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Wed Feb 25 15:51:51 GMT 2009

On Wed, Feb 25, 2009 at 9:42 AM, Thomson, Dave <dthomson at phihelico.com>wrote:

> The current dispatch criteria have been out since 2003.  They no doubt
> need revision, but nevertheless they have been available and have been
> endorsed by several groups.  I think the new trauma triage guidelines
> from CDC may help decrease some unnecessary scene responses.
>

I agree.  However, I think that perhaps we should not wait on the CDC to get
around to it.  Maybe now is the time for the AAMS and several of the
professional medical groups related to trauma, critical care, and emergency
medicine (in-hospital and pre-hospital) to sit down and work out an
understanding on the topic.

>
> I agree that utilization review is the key.  Currently some programs do
> a good job, while others don't do any UR.  The excuse that many
> organizations use is "If we upset the referring organizations then they
> won't call us when we are truly needed."  That's bunk - you can
> instruct, rather than belittle, and most people will respond in a
> positive manner.
>

Agreed.  What I detest is the "Here some free crap, now please call us for
anything!" approach that some services (speaking with one lower end program
in particular in mind) utilize.  I have a rather high opinion of some
helicopter operations; Lifeline out of Indianapolis being one of them- well
trained crews, nice equipment and the people they send out to educate
personnel actually know the science (unsupportive as it is of the use of
helicopters on a large scale ) underpinning the when and why of aeromedical
evacuation.

>
> The insurance carriers are the ultimate external UR in many cases - but
> they also suffer from a lack of knowledge.
>

I agree, but think you just made the understatement of the year with the
last half of that sentence.

>
> There are two other important questions that need to be addressed in
> this discussion: What are the alternatives, and how safe are they?
>

1. Increased use of fixed wing evacuation in situations where it is
absolutely necessary to effectively cover long distances (western US, etc).
2. Elimination of scene responses or limiting flights only to pre-selected
and surveyed landing zones.

3. Development of an "echelons of care" approach for trauma patients in
civilian settings similar to what is used by the US military in Iraq and
Afghanistan

>
> In some areas there are ground ambulances with well trained crews who
> can efficiently and cost-effectively transport patients. That is one
> alternative to air medical transport.  The other alternative is having
> the ability to manage these patients in place.

> The former is, unfortunately rare, especially in rural areas.

As someone who cut his teeth as a rural EMT and EMT-I, I take some small
degree of offense at that.  While we may not have the call volume or the
massive numbers of personnel that are seen in urban areas, one must keep in
mind that ALS and especially aeromedically provided ALS has very few
circumstances where it is going to significantly improve outcomes over BLS
ground transport.  However, I do see where you are coming from and agree
that rural EMS certainly has a lot of room for improvement but then again,
I've yet to see a service that does not.

>  The latter capability is  also rapidly decreasing, as hospitals close or
> become essentially free-standing emergency departments.

Then you transfer the patients by ground to the emergency department and
then fly out the minority that actually need emergent evacuation and arrange
ground transportation for the rest.

It is also not clear exactly what  the risks are with ground ambulance
> transport.  We have some reasonable data that emergency response with red
> lights and sirens is a high-risk procedure.  What we don't know is what the
> risks are for routine-traffic
> critical care transport (both patient care and vehicle risk).

Actually the CDC did a study that can be used to answer this  when they went
about looking at line of duty deaths for EMTs and paramedics.  The rates
were (at first glance lower for ground ambulance personnel dying in ground
ambulance crashes than the most often cited rate of aeromedical personnel
dying in helicopter crashes, even adjusting for the far smaller aeromedical
community.

http://findarticles.com/p/articles/mi_m0906/is_8_52/ai_99206286

During 1991-2000, the most recent year for which data were available, *300
fatal crashes occurred involving occupied ambulances, resulting in the
deaths of 82 ambulance occupants and 275 occupants of other vehicles and
pedestrians. The 300 crashes involved a total of 816 ambulance
occupants.*FARS does not differentiate ambulance workers from
passengers among those
experiencing nonfatal injuries in fatal crashes; however, the seating
positions for all occupants and the severity of injuries can be determined
from FARS data (Table).

Although which occupants were EMS workers and which were patients or other
passengers cannot be ascertained precisely, calculations using the FARS
"fatal injury at work" variable based on death certificate information
indicate that 27 of the occupants killed were on-duty EMS workers.* These
comprised 3% of all ambulance occupants and 33% of occupant fatalities.*

*EMS personnel in the United States have an estimated fatality rate of 12.7
per 100,000 workers, more than twice the national average (1).*"

Keep in mind that there are approximately 16.2 million ground ambulance
transports in the US to emergency departments (SOURCE:
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WB0-4J90VSS-2&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=204171030357352b382511e2348a3a05)
.    Using an average of 6 deaths (55 deaths in the 10 year period studied)
per year for ground transport patients, that is about 1 patient death in
2,700,000 patient movements.  Compare this to what Ira Blumen of Chicago
cited before the NTSB for helicopters: 34 out of about 4.3 million
transported since 1972.  For those of you who don't want to do the math,
that's 1 out of 126,471.  In 2008, the rough odds of a patient dying while
being transported by helicopter were 1 in 80,000.

