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Change Should Be in the Air

JEMS.com Editor's note:After October 2008 JEMS went to press, MSP Trooper 2 crashed, killing four people -- the crew, a local EMS provider/firefighter and one of the two patients.

"The thing is helicopters are different from planes. An airplane by its nature wants to fly, and if not interfered with too„strongly by unusual events or by a deliberately incompetent pilot, it will fly. A helicopter does not want to fly. It is maintained in the air by a variety of forces and controls working in opposition to each other, and if there is any disturbance in this delicate balance, the helicopter stops flyingƒimmediately and disastrously." ƒHarry Reasoner,60 Minutes

This quote has been etched in my„mind for decades. I read it on the wall in a helicopter hangar in Long Beach, Calif., in 1981, just weeks before my„EMS region's helicopter program went operational. It was posted to remind the pilots not to take unnecessary flights (or risks) because they were flying a machine that_s complicated to fly even under the best of circumstances.„

There was a lot of hype and training in our region about when to call for a helicopter, what types of patients should be flown and the hazards associated with landing zones and operations. We felt confident we were ready.„

Then, just two flights into our prehospital operations, our helicopter crashed into the ground on takeoff from a dark, rural scene and everyone on board perished. I lost some good friends that night and watched others go through the emotional turmoil of wondering if they had brought the crew out on an unnecessary mission.

We set up a regional review process after the crash that looked at the appropriateness of every flight, labelling each as valid, non-valid or valid false positive (influenced by patients impaired by drugs or alcohol, mechanism of injury or other factors). The crews that called for flights judged to be non-valid received a letter explaining why it was deemed non-valid so they would refrain from inappropriate use in the future. The process worked fine until additional helicopter programs worked their way into the region and balked at having to have each case reviewed by a panel of physicians they felt had conflicts of interests and political reasons for reducingtheir flights.

"Their" flights? These weren'ttheir flights, but rather EMS on-scene patients thatour units chose to send to specialty facilities in their helicopter. I was overruled, the committee faded away and, by the time I moved to California, there were six helicopters competing for patients in the same catchment area previously served by two.„

Fewer patients for each program to retrieve and bill, more maintenance and operational dollars spread over fewer patients, and reduced regional accountability is a recipe for financial disaster and an increase in non-valid flights. And the helicopter programs aren't the only ones to blame for over-utilization of helicopters EMS agencies that call for air transport that isn_t necessary are just as guilty.

Maryland's Medevac program has recently implemented changes that will reduce unnecessary use of its state police helicopters. For example, if patients are within a 30-minute drive to a trauma center, they'll now be transported by ground ambulance unless there are "extenuating" circumstances, such as major traffic delays.

Maryland paramedics will also no longerautomatically send to trauma centers patients who have been involved in automobile roll-overs, high-speed crashes, vehicle extractions lasting longer than 20 minutes and other situations that were formerly believed to indicate a high likelihood of serious injury.

This change is occurring because Maryland_s statistics have shown that almost half of the nearly 5,000 patients flown by helicopter to Maryland trauma centers are released within 24 hours, suggesting many of them may not have needed the more expensive, resource-intensive helicopter flight. These actions come at a time when Maryland's Joint Committee on Health Care Delivery and Financing is holding hearings to address the statewide helicopter system_s flight volume and finances.

Most of the 700 medical helicopters in operation across the country are hospital-based and operated by for-profit companies that would never air their business strategies, unnecessary flight statistics, budgets or program deficiencies in public. So these discussions and changes by one of the few government-operated air medical systems give us the rare opportunity to review current air medical issues relevant to all„EMS systems.

My BP rises every time I hear of a skateboarder falling, walking around at a scene and then being flown 25 miles to a specialty center for "evaluation." And my blood boils when I hear that a local EMS provider likes to use the helicopter for missions of this nature so they don't have to commit an ambulance to "drive all the way down to the city and back," tying up their crew (and rig) for two hours, when they can "go back into service" as soon as the chopper lifts off.

With air medical crashes increasing 130% in the past 15 years, and eight crashes and 20 fatalities already in 2008, it's time for the medical community and EMS administrators to re-evaluate their helicopter dispatch criteria and end the practice of crews calling for helicopters based solely on mechanism of injury or outdated patient triage categories.

Editor's Note:There were 13 crashes and 24 deaths in 2008 at the time this article was published. We regret the error.

References

1.„Dechter G: "Medevac copters' usage curtailed, legislators told." The Baltimore Sun. Sept. 4, 2008.

2.„National Transportation Safety Board.www.ntsb.gov.

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