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Gross, Ronald Ronald.Gross at baystatehealth.org
Mon Dec 29 22:05:15 GMT 2014

Unless you add Long or Staten or Manhattan or Block to the word Island!  Sorry - I just couldn't resist!!

Happy New Year to all,

Ronald I. Gross, MD, FACS
Chief, Division of Trauma, Acute Care Surgery & Surgical Critical Care
Baystate Medical Center
Associate Professor of Surgery
Tufts School of Medicine
759 Chestnut Street
Springfield, MA 01199
ronald.gross at baystatehealth.org

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Gustavo E. Flores
Sent: Monday, December 29, 2014 4:33 PM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: Medivac

I work for a fixed wing provider in San Juan. We service the Caribbean very frequently. There are many good arguments to be said about the use of ground vs. rotor wing in metro areas but they all become moot when we insert the word "island" into the equation. 

Gustavo E. Flores, MD, EMT-P

> On Dec 29, 2014, at 14:38, William Bromberg <brombwi1 at memorialhealth.com> wrote:
> I used to be very much more hardline in my opinion that HEMS had to make major improvements in the manner that you guys discuss. However the more I get involved with the smaller hospitals the more grey I see.
> For example, about 20% of our transfer flights have essentially no medical justification and that used to drive me insane until I started to do RTTDC and found out that many of these small towns (1-3 hours away by ground) have only one ambulance so if they send their crew away to Savannah, their town is essentially without EMS for hours. The same is true for scene responses as the crews out there know that if the patient is significantly injured they are coming to us anyway, and coming by air (for the reason above), so why not cut out the middleman?
> The rest of the changes can all be lumped into costs v. benefits and I cannot pretend to know exactly where the line is (although I bet the line would be clearer if actual individuals had to carry both the costs and get the benefits but I admit that is a quasi-religious belief in this particular instance). To me this debate may be like the booster seats on airplanes issue -- there is no doubt that requiring them with the same rules as cars would save lives in a crash but it turns out that because of the increased costs (both in money and time/trouble) more people would substitute driving instead of flying and overall safety would be reduced (I believe the same is true of the TSA BTW but "security" seems resistant to cost benefit analysis). In this case the potential loss of life due to reduced EMS services, increased incentives to keep inappropriate patients instead of transferring them, increased incentives to NOT call HEMS from the scene and the like need to be taken into
> ccount rather than the simpler analysis of "HEMS is less safe than commercial flight" so this must be fixed. I would personally prefer a state by state methodology of regulation for two reasons: 1. this would generate data that we could review to determine best practice and 2. HEMS is going to look a lot different in S. Dakota than in Maryland and maybe the needs/requirements should be different (for example commercial aviation in Alaska has a whole bunch of different rules than anywhere else in CONUS). The FAA makes this very difficult however.
> Bill Bromberg
> William J. Bromberg, MD, FACS
> Savannah Surgical Group
> 912-350-7412
>>>> Stephen Richey <stephen.richey at gmail.com> 12/29/2014 3:37 AM >>>
> You and I think so much alike in those regards that it's scary.
> My medical director in my ground EMS days made it clear that we were only
> to call for a helicopter under extreme circumstances and then be prepared
> to defend that decision at an audit and review.  Some of those audits being
> called "critical" would be a masterpiece in understatement.   I know of
> several providers- usually young, insufficiently educated (no significant
> knowledge beyond the standard training) and immature- who lost their jobs
> and, in at least two cases, their certifications for calling for a
> helicopter under circumstances that were medically indefensible (one did it
> simply to put on a good show for an attractive girl who was doing a ride
> along).
> I can count on both hands the number of times I called for a scene response
> because I was well educated, given the tools and supplies needed to handle
> 99.99% of critical patients and supported by an effective medical control
> system.  I have always felt such reviews should be mandatory for every HEMS
> flight, whether it be a scene flight or interfacility transfer.  It's good
> to know I'm not alone in that thought.
>> On Dec 29, 2014 3:09 AM, "Charles Krin" <cskrin2 at hughes.net> wrote:
>> I'm familiar with the problems of commercial outfits using JetRangers
>> under Single Pilot VFR/one medic conditions. I've spoken out a couple of
>> times in the past about the problem and caught a fair share of flack
>> over it...especially when I mention that I felt that 'industry best