I am working on pulling together a complete set of comparable data for the
aeromedical helicopter side of things and will report back.   However, even
with the data that one can readily pull from the literature and recent
hearings, it's quite apparent that ground transport is by far a safer
alternative and any attempt to hide behind the claim of "Well, there are a
lot more ambulance crashes annually" as has been touted by various
aeromedical industry advocates is simply a smokescreen that will not stand
up to any form of scrutiny.

We also don't have guidelines for when those transports need to be run with
> red
> lights and siren.
>

Agreed.

>
> There are groups, such as CCT-CORE that are attempting to shed some
> light on some of these issues.  Until we have those data the best thing
> we can do is to encourage everyone to use the appropriate resources in
> the safest manner possible to provide patients with the best care
> available.
>

Right, but the problem is that we (the two sides of the argument and
everyone caught in between) can not come to agreement on what "safest" and
"best" is.   The best and safest approach is probably somewhere in the
middle ground between the two camps but I really don't want to stand there
for it is a no-man's land at this point in time.

>
> Dave Thomson
>
> David P. Thomson, MS, MD, FACEP, CMTE, CHC
> National Medical Advisor
> PHI Air Medical
>
> -----Original Message-----
> From: Bjorn, Pret [mailto:pbjorn at emh.org]
> Sent: 24 February, 2009 10:10
> To: Trauma &amp; Critical Care mailing list
> Cc: HEMS at ntsb.gov
> Subject: RE: NTSB to Issue Helicopter EMS Safety Recommendations
>
> I'm not seeing any recommendation of even the most rudimentary triage
> and activation (case selection) criteria.
>
> Preventable injuries and deaths are bad enough, I'll grant; but is no
> one (beyond those who pay the bills) interested that a significant
> number of these fatalities did not suffer time-sensitive or otherwise
> critical medical issues?  Such is not merely a punctuation of the
> tragedy; it's a conspicuous symptom of an inadequately controlled and
> inefficient system.
>
> Licensed air medical operations should be required to demonstrate
> medical necessity to an external oversight process.  Such a simple
> amplification of accountability -- at all levels -- would save more
> lives than any on-board gizmo.  Indeed, it would refine and enhance all
> aspects of the air medical system.
>
> Pret Bjorn, RN
> Bangor, ME USA
>
>
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of listasmsd
> Sent: Monday, February 23, 2009 6:10 PM
> To: Trauma &amp; Critical Care mailing list
> Subject: NTSB to Issue Helicopter EMS Safety Recommendations
>
>
> NTSB to Issue Helicopter EMS Safety Recommendations
>
>
>
> Who Pays for Safety Measures?
>
> Suzanne Wedel of Boston MedFlight testified that the operation's new
> Sikorsky S76 C++ aircraft has $1.1 million worth of enhanced safety
> features, including night vision goggles, SPIFR (single pilot instrument
> flight rules) auto pilot, ground proximity warning, cockpit voice
> recorder, traffic avoidance collision system, moving map, satellite
> position tracking, airborne weather radar, satellite weather data,
> electronic nav charts, integrated GPS (global positioning system),
> emergency locator transmitter, Nightsun, and lightning strike
> protection.
>
>
>
> According to Marc Harstein, Medicare and Medicaid Services, Medicare
> covers helicopter EMS transport to medical facilities at a rate of
> $3,308 urban and $4,962 rural if the facility is not accessible by
> ground vehicle, transport is over great distances or is complicated by
> other obstacles (such as heavy traffic), or the patient's condition is
> not appropriate for ground transport.
>
>
>
> Air ambulance trips reimbursed by Medicare increased 24%, from 1.65
> transports per 1,000 beneficiaries in 2001 to 2.04 transports 1,000
> beneficiaries in 2004, Harstein said.
>
>
>
> Two nurses were among experts who testified before the National
> Transportation Safety Board's four-day hearing on helicopter EMS safety,
> which was prompted by a record year in helicopter EMS accident
> fatalities.
>
>
>
> "The take-home message for nurses here is we need to be engaged," said
> Kevin High, RN, president of the Air & Surface Transport Nurses
> Association and trauma program manager for Vanderbilt LifeFlight,
> Nashville, Tenn. "We've got skin in this game. Nurses are losing their
> lives in the line of duty."
>
>
>
> High was one of the nurses who answered questions from the board of
> inquiry Feb. 3-6. in Washington, D.C.
>
>
>
> "What I wanted them to know is this is a multi-factorial problem," High
> said. "All week, what I kept hearing over and over again is, 'There's no
> silver bullet and no one thing that's going to make [accidents] stop.'"
>
>
>
> The hearing was held to learn more about helicopter EMS operations so
> the NTSB can better evaluate the factors that lead to accidents and
> recommend safety improvements to the Federal Aviation Administration,
> which oversees the field. The issues discussed included operational
> structure and models, flight operations, aircraft safety equipment,
> training, and oversight.
>
>
>
> "I don't think the solution to the problem can be found inside the
> industry alone," High said. "I think whatever [the NTSB] comes up with,
> not everybody is going to like it. I think it will probably be some type
> of compromise. [But] I'm not worried about it. Inaction would worry me."
>
