Administration and Leadership, News, Operations, Patient Care

Media Turns Up Heat on HEMS Safety

Issue 9 and Volume 35.

In the wake of July medical helicopter crashes in central Oklahoma and Tucson, Ariz., that killed a total of five people, the nation is beginning to take notice of what the EMS community has known for years—that helicopter EMS (HEMS) doesn’t just save lives, it can cost them too.

Both the Wall Street Journal and Washington Post have cited a 2009 study to declare that working on air ambulances is the most dangerous job in America. Popular Mechanics’ July issue noted that “medical helicopters accept the most dangerous missions in commercial aviation.”

So far, there have been four fatal crashes this year. In 2008, eight HEMS accidents resulted in fatalities.

University of Wisconsin (UW) Med Flight Chief Flight Physician Michael Abernethy, MD, FAAEM, knows all too well about the dangers. In 2008, three of his colleagues died when their helicopter crashed during a nighttime operation.

Abernethy says UW Med Flight was one of the first operators in the country to adopt instrument flight rules for flying in poor conditions.
However, cost, technology and diversion of safety resources for war have made it difficult for them and other operators to fulfill all the federal safety recommendations that arose from previous crashes.

One of those is that HEMS be equipped with Terrain Awareness Warning Systems (TAWS). “At the time of the actual recommendation of the National Transportation Safety Board, it was just in its infancy of its availability,” Abernethy says. “If everyone followed the recommendations, it would not have been close to available.”

By the end of 2008, UW Med Flight’s helicopters were equipped with TAWS, but this past year the Federal Aviation Administration (FAA) found that only 41% of the operators they surveyed had adopted it.

One positive development is the increased use of night-vision goggles. Three years ago they were rare in HEMS. The Iraq war severely limited the supply for civilian use. The $12,000 cost didn’t help either, Abernethy says, especially when multiple sets were needed for each helicopter. Today, many HEMS operators, including UW Med Flight, have obtained them.

Abernethy warns that profitable Medicare and insurance reimbursement policies have led to too many flights that aren’t medically essential, thus indirectly affecting safety.

“Patients that we wouldn’t have dreamed of flying 20 years ago are being routinely transported by air,” he says. “If it [becomes less] profitable to transport these patients, you’re going to see a change in the industry.”

The FAA has been working on updated HEMS regulations since 2004. A spokesman told JEMS they don’t have a timeline of when the rules will be finalized, but the proposed rules will be released soon.—Geoff Dietrich

Quick Takes
Paramedic Academy Offers Hands-On Instruction

The Las Vegas National Center of Technical Instruction (NCTI) and the University of Nevada School of Medicine (UNSOM) recently celebrated the first graduating class of their Critical Care Paramedic Academy. Employees from both AMR-Las Vegas and MedicWest Ambulance participated in the three-week (116-hour) intensive program developed by JEMS Editorial Board Member Bryan Bledsoe, DO, FACEP, FAAEM, EMT-P, of UNSOM and course director Larry Johnson of AMR-Las Vegas.

“The goal of this endeavor is to train and provide AMR paramedics as well as others with the education and skills necessary to provide the very best care for our most critical patients and customers,” says Johnson.

For more information about future courses, contact Stephen Johnson at [email protected].

A JEMS Editorial Board member was among the 23 professionals appointed by the U.S. Department of Transportation July 16 to serve on the National EMS Advisory Council (NEMSAC). Jeffrey P. Salomone, MD, a trauma surgeon, is associate professor of surgery at the Emory University School of Medicine and deputy chief of surgery at Grady Memorial Hospital in Atlanta.

Rounding out the list are 2010 JEMS/James O. Page Leadership and EMS 10: Innovators in EMS award recipient Dia Gainor; Linda K. Squirrel; Kenneth R. Knipper; JEMS columnist Gary G. Ludwig, MS, EMT-P; James McPartlon; 2009 EMS 10 award winner Gary L. Wingrove; Kyle R. Gorman; Marc Goldstone; Daniel Patterson, PhD; Troy M. Hagen; Arthur Cooper, MD; Thomas Judge; Aarron Reinert; Robert Oenning; Leaugeay Barnes; Matthew Tatum; Sherri-Lynne Almeida, MSN; Kenneth Miller, MD, PhD; Ritu Sahni, MD; Baxter Larmon, MD, PhD; Joseph Wright, MD; and Scott Somers, PhD.

