Houston, We Have a Problem

The media has paid more attention to EMS during the past few months. Unfortunately, it hasn’t been the sort of attention we need. Certainly, the recent cluster of medical helicopter crashes has made the national and international news. Then, there have been the stories of stolen drugs, misappropriation of finances, sexual assaults, and even theft from patients. If it weren’t for bad luck, we would have no luck at all.

Thus, when faced with issues such as these, it’s time to become introspective and re-evaluate some of our practices. Most importantly, we have to educate the public and the politicians about what we really do, what we really can do and what we really can’t do. The television show “Emergency!” was shot on a back lot at Universal Studios in Hollywood, and, unfortunately, many people believe in the message from Hollywood like it was the divine, inspired word of some deity. One of our jobs, then, is to show that Hollywood is far removed from reality (or even common sense).

First, let s make politicians understand that response times for EMS are not as critical as once thought. Recently, in the “Austin American Statesman,” there was concern that Austin, Texas, might cut an ambulance and an academy class because of a budget shortfall. The 2008 proposed budget for EMS in Austin is $44.1 million, making them one of the most well-funded EMS systems per capita in the United States. But people began screaming about response times despite the fact that there’s no evidence that response times greater than four minutes make any significant differences in patient outcomes.(1-5)

Austin, which has a great EMS system, generally targets 10 minutes for most of their area. Granted, EMS responses less than four minutes are highly associated with improved outcomes from cardiac arrest. But there’s no way an EMS system can expect to routinely achieve response times less than four minutes (except for the casinos in Las Vegas).(6) Attempting to meet benchmark response times (which are not rooted in scientific fact) place EMS and helicopter crews at risk. Everybody assumes out-of-hospital time makes a big difference. In reality, it makes little difference for most of our patients.

The “Baltimore Sun” and “The Capitol Gazette” (Annapolis, Md.) have been extremely critical of the highly regarded Maryland State Police (MSP) Medevac system. I’ve always touted the Maryland system as a model for helicopter EMS operations. But when it recently became necessary to replace Maryland s aging fleet of 12 Eurocopter Dauphins at a cost of over $130 million (at a minimum), the Maryland Institute of Emergency Medical Services System (MIEMSS) was called on the carpet because of poor maintenance and a lack of accountability in the MSP Aviation Division (although the MSP has had an impeccable safety record).

It turned out that in 2007, there were 4,383 helicopter transports by the MSP. Of these, 35% were discharged from the Shock Trauma Center in under 12 hours and another 11.5% were discharged in less than 24 hours. This would imply that these patients, for the most part, had minor injuries and did not require trauma center care. Further, the average helicopter transport time by the MSP is 14 minutes. It seems that considering the short 14-minute helicopter trip (including startup and shutdown), most patients would probably have arrived at the trauma center faster by ground ambulance. (MIEMSS now requires that patients less than 30 minutes from Shock Trauma be transported by ground.) Thus, virtually half of all patients transported by the MSP in 2007 had minor injuries.

Now, you always want to have some degree of over-triage to catch outliers. But a 50% over-triage rate is over the top. This is especially true when the annual operating budget for the MSP Aviation Division is approximately $20 million a year. That works out to approximately $10,000 per patient who was not discharged in less than 24 hours.

Additional light was shed on this issue when a report summarizing the scientific literature on helicopter trauma transport by Johns Hopkins University (requested by a member of the Maryland legislature) failed to show any overall benefit to patients from helicopter transport. But proponents stuck to the age-old mantra of meeting the “Golden Hour,” even when the literature suggested that the Golden Hour wasn’t based on scientific evidence.(7)

Now, there’s no doubt trauma centers save lives. Anybody who does a great deal of the same thing usually gets good at it. I wouldn’t take my Acura to a Chevrolet dealer because they’re probably not good at working on Acuras. But specialty care centers (e.g., burn centers, trauma centers, spinal injury centers) are expensive to operate and we should ensure the right patients get there. Because prehospital personnel cannot fully detect all injuries in the field, we accept an over-triage rate. But nobody seems willing to say what the overall over-triage rate should be.

In a study we published in the “Journal of Trauma” in 2006, we found that two out of three patients transported from the scene in a helicopter had minor injuries by objective criteria.(8) Other studies have shown anywhere from 25 33% of patients transported by helicopter from a trauma scene are discharged within 24 hours. We need to refine our trauma triage criteria to reduce the usage of precious resources. Statistics can help.

