Half of Maryland's Medevac Transports Not Seriously Injured


 
 

| Tuesday, April 1, 2008


BALTIMORE -- When an Anne Arundel landscaper was caught in a stump grinder and a young woman was thrown headfirst through her car windshield, their lives were saved by Maryland State Police medevac helicopters and the University of Maryland Shock Trauma Center.

The system considered by many the best medevac and trauma treatment system in the nation was designed precisely for their types of massive, life-threatening injuries.

But in recent years, about half the patients transported by state police helicopters to a trauma center are not seriously injured; they are treated for nonlife-threatening injuries and released within 24 hours.

That has raised questions about whether the more than $20 million a year taxpayers spend to keep the choppers flying so frequently is necessary or if it's being used to bolster billing at the trauma center.

Maryland is the only jurisdiction in the country where a state agency the state police runs a comprehensive statewide medevac system financed by the public. Other states rely on hospital-based commercial operators that bill patients and their insurance companies. When patients don't have the resources, the medevac operators swallow the expense.

A typical medevac bill runs about $10,000, sources said, depending on travel distance and the geographic market.

The Maryland State Police Department never bills for medevac flights, though patients treated at trauma hospitals and the University of Maryland Shock Trauma Center do pay for their medical care.

"When you get a helicopter ride from us, you are not going to get a bill, you ride free," said Maj. A.M. McAndrew, commander of the Maryland State Police Aviation Command. "You get a ride in some other states with private companies, you are going to pay, you are going to get a bill for $6,000 or more."

The $20 million a year it costs to keep the choppers flying doesn't include the roughly $139 million the state is looking to spend to replace its aging fleet of 12 Eurocopter Dauphin helicopters. (Some experts say the purchase price ultimately will be closer to $200 million.)

The annual operating costs come mainly from a $13.50 registration fee charged for each motor vehicle in the state, but state officials say this fund is heading into the red and the fee may need to be increased in as little as four years.Medevac experts said they can't think of a state where the public treasury subsidizes medevac flights, though in some states, such as Florida, a few local fire departments run air ambulance services. In New Jersey, the state police run only two helicopters and the bulk of medevac missions are flown by commercial operators and hospitals.

Some critics say Maryland should follow these states' example and privatize services, but the argument never gets off the ground.

Several members of the General Assembly said lawmakers get so much pressure from state police and the group that oversees trauma care, the Maryland Institute for Emergency Medical Services Systems, that it's impossible to have an open discussion about major changes to the existing system.

"We have some concerns about the system, and the public needs to know," said Sen. Nathaniel Exum, D-Prince George's, who sponsored a bill four years ago to establish a medevac privatization pilot program.

"But we aren't even able to talk about it," Mr. Exum said of the intense lobbying pressure. "They (state police and the Maryland Institute for Emergency Medical Services) call all the little people back home, the firefighters and the paramedics, and tell them we are trying to dismantle the system, and they come running." Mr. Exum said.

"The people who are running the program think it is their program, and they don't want to recognize that it belongs to the people," Mr. Exum said.

When told about lawmakers' perceptions, Maryland State Police Secretary Col. Terrence B. Sheridan laughed and said it was news to him.

"I have never heard that before and I don't know of any leader who has been leaned on," he said.

"If (a private person) out there wants to speak out on their own position, I can't control that," Col. Sheridan said.

Shock Trauma Center

Maryland is the only state in the nation with a hospital University of Maryland Shock Trauma Center dedicated entirely to treating adult trauma patients, according to John Spearman, the center's vice president.

Besides the University of Maryland Shock Trauma Center, there are eight other hospitals around the state with trauma units, and still other hospitals that specialize in areas of care such as eye injuries and burns.

Not counting these other hospitals, keeping the University of Maryland Shock Trauma Center's doors opens costs about $185 million a year, most of which is paid for by patients and their insurance companies.

"It saves lives, no question about it," Del. Bob Costa, a Republican from Deale, said of the helicopter-hospital system.

But Mr. Costa, a career paramedic, said he agrees with the pilots, paramedics and doctors who say the system is overused.

"It is a huge source of income," said Mr. Costa, who explained that patients with minor injuries help pay the hospital system's operating expenses.

The heads of the state trauma system say that treating people with minor injuries is inevitable.

Patients cannot be screened properly until they have undergone a battery of sophisticated tests, according to these officials, and those tests must be done in a trauma center.

"We have said as a medical society 'We will overtriage, we will bring people here who don't need to be here, rather than miss someone,' " said Dr. Thomas M. Scalea, physician-in-chief at shock trauma center.

Shock trauma's Mr. Spearman said, "Your aorta could separate and it won't show itself for two hours. But the moment it does choose to reveal itself, you are dead within two minutes."

Overkill

"It is overkill," Dr. Bryan Bledsoe, a Dallas resident who writes about trauma medicine nationwide, said of the Maryland medevac-trauma center system.

