Administration and Leadership, Cardiac & Resuscitation, News, Patient Care

Mandating Safety: Feds to require HEMS safety measures

Issue 6 and Volume 34.

Despite voluntary safety measures on the part of helicopter EMS services (HEMS), 2008 was the deadliest year ever for air ambulances, with 35 fatalities. According to the Federal Aviation Administration (FAA), investigations of recent HEMS crashes found four common factors:

  • Controlled flight into terrain;
  • Loss of control of the aircraft in flight;„
  • Inadvertent flight into bad weather conditions; and„
  • Night operations.„„„„„

A January FAA survey found that “well over 80%” of HEMS operators have voluntarily adopted FAA-recommended training programs and control-center practices; 90% now use radar altimeters; and 40% equip at least some aircraft with newly developed helicopter terrain awareness warning systems (HTAWS), a $100,000 device that warns pilots when they get too close to the ground or other hazards, such as radio towers.

But at an April 22 Congressional hearing, FAA Director of Flight Standards John Allen said, “We recognize that relying on voluntary compliance alone is not enough.” He said the agency would soon propose new HEMS safety regulations that should take effect in 2011. He hinted the new rules would require HEMS operators to:

  • Install HTAWS, radar altimeters and flight recorders (to help investigators determine crash causes);„
  • Identify the entity responsible for operational safety;„
  • Use risk-assessment protocols for deciding whether to fly;„
  • Improve pilots_ skill for flying in the dark and in bad weather; and„
  • Foster collaborative decisions between ground and flight staff.„„„„

During his testimony, Allen knocked two HEMS safety bills now before Congress, saying, “We don_t believe that new safety legislation is needed at this time.” He said the FAA was already addressing the safety issues in the bills and expressed concerns that the legislation would allow more state regulation of HEMS because “economic issues could serve to limit market entry and could ultimately have a negative effect on available services.”„

Members of the Association of Air Ambulance Services (AAMS) also testified at the hearing, offering the association_s own set of proposalsƒcompletely different from those suggested by the FAA.

Two days before the Congressional hearing, the Flight Safety Foundation (FSF) released a comprehensive new report on HEMS risks, which is being printed and disseminated by the AAMS Foundation of Air-Medical Research and Education. (Download it

According to the FSF, the report would kick off a “comprehensive joint HEMS risk reduction plan to be in place” by Aug. 31. But that_s unlikely to deter the FAA from forcing the issue.„
ƒMannie Garza

New Cardiac Devices Offer Early Detection
Two new cardiac monitors, the Guardian and the AVIVO, are undergoing clinical trials in the U.S., and EMS crews may encounter them on patients in the future. Angel Medical System_s Guardian is implantable, with leads that attach to the heart, and is designed for outpatient use. Corventis_ AVIVO Mobile Patient Management System includes the externally applied PiiX and is being tested in hospitals.

The Guardian system consists of the implantable medical device (IMD), an external device (EXD) and a programmer. The IMD collects and stores information from the heart, and the EXD alerts the patient if there_s an anomaly. The programmer allows a physician to configure and retrieve data from the IMD.„

The IMD detects ST-elevations using algorithms on the blood flow within the heart. Researchers found the internal device to be more sensitive and able to detect changes in electrical activity more quickly than an external ECG.„

If the IMD senses signs of heart attack, it generates a buzz on the patient_s skin. The EXD_s beeps and flashing LEDs further alert the patient or caregiver. It analyzes the information and advises the patient to either make an office appointment or call 9-1-1. A physician can retrieve information from the EXD to see exactly what was going on when the alarm sounded.

Guardian_s senior field clinical engineer Nick Nudell is training EMS providers working in the locations where patients receiving the implants live. He gives them a description of the system so they understand its components. EMS providers are told to treat patients whose alarms have gone off with the same urgency as a STEMI, even if the ST elevations don_t show up on an ECG.