One thing to recognize, though, is that mechanism of injury (MOI) is a poor predictor of injury. This has been beat into EMT and paramedic students for more than a decade. Like the “Golden Hour,” there’s little scientific support for MOI criteria (except for ejection from a vehicle). We need to eliminate MOI alone as criteria for calling a helicopter or taking a patient to a trauma center.(9) The American College of Surgeons needs to revisit trauma center usage criteria soon, especially because the helicopter usage criteria are widely based on the ACS criteria. Thought leaders in trauma surgery, such as Jeff Salomone, MD, are working hard at this.

As we take a closer look at our practices, we should note where EMS stands within the health-care picture. Health-care spending in the U.S. continues to rise. Total health-care spending in 2007 was $ 2.3 trillion, or $7,600 per person.(10) Stated another way, 16% of our gross domestic product (GDP) goes to health care. Despite spending more of our GDP on health care than any country in the world, the World Health Organization (WHO) ranks the U.S. 37th in health care quality.(11) EMS accounts for only a small part of the health-care dollar and should receive more. But we all have a duty to help lower health-care costs.

We can start by carefully using resources, such as trauma centers and medical helicopters. We can no longer accept emotional arguments and anecdotes when it comes to making important patient-care decisions. I was actually told by a group of paramedics last year (in a state that will remain nameless) that they often call a helicopter for patients after midnight because it takes an hour-and-a-half to get the patient to the hospital and then return and they have to go to work at their part-time jobs the next day. Whether this was an issue of pay or laziness is unknown. But it shows that our system is broken, and we must work together to fix it.

JEMS.com Editor’s note: Prior to publication, MSP Trooper 2 crashed, killing four people, bringing the number of deaths in helicopter EMS crashes to 24 for the 2008 calendar year. For an additional perspective on air medical transportation, read JEMS Editor-in-Chief A.J. Heightman’s From the Editor in October JEMS. Also,click here to read news stories and watch a video about the investigation into the crash.

References

  1. De Maio VJ, Stiell IG, Wells GA, Spaite DW; Ontario Prehospital Advanced Life Support Study Group: “Optimal defibrillation response intervals for maximum out-of-hospital cardiac arrest survival rates.” Annals of Emergency Medicine. 42(2):242 250, 2003.
  2. Pons PT, Markovchick VJ: “Eight minutes or less: Does the ambulance response time guideline impact trauma patient outcome?” Journal of Emergency Medicine. 23(1):43 48, 2002.
  3. Blackwell TH, Kline J, Willis J, et al: “Lack of association between prehospital response times and patient outcomes.” Prehospital Emergency Care. 11(1):115, 2007.
  4. Vukmir RM, Sodium Bicarbonate Study Group: “The influence of urban, suburban, or rural locale on survival from refractory cardiac arrest.” American Journal of Emergency Medicine. 22(2):90 93, 2004.
  5. Turner J, O Keefe C, Dixon S, et al: The Costs and Benefits of Changing Ambulance Response Time Performance Standards. Medical Care Research Unit School of Health and Related Research: University of Sheffield, 2006.
  6. Valenzuela TD, Roe DJ, Nichol G, et al: “Outcomes of rapid defibrillation by security officers after cardiac arrests in casinos ” New England Journal of Medicine. 343:1206 1209, 2000.
  7. Lerner ED, Moscatti RM: “The Golden Hour: Scientific fact or medical ‘urban legend’?” Academic Emergency Medicine. 8:758 760, 2001.
  8. Bledsoe BE, Wesley AK, Eckstein M, et al: “Helicopter scene transport of trauma patients: A meta-analysis.” Journal of Trauma. 60:1257 1266, 2006.
  9. Boyle MJ, Smith EC, Archer F: “Is mechanism of injury alone a useful predictor of major trauma?” Injury. 39:986 992, 2008.
  10. Poisal JA, Truffer C, Smith S; the National Health Expenditure Accounts Projections Team: “Health spending projections through 2016: Modest changes obscure Part D s impact.” Health Affairs. 26(2): W242-253, 2007.
  11. Photius Coutsoukis: “The World Health Organization’s ranking of the world’s health systems.” www.photius.com/rankings/healthranks.html

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