Now a professor at the University of Nevada Medical School in Las Vegas, Dr. Bledsoe taught until recently at George Washington University Medical School in Washington, D.C.

He said shock trauma care and medevac helicopters swept the medical world off its feet about three decades ago, but the movement was "based on emotion and not on science."

"It started in Maryland and Connecticut," Dr. Bledsoe said. "It was a good idea, but the situation just got crazy the majority of patients transported by helicopter don't benefit from it."

A doctor who helped develop the Maryland system, Dr. Clayton H. Shatney, said the shock trauma center and state police helicopters were designed to be overused.

Dr. Shatney worked with the center's founder, Dr. R Adams Cowley, and taught medicine at the University of Maryland between 1979 and 1982. He went on to help establish a trauma center in Jacksonville, Fla. and to teach trauma medicine in California.

"Cowley wanted to keep shock trauma center full the helicopters would fly over (lower-level but adequate) hospitals and bring patients to shock trauma center," Dr. Shatney, now retired, said of the Maryland system.

"Part of it is finance," Dr. Shatney said. "If you can bring a steady stream of (slightly injured) patients into the trauma center, it helps offset the care in ICU, which is truly expensive."

Dr. Shatney has studied the use of medevac helicopters in California, studying transportation times and types of injuries, and concluded that only 23 percent of patients benefitted from being flown.

He said he thought a study of Maryland's helicopter and trauma care system would produce similar results.

As for the cost of treating a minor injury (such as a broken arm) at a trauma center, versus the cost of care at a community hospital such as Anne Arundel Medical Center, Dr. Shatney said he has never been able to compute the difference, but estimated it at "three to five times as much."

After trying to conduct an analysis for The Capital, the state Health Services Cost Review Commission concluded there are too many variables to compare the cost of care at the two types of hospitals.

Dr. Shatney said trauma centers and helicopters are overused because the public likes to believe these tools can work magic.

When asked if his report on overuse of helicopters in California resulted in a decrease in the number of flights, he said, "Hell, no."

Costly system

"What I like about the state program is whether you are the homeless man crossing Interstate 95 or Donald Trump, whose limo crashes on I-95, you will get treated by MSP," said veteran state police pilot Bill "Nitro" Bernard. "We build stadiums for millionaires to play ball in, so why shouldn't we do this?"

But keeping helicopters flying is an expensive proposition.

It costs between $1,500 and $2,000 an hour to operate one of these helicopters, medevac experts said, and that does not include fixed costs such as renting hangars and paying crews. Just the fuel for one of the twin-engine Maryland State Police helicopters costs upwards of $400 an hour, state police officials said.

Everything about a helicopter has to be made according to high and costly standards. The Dauphin's engines weigh only about 300 pounds each, but produce roughly 800 horsepower apiece. The four rotor blades weigh only 90 pounds each, but together they hold the 9,000 pound helicopter in the air and transport patients and crew at well over 150 mph. Replacing the four rotor blades costs more than $400,000.

State police received a big vote of confidence last fall when the General Assembly earmarked $110 million in sales taxes to go toward replacing the existing helicopter fleet.

Lawmakers agreed to the expense during a special legislative session called to address a budget shortfall by raising taxes and cutting spending.

State audit

There have been claims of mismanagement in the Maryland State Police Aviation Command. The General Assembly's Joint Audit Committee, which consists of 10 senators and 10 delegates, has asked the nonpartisan Department of Legislative Services to audit the unit's operations.

The audit is to determine if state helicopters are used frivolously or "beyond operational purposes," Department of Legislative Services Chief Auditor Bruce A. Myers said, and to see if patients are transported in a timely manner.

While Mr. Myers declined to discuss his findings so far, a pilot's personal notes obtained by The Capital show that state police helicopters sometimes are used for missions that have little or nothing to do with saving lives or protecting the public.

"Trooper 8 (the helicopter based in Montgomery County) overflew the (accident) scene and the mission was given to Trooper 2 (from Andrews Air Force Base), who transported a Priority 1 intubated patient. Why? Trooper 8 was dedicated to a demo at the hangar for 13 kindergartners," the pilot's notes stated.

Another time this pilot wrote, "After being out of service for three days due to aircraft maintenance and inspections, Trooper 8's first mission was to attend a dinner party demonstration at the Elkridge Furnace Inn."

Auditors have had a difficult time getting documents from the Maryland State Police Department, according to some members of the General Assembly, but Mr. Myers said the audit will be completed by early summer.

The report will not look at whether state police transport too many patients who have only minor injuries.

Standard of care

Commercial medevac operators say they not only would save taxpayers money, but would provide better service.

Under state licensing requirements, state police helicopters are required to carry only a pilot and one flight paramedic, while commercial operators must carry a pilot and two medical providers, typically a paramedic and a registered nurse.

Currently, when a patient's condition necessitates a second caregiver, the state police flight paramedic will recruit a member of the local ground crew at the accident scene, who may be a professional or a volunteer.