JEMS Editorial Board Member Edward M. Racht, MD, has been appointed to the newly created position of Chief Medical Officer for American Medical Response (AMR). Having most recently served as chief medical officer for Piedmont Newnan Hospital in Atlanta, as well as a frequent lecturer, the move marks Racht’s full-time return to EMS.

Pro Bono
Don’t Get Burned Out By “Brownouts’
A new (and unfortunate) phenomenon in EMS is the “brownout.” As cities struggle to deal with difficult financial times, they’re temporarily closing stations or limiting the hours they’re staffed to save costs. Some may see this as a better alternative to layoffs, but nonetheless, patient care may be compromised due to the added response times that will invariably occur. Public safety budgets should be the last budgets cut when money is tight.

Can a city be liable for a delayed response time? Most local governments enjoy “governmental immunity” that may completely protect the city from liability, or may allow liability only if the city was “grossly negligent” in its actions. Some states also have monetary limitations on the recovery amount if the law allows an action based on negligence.

In cases where a city has strong protection from negligent actions, the patient may bring a federal claim for violation of the “due process” or “equal protection” clauses of the U.S. Constitution. This is often seen in a case in which a member of a minority group isn’t afforded the same rights as other citizens. How could that happen? Suppose a city decides to limit the hours of one of its substations—a “brownout” from 6 a.m. to 6 p.m.—and the station affected serves a predominantly minority population neighborhood that’s much busier than another substation serving an affluent non-minority neighborhood. But the city browns out the busier station, and a child dies due to a delayed response into that neighborhood. The potential for litigation is clear.

Decreasing EMS response is a slippery slope. Cities need to be careful when making response changes, and they should obtain public input when possible. They should rely on objective call volume data to ensure the fewest number of citizens are adversely affected when resources are limited. Weighing the pros and cons of alternative deployment strategies and seeking expert advice to assist in making staffing changes are a must to help avoid a potential lawsuit and to minimize public outcry.

What should field providers do to minimize risk of a lawsuit? Keep a positive attitude—don’t get burned out by the brownout—and don’t let the decisions of the city leadership affect how you treat your patients. You might feel added time pressure with increased call volumes, but you don’t want to be caught in the “abandonment trap,” which can bring even more potential liability. Take the time you need to adequately take care of your patients. Don’t shortchange them or encourage a refusal simply because of a concern that another call may come in. Leaving a patient who truly needs help and then getting sued for wrongful death or abandonment can lead to jury awards of large amounts.

Finally, if you’re a municipal employee, speaking out in the appropriate forum about decreased staffing would likely be seen by the courts as touching on “matters of public concern,” thus giving you protection under the First Amendment of the Constitution. As a citizen, you have the right to criticize your elected officials for poor decisions and to let the community know how public safety is affected by those decisions—without worrying about losing your job for doing so.

Should nonresidents have to pay for response?
It’s getting more expensive for visitors to get hurt in some cities. Several municipalities across the nation, such as Garden Grove, Calif., have instituted nonresident fees (usually to the tune of $300–$400) for emergency response to stall budget shortfalls. According to a recent article in Emergency Management, the thinking goes, residents and business owners pay for those services through taxes but visitors don’t, so visitors should be charged. Ashland, Ore., implemented a nonresident fee program in June, and Denver is debating a similar fee for Denver Fire Department motor vehicle collision responses for visitors. However, 10 states have banned such fees: Alabama, Arkansas, Florida, Georgia, Indiana, Louisiana, Missouri, Oklahoma, Pennsylvania and Tennessee.

What do you think? Should nonresidents have to pay for response?
– No, EMS should provide care without a tit-for-tat mentality.
– No, it’s not fair that visitors cover it in their home cities through taxes and have to pay for response elsewhere.
-Yes, they shouldn’t get response for free while others foot the bill.
-Yes, it’s a smart and fair system of regaining lost revenue.

This article originally appeared in September 2010 JEMS as “Crash Course: Media turns up heat on HEMS safety.”

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