Marcia Makoviecki, Guardian spokesperson says, ˙This trial is designed for people who have already had a heart attack.Ó In early May, there were about 30 people in four participating states. The plan is to expand to 50 centers across the country.

Although similar to an internal defibrillator, the Guardian does not treat symptoms; it just alerts the patient that something unusual is happening. When asked about the possibility of connecting the Guardian to an internal defibrillator, Makoviecki said, ˙At this stage, I can_t comment on that.Ó

Corventis_ AVIVO Mobile Patient Management System includes the PiiX, zLink and Corventis Web Services. The PiiX looks like a large Band-Aid and adheres to the chest. It monitors heart rhythm and rate, respiration rate, patient activity level and body fluid accumulation. The zLink serves as a wireless communicator between the PiiX and Corventis.„

If the PiiX detects a problem, it creates an ECG waveform. The zLink sends information to Corventis, which analyzes the data and sends an alert to the physician if necessary.„

˙Our system allows the computer to watch a patient all the time, not requiring the physician to continually look at data and act on it,Ó said Corventis President Ed Manicka. He also says patients_ daily data will be available to physicians.

The trials are being conducted in hospitals, so that any room can serve as a telemetry room. ˙The device is intended as a diagnostic. To draw attention to patients [who] really need care,Ó said Manicka. There is no schedule yet for outpatients to use the device. It will be awhile before EMS encounters it.„
ƒAnn-Marie Lindstrom

Pro Bono
Don_t Get Called TwiceƒMake Sure No One_s Home„

A jury in Pennsylvania recently found an ambulance service negligent for failure to break into the home of a dying patient, but awarded no damages to the family of the deceased.„

According to news reports, the 45-year-old female patient called 9-1-1 after midnight, stating she was having difficulty breathing. She had a history of asthma and heart problems and told the dispatcher that she would try to unlock her door to let the ambulance crew in once they arrived. She never made it to the door, and when the ambulance arrived, the house was darkƒno one answered the door after repeated knocking, and no patient could be seen through the windows. The ambulance crew left the scene. About an hour later, the crew was called back after the patient_s nephew came home and found his aunt in cardiac arrest. The patient was pronounced dead at the hospital where she was taken.„

The jury ruled that the ambulance service had a ˙dutyÓ to gain access to the residence and locate the patient. Do EMS providers really have a duty to find their patient? Under the common law of negligence, a jury could find EMS providers and their agencies negligent when they ˙fail to act as another reasonable and prudent EMS provider would act given similar circumstancesÓƒwhich could include a duty to locate the patient in some cases.„

A jury could conclude that you are negligent even when there is no ˙patient contact.Ó Juries will look at all the evidence and the entire call from start to finish before reaching their conclusion. And you never know what they will decideƒlike in this caseƒwhich is precisely why you want to avoid the courthouse in the first place.„

Getting called back to the scene after leaving the first time can lead to claims of negligence, abandonment and wrongful death. The most common scenario occurs when you obtain patient refusal, you depart the scene, and then later the patient deteriorates, you get called back, and the patient does not survive the ˙secondÓ ambulance call. That_s why convincing patients to be transported and obtaining a fully informed refusal from those who truly don_t need our help is so important.„

Another common getting-called-back situation is when you get called and upon arrival you simply can_t locate the patient. You_ll likely be much more closely scrutinized for your actionsƒor inactionsƒon the first call in these ˙two callÓ situations because jurors will invariably ask, ˙Did the ambulance crew do everything they could have possibly done the first time?Ó Here are some tips to help avoid the risks of getting called back with the goal of providing the best patient careƒand to reduce liability potential at the same time. It answers the question, ˙What should a reasonable and prudent EMS provider do when there is Âno patient found_?Ó