Critics of the current system also stress that response time would not suffer because of privatization.

"If you had eight commercial helicopters in the same eight places MSP has helicopters, you would have the very same function," said Ed Rupert, vice president of Colorado-based Air Methods Inc.

Air Methods is publicly traded and is the world's largest air ambulance service with 345 helicopters and 20 airplanes. Mr. Rupert's office is on Kent Island, and he is responsible for operations in an area that extends from Virginia to New England, and from Delaware to Michigan. But, Mr. Rupert said, Air Methods does not base helicopters in Maryland.

Commercial medevac operators do fly missions in Maryland, mainly transferring patients between hospitals.

These helicopters are almost never called to accident scenes.

Under state guidelines, if a state police helicopter is within 25 minutes' flight time from a trauma scene and a privately-owned medevac is 10 minutes away, the state chopper gets the call and that call comes from the Maryland State Police dispatcher working out of the Maryland Institute for Emergency Medical Services Systems building in Baltimore.

"We're usually on the L(anding) Z(one) and waiting for the patient," said Trooper First Class Michael Johnson, a flight paramedic stationed at the Martin State Airport hangar east of Baltimore.

He gave the following example of a typical call: "We have a 20-minute flight time to Cecil County, and (by the time I get there) I still have to wait for the ground crew to complete the extrication."

Dr. Robert Bass, executive director of the Maryland Institute for Emergency Medical Services Systems, said the average state police response time is about 18 minutes, and the flight time from the accident scene to a trauma center is 11 minutes.

"There is no other state I know of that can say they have an 18 minute response time statewide," Dr. Bass said. "I don't think there is any other state that does it as well as we do."

Mr. Rupert countered that the state's goal of getting patients to the hospital as fast as possible does not jibe with the practice of giving state police helicopters priority over the closest helicopter.

"You either need the closest helicopter or you don't need a helicopter, and if you don't need a helicopter, then why are you being flown?" said Mr. Rupert, who is a registered nurse.

He has supporters in the General Assembly.

"I really believe it would be cost-effective for the people of Maryland if we were to privatize the system," said Sen. John Astle, an Annapolis Democrat and retired medevac helicopter pilot.

Mr. Astle flew for MedStar, a non-profit corporation that operates hospitals and medevac transportation systems.

Mr. Astle emphasized that he's not trying to line his own pockets by supporting privatization.

"I no longer have a dog in the fight," he said.

It may never be known whether commercial operators' claims an ability to transport patients competently without costing taxpayers have merit, because not many lawmakers are listening.

Sen. Ed DeGrange Sr., a Democrat who represents the Glen Burnie area and serves on the powerful Budget and Taxation Committee, for example, said the issue of privatization surfaces from time to time, and he always opposes it.

"Am I going to be relying on a private carrier who may not put the resources into it?" he said. "They are in it to make money, and what happens if they don't make money and leave?"

Gag order

"You are about to get your wrists slapped," Mr. Costa said of anyone who dares ask whether state police helicopters and the University of Maryland Shock Trauma Center are being used unwisely.

Sen. E.J. Pipkin, an Eastern Shore Republican, has supported privatizing the helicopter system in the past, but got nowhere.

This year, he introduced a bill to allow private helicopter companies to be compensated by the state for transporting a very small handful of patients about 20 a year from accident scenes to trauma centers. The charges would total less than $200,000 and would come out of the roughly $54 million yearly fund that supports state police helicopter operations and other emergency medical services.

State officials, some from the Maryland Institute for Emergency Medical Services Systems, recently testified that the bill would undermine the entire state emergency medical system.

"The power down here from the Maryland Institute for Emergency Medical Services Systems and the state police is just incredible," said Katie Nash, Mr. Pipkin's chief of staff.

The pressure on lawmakers comes from the local firefighters and paramedics back home.

The Maryland State Police Department and the Maryland Institute for Emergency Medical Services Systems control to a large degree the grants that go to local fire departments for emergency equipment, and anytime state police sound the alarm, the local emergency medical providers come to Annapolis.

Local paramedics who were questioned did not want to talk for the record, saying their unit could be denied grants for new equipment.

In Annapolis, state police medevacs seem to fly under the political radar: conservatives support the police and aren't eager to cut their budgets, while liberals like that the idea that medevac flights are financed by the state and not billed to the patient.

The commercial medevac industry's chief lobbyist in Annapolis, attorney Bryson Popham, said his clients have given up, and he didn't even get his "helicopter" files out of storage this session.

Mr. Rupert, of Air Methods, said his company has abandoned hope that anything will ever change.

"The state police are the most powerful lobby in the state they provide security for the governor, the Speaker of the House, and the President of the Senate," he said. "I don't think anything is going to change in my lifetime."




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Related Topics: Extrication and Rescue, Head and Spinal Injuries, Operations and Protcols

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