>
>
> The NTSB added helicopter EMS safety to its Most Wanted List of
> Transportation Safety Improvements in October, along with a list of
> recommendations: Conduct all flights with medical personnel on board in
> accordance with charter aircraft regulations. Develop and implement
> flight risk evaluation programs. Require formalized dispatch and
> flight-following procedures, including up-to-date weather information.
> Install terrain awareness and warning systems on aircraft.
>
>
>
> Accident Statistics
>
>
>
> Each year about 400,000 patients and transplant organs are safely
> transported via helicopter EMS, according to Robert L. Sumwalt, chairman
> of the board of inquiry. "In the last six years, we have seen 85 HEMS
> accidents, resulting in 77 fatalities," Sumwalt said in his opening
> statement at the hearing. "In calendar year 2003, we saw 19 accidents
> and seven fatalities; in 2004, there were 13 accidents with 18
> fatalities; 2005 had 15 accidents and 11 fatalities. In 2006, 13
> [helicopter EMS] accidents occurred with a total of five fatalities. In
> 2007, there were 11 accidents with a total of seven fatalities. However,
> 2008 was the deadliest year in HEMS on record, with 13 EMS helicopter
> accidents, and 29 fatalities.
>
>
>
> "The Safety Board is concerned that these types of accidents will
> continue if a concerted effort is not made to improve the safety of
> emergency medical flights,"Sumwalt said.
>
>
>
> Ira Blumen, MD, professor of medicine, medical director and program
> director, University of Chicago Aeromedical Network, testified there
> were 131 fatalities in 146 helicopter EMS accidents between 1998 and
> 2008, 77% of which were due to human error.
>
>
>
> There were 668 dedicated helicopter EMS units from 21 companies in
> operation in 2008, Blumen said.
>
>
>
> Kevin Hutton, MD, testifying on behalf of the Association of Air Medical
> Services, said growth in helicopter EMS use is spurred by: rural level
> of care requirements; increased time-dependent care; consolidation and
> critical care regionalization; increased patient destination
> legislation; limited or no rural ground transport capability;
> malpractice lawsuits; decreased local specialty capability; growth and
> consolidation of providers (economies of scale); and more consistent
> reimbursement.
>
>
>
> Hutton is CEO and chairman of Golden Hour Data Systems Inc., which
> provides air medical and ground transport services, integrated
> computer-aided dispatch, clinical charting, and other services.
>
>
>
> Focusing on Solutions
>
>
>
> Nine states require that helicopter EMS programs be credentialed by the
> Commission on Accreditation of Medical Transport Services, based in
> Anderson, S.C. Eileen Frazer, RN, executive director of the
> organization, testified at the hearing that CAMTS added new safety
> guidelines Jan. 30. "The No. 1 issue we have concerns about is fatigue
> and sleep deprivation," Frazer testified. She said 49% of helicopter EMS
> accidents happen at night, while only 34% of flights take place at
> night. "One of our biggest concerns is sleep inertia - that period after
> you wake up. What is your cognitive function? What are your psychomotor
> skills and what activities must you do immediately after being
> awakened?"
>
>
>
> CAMTS is looking to secure funding for a study on sleep deprivation and
> sleep inertia spefically targeting helicopter EMS crews, possibly using
> simulators, Frazer said. "We see more and more medical personnel working
> 24- and 48-hour shifts."
>
>
>
> Until that study can be done, educating personnel on the signs of
> fatigue is important, she said.
>
>
>
> Another hot topic is safety management systems, Frazer said. "One of the
> issues we run into when we go out and review programs is that there may
> not be anyone at a hospital helipad that you can directly communicate
> with you are coming in," she said. "If it's a program that's based at
> that hospital, usually there's sophisticated procedures and there's
> somebody to meet you. That may not be the case with a hospital helipad
> that's not within your own system."
>
>
>
> Helicopter Association International president Matt Zuccaro, who is also
> co-chairman of the International Helicopter Safety Team, addressed
> recommendations including mandatory use of night vision goggles; an all
> IFR (instrument flight rules) operating environment; elimination of
> launch/response times; study of fatigue factors in helicopter EMS;
> education programs; non-punitive safety reporting environments; and
> implementation of safety management systems.
>
>
>
> Zuccaro also asked for discussion on "the need to provide a sterile
> operating environment for pilots and technicians, absent of undo
> pressures, so that any considerations are limited to safe aeronautical
> decision making."
>
>
>
> "You need to be engaged on a national level - know what's going on, pay
> attention, read, and make your voice heard," ASTNA's High said. The NTSB
> invites members of the EMS community, including RNs, to make submissions
> related to the safety of the industry through March 9. Materials should
> be submitted to NTSB, Ms. Lorenda Ward, Hearing Officer, 490 L'Enfant
> Plaza East SW, Washington, DC 20594, or they may be submitted
> electronically to HEMS at ntsb.gov.
>
> http://include.nurse.com/article/20090223/NATIONAL02/302230044/-1/frontp
> age
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-- 
Stephen L. Richey, CRT

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