  • Make sure your dispatchers communicate.In many 9-1-1 systems, the communicator who actually dispatches the responding units is not always the one who speaks to the caller. They could miss some key things the caller said. The people performing the call-taker and dispatcher functions need to communicate effectively to ensure all vital information is conveyed to the responding units. If the dispatcher communicates that the patient is ˙trying to get to the front door and is in severe distress,Ó it might encourage the EMS personnel to go the extra mile to access and locate the patient.„
  • Develop a ˙no patient foundÓ protocol.Make sure your system has procedures on what to do in this situation and follow the checklist every time. Specific steps should be followed, such as calling the residence back; contacting other agencies, such as police and fire departments, to assist and to make access; and notifying a supervisor to assist and offer another assessment of the situation.
  • Don_t give up easily.The most telling information in a case like this will be your on-scene time on the first call. Any on-scene time less than 10 minutes is likely to be seen by a jury as not enough time for a reasonable and prudent EMS provider to make absolutely certain there is no patient at the locationƒwhich is what you must do.„
  • Consider the source of the call.If no patient is found when responding to an accident called in via cell phone by someone driving by a vehicle along the side of the road, it_s much less of a risk than a call for help in the middle of the night made by someone in a residence. Look at the big picture when responding to these calls and exhaust all possible avenues of investigation when appropriate.„
  • Document, document, document!Cases like this require that you document each and every step you take to ensure that you exhausted all avenues to locate the patient. And make sure your timeline is accurate.„„„„„

Pro Bono is written by attorneys Doug Wolfbergand Steve Wirth of Page,Wolfberg & Wirth LLC, a national EMS-industry law firm. Visit the firm_s Web site at„ for more EMS law information.„

On Strike! But Still Working
In British Columbia, Canada, all EMS practitioners are called ˙paramedics,Ó and all 3,500 British Columbia Ambulance Service (BCAS) paramedics went on strike April 1 and were still striking when this issue went to press in early May. So who_s transporting patients in B.C.? The paramedics.

Forbidden from halting patient care and transports by an ˙essential services orderÓ from the Labour Relations Board, BCAS paramedics have been refusing to perform ˙nonessential tasksÓ until their union reaches agreement with the provincial government on wages and working conditions.

˙It_s mainly business as usual,Ó says BCAS spokesperson Chris Harbord, explaining that the paramedics have been refusing such tasks as scanning patient care reports and ˙moving ambulances around for such things as maintenance.Ó B.J. Chute, director of public education for the Ambulance Paramedics of British Columbia (Canadian Union of Public Employees, Local 873), says, ˙We_re not in a position to refuse service to the public, nor do we wish to do so. But we_re trying to make it as inconvenient as possible to run the day-to-day service.Ó„

The union began negotiating a new contract with BCAS last December, but the parties were unable to reach agreement before their old contract expired March 31. They want a 16% increase in pay over four years, which should bring them closer to pay parity with other public safety responders in B.C. and paramedics in other Canadian provinces. ˙We_re currently the lowest paid emergency responders in B.C.ƒthere_s a wage gap of about 30% with police officersƒand among the lowest paid paramedics in Canada,Ó Chute says.

The union also wants BCAS to address the issue of pay for 2,100 rural paramedics, who now receive $2 per hour (Canadian) when on call and $14Ï$24 per hour (for a minimum of four hours) when actually working a call. ˙Starting pay for a full-time paramedic is $54,000 (Canadian), but everyone first must work part-time for four to five years in a rural community,Ó Chute says.„

Harbord notes that the rural paramedics ˙are not required to stand by at the ambulance station, but instead respond to calls via pager, similar to volunteer firefighters. These paramedics Ú often work at other professions and Ú ambulance services in remote communities typically receive one or two calls per week.Ó„

The strike will likely continue until at least after provincial elections May 12. Although the paramedic union hasn_t taken an official stand, Chute says, ˙We_re favoring the government that_s not currently in power.Ó

Also on April 1, the government of Alberta officially took over that province_s ambulance service, making it the fifth (after B.C., Nova Scotia, New Brunswick and Prince Edward Island) of Canada_s 1 provinces to do so.

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