hospital arrival intervals at all distances greater than 10 miles from the hospital. Nonsimultaneously dispatched helicopter transport was significantly faster than ground at distances greater than 45 miles, and simultaneous helicopter dispatch was faster than nonsimultaneous at virtually all distances. Ground transport was significantly faster than either air transport modality at distances less than 10 miles from the hospital.

Conclusion: Ground ambulance transport provided the shortest 911-hospital arrival interval at distances less than 10 miles from the hospital. At distances greater than 10 miles, simultaneously dispatched air transport was faster. Nonsimultaneous dispatched helicopter transport was faster than ground if greater than 45 miles from the hospital.​

and

A cost and outcomes comparison of a novel integrated pediatric air and ground transportation system.

Safford SD, Hayward TZ, Safford KM, Georgiade GS, Rice HE, Skinner MA.

Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.

BACKGROUND: The purpose of this study is to compare air transportation of critically ill pediatric patients with a mixed air-ground transportation system by evaluating timeliness, safety, and cost. The setting was a tertiary care "hub" center with three outlying-referral "spoke" facilities. STUDY DESIGN: Our study included 96 children transported between June and December 1997, with 45% constituting surgical admissions and 55% medical admissions. Data collected at the outlying facilities, en route, and at our institution included vital signs, laboratory values, and Glasgow coma scores. We evaluated transport time, transport cost, Pediatric Risk of Mortality scores, and Pediatric Index of Mortality of the children during transportation using ANOVA statistical analysis. We also compared adverse events in transportation, total hospital length of stay, and mortality at 24 and 72 hours in both the air and ground transport groups to determine differences in predicted and observed mortality. RESULTS: A total of 96 children were transported (48% by ground and 52% by air) between June and December 1997. The time at the referring facility was significantly shorter in the ground group than in the air group (air, 55.4 minutes versus ground, 36.7 minutes, p < 0.01). Total transport time differed by only 27 minutes between groups. No difference was identified in morbidity or mortality between air and ground groups. Actual mortality was not significantly different from predicted mortality in either group. The cost of ground transportation was significantly lower (air, $4,236 versus ground, $1,566). When our system of a combined air and ground group transport system is compared with a hypothetical 100% air transport system, we saved an average of more than $240,000 annually. CONCLUSIONS: We have demonstrated that a "hub-and-spoke" ground transportation system supplements air transportation in a safe, timely, and cost-effective manner.​

So what is the gist? Air medical transport is overused, but does have a role in EMS. It can reduce mortality and morbidity in the trauma patient, can extend the "reach" of cath labs to outlying facilities ("regionalized" STEMI protocols - show up at a small town hospital, get flown to a tertiary center with a door-to-balloon time from the first ED door of < 120 minutes), and can serve as "back-up" ALS for rural services.

To the OPs question of risk versus benefit, that itself requires more study. The Candian experience (note: there are virtually no EMS helicopter crashes in Canada) suggests that the crew, aircraft, and equipment might change the risk benefit analysis drastically. In Canada, EMS helicopter missions are required to be flown IFR, with two pilots, and NVGs are required for night-time operations. This is far more restrictive than the U.S. standards, which allow VFR, single pilot missions in non-NVG equipped aircraft. Also allowed are operations from aircraft which are not even certified for IFR operations.

- H
 

flighterdoc

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Stratification based upon Trauma Score demonstrated a 35% reduction in mortality for victims transported directly from the scene with scene scores between four and 13, and essentially no difference in outcome for patients at Trauma Score extremes.​

A GCS of 4 is an extermely ill individual, a 13 is not. Including 13's in with the 4's skew the data and show a positve influence in some that may not be valid. I would expect 13's to generally do pretty well no matter what the treatment delivery modality, they could even walk to the ED and have a positive outcome.

How about stratifying the data to include GCS's 3-7, 8-12 and throw out the 13's and above and 3's? The odds are pretty much against a patient with a 3 no matter what, and pretty much for anyone with a stable 13 or above.

Interestingly, DocShazam has an interesting weblog entry about the misues of aeromedical EMS: http://docshazam.blogspot.com/2005/02/flight-027.html

Now, I agree that there is way too much blade spinning going on, for cases that don't necessarily qualify. I've actually flown (as both a paramedic, back in the day), and as an EMS pilot (fixed wing) and know that it's a terrible business to make money in and the crews are given less than ideal equipment, pressured to fly in bad wx and on the extremes of performance envelopes, etc, and that the FAA is doing a truly $hitty job monitoring the industry. But, better data would be useful, a flawed study (or abstract) doesnt help.
 

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The study is not discussing GCS (Glasgow Coma Scale) rather it is discussing the Trauma Score. They are different scores. The GCS measures level of cosciousness and measures best eye response, best motor response, and best verbal response. The Trauma Score is a measure of trauma severity and uses GCS, Systolic Blood Pressure, and respiratory rate to determine how severe the trauma is. A score of 13 for a trauma patient is still a relatively sick individual. That may be part of the confusion here. For more information see http://www.trauma.org/scores/rts.html
 

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In the area of SC that I am working whe have 3 helicopter services flying. Plus about 5 others that stop by with surprising frequency. The primary excuse that everyone gives for using the helicopter is time... then why is it that the family members in the 'ole family truckster beat the helicopter to the hospital MORE than half the time (in my N=1).

Many of the providers nearby Pre-hospital and In-hospital are far too eager to "call the helicopter". Currently there is no oversight of the calls and the helicopter responds if called... (talk about an overpriced taxi service).

Last year there was a woman who was struck on the interstate. Per the papers she was alert and stable... 3 helicopter services were called and refused to fly because of the weather. Finally 1 hour after the first ambulance got to the scene, a 4th helicopter service accepted the call, picked her up and crashed minutes after take off killing the crew of 3 and the patient. There were THREE Level 1 trauma centers within 1 hour of the accident scene.

There are too many services, running calls that do not need a helicopter, with little or no oversight. Finally someone has noticed that people are dying and hopefully some good will come out of it...
 

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One place I worked as a firefighter was about 20 miles up in the mountains from the town with the hospitals. We responded locally but the transport ambulance had to come from town so call to destination time was usually ~1 hr. In reality the helos didn't do much better than that. However we called them a lot due to the perception (justified or not) that if a patient had a problem enroute by ground we'd get sued for not calling the helo. Defensive medicine is not practiced just at the physician level.
 

FoughtFyr

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EMRaiden said:
There are too many services, running calls that do not need a helicopter, with little or no oversight. Finally someone has noticed that people are dying and hopefully some good will come out of it...
Where I was a FF/EMT-P (the near Chicago suburbs), paramedics could not call the helicopter directly. We had to call medical control and speak to a physician to get an order for the 'bird. As much as I disliked it at the time, the system worked well to control the "useless" flights. Of course, we were situated with a plethora of Level I and II TCs close by. The most common reason for a scene flight was obvious life threatening injuries coupled with extended extrication times.
- H
 

pushinepi2

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FoughtFyr said:
Where I was a FF/EMT-P (the near Chicago suburbs), paramedics could not call the helicopter directly. We had to call medical control and speak to a physician to get an order for the 'bird. As much as I disliked it at the time, the system worked well to control the "useless" flights. Of course, we were situated with a plethora of Level I and II TCs close by. The most common reason for a scene flight was obvious life threatening injuries coupled with extended extrication times.
- H
This is always an interesting discussion. Like the other posters, I too have flown in a past life. Most of my experience, however, was as a meager ground-based paramedic. Like advanced life support EMS in general, aeromedical transport has yet to firmly prove its benefits in terms of decreased morbidity in mortality. It is important to remember that helicopter transport is implemented in a wide variety of geographic locations and requests for service.
In rural north central florida, for example, many flight programs exist. Helicopters can be activated with little or no discretion. Even off-scene EMS district chiefs had the ability to activate the local aeromedical transport team. Considering the high cost involved in activation, it often makes decent economic sense to complete the mission and transport the patient to the hospital. In many cases, the helicopter was used to augment local community EMS resources. In counties surrounding Gainesville, EMS services are woefully understaffed. The aeromedical team often functioned to decrease the time to definitve care. Whether providing advanced airway interventions or much needed thrombolysis, there is little debate over the critical care team's augmented capability.

The issue of pediatric critical care transportation often involves helicopter activation. For hospitals without dedicated pediatric ICU/ERs, the transport team provides the level of care necessary to effect an EMTALA compliant patient transfer. Recent studies featured in Pediatric Critical Care Medicine journals demonstrated at least a modest decrease in the mortality severely ill and injured children conveyed by helicopter. Like other studies, it is impossible to account for all potential variables. There is no means consensus over the ideal activation and subsequent composition of a pediatric critical care team.

Even though protocols over the use of helicopter transport in Alachua County permitted and sometimes encouraged overusage, the helicopter was an indisputable extension of municipal EMS response. I can think of several mutliple vehicle accidents in which two helicopters were used to transport severely injured/entrapped patients. Though functioning as a flying ALS ambulance, these patients surely benefitted from a rapid transfer to definitive care instead of waiting on scene for the arrival of a third due rescue unit.

Other missions that I can recall involved directly assisting personnel in outlying rural hospitals. In one instance, our critical care team facilitated and extremely difficult intubation in a remote ICU. Anecdotes do not stength of evidence make, however, and it is important to consider the feasability of each individual mission. Activating the whirlybirds has economic, social, and human consequences. The decision is often made on incomplete information.

The debate over a helicopter's usefulness can't be divorced from its military roots. Helicopter EMS greatly contributed to decreased morbidity and morality during both the Korean and Vietnam conflicts. Parallels between civilian and miltary protocols might are not always intuitive; what held true in the battefields of Da-Nang might have little relevance to inner cities blessed with the proximity of level I and II trauma centers. The intrinsic value of helicopter teams should remain under continued scrunity. With continued dialogue, it may be possible to revise activation and use protocols with increasing usefulness and achieve better patient outcomes. In the meantime, I still think helicopter ride alongs are cool.

-Push