>> practice' should emulate the military model (two pilots, night IFR
>> qualified, with at least two crew in the back, room to work on at least
>> two patients, with room for at least one more attendant if needed). Dang
>> near got me run out of the conference one time!
>> I don't think that most commercial outfits need Sikorsky S-70s (UH-60
>> Blackhawks), much less  S-61s (SH-3 SeaKings), but at least EC 135s,
>> SuperHueys, Dauphins or the equivalent- rigid rotor systems, twin
>> engines, ducted fan tail rotors, basic anti icing equipment on critical
>> moving parts, radar altimeters, stability augmentation control systems
>> and *large* doors...
>> And I've also promoted the idea of *every* transfer receiving a follow
>> up equivalent to Mortality & Morbidity conferences in the past. Again,
>> not something that has made me popular in some circles....because, among
>> other things, I tended to point out that too many transfers were being
>> made for borderline reasons in terms of staff doctors at small hospitals
>> not wanting to come in and properly evaluate a patient, instead sticking
>> the ED doc with the problem of finding a bed at a tertiary care facility.
>> ck
>>> On 12/29/2014 01:37, Stephen Richey wrote:
>>> The fixed wing we operated in was in and out of some very heavy traffic
>> due
>>> to all the cargo jets at our base.  It's not that bad of a mix.
>>> I can't argue about terrain in your part of the world.  We have it good
>>> because even in the hilly southern part of Indiana, you generally have
>>> airport within easy transport distance of any town big enough to have a
>>> hospital.  Almost all of them have at least a GPS/RNAV approach as do the
>>> majority of public airports in the US.
>>> I think the military helo comparison is a potentially dangerous one
>> because
>>> the skills, training and proficiency standards of those pilots are so
>> much
>>> higher than some for profit HEMS outfit.  It leads to a mindset, if not
>>> tempered by knowledge of the subject as in your case, to the idea that
>>> civilian operators are comparable.  A few are but most are not if for no
>>> reason other than relying on single pilot operations in marginal VMC or
>> IMC
>>> (night operations in rural areas even on crystal clear nights should just
>>> as a precaution be treated as IMC due to the frequency of the black hole
>>> effect; this goes for fixed wing as well but it's a bigger problem in
>>> medical helicopters) in aircraft that often are not equipped with full
>>> autopilot systems.
>>> There's a time, place and way use any tool as you said.  Unfortunately,
>> the
>>> aeromedical industry seems resistant to doing what seems necessary to
>>> achieve high operational efficacy with sacrificing ten to fifty crew
>>> members and patients annually.  Fortunately, the FAA finally seems to be
>>> getting the message that the NTSB has been screaming at them for ten
>> years
>>> or so and is mandating improvements in training and equipment.  Time will
>>> tell if it has significant implications for safety or whether loopholes
>>> will be found to allow business as usual to continue.  I am optimistic
>>> about it.  I'm ready to see comparable safety between the two sections of
>>> aeromedical transport in this country.
>>>> On Dec 28, 2014 10:44 PM, "Charles Krin" <cskrin2 at hughes.net> wrote:
>>>> Stephen:
>>>> I agree that for distances further than the unrefueled operational
>>>> radius of the helo, fixed wing should be considered as primary... many
>>>> of the facilities I worked at did NOT have an airstrip of over 3000 feet
>>>> within 30 miles, and even those that did had *at best* a Visual Approach
>>>> Slope Indicator (VASI) system. Add in the additional transfer/transport
>>>> time from even the smaller 'downtown' air port to the receiving
>>>> hospital...and the near 'door to door' of a helo flight can cut
>>>> significant time off- one memorable trip from Ft Sill Indian Hospital to
>>>> Parkland Dallas ended up with us having to land at Love Field for some
>>>> reason, and wait for ground transport- I seem to recall that for some
>>>> reason, the Parkland helopad was occupied and could not accommodate our
>>>> Huey... since our patient was a 400 pound alcoholic GI bleeder...that
>>>> was NOT a comfortable wait for *either of us*-
>>>> In the early 1980s, our Hueys could leave Ft Sill, make a pick up at any
>>>> hospital within 80 miles or so and get to Oklahoma City or Wichita Falls
>>>> generally before a ground ambulance could go direct from the little
>>>> hospital into the city...at least partially because there frequently was
>>>> no 'good way' to get from the small hospital to OKC or WF. Additionally,
>>>> because of common weather patterns, even after civilian air ambulances
>>>> started springing up in OKC, Tulsa and WF, we would frequently get the
>>>> call, because we could sneak around a weather front and follow said
>>>> weather into the City...while the city units would have to punch through
>>>> the weather- it also helped that we were equipped and staffed to fly
>>>> dual pilot night IFR and could handle light icing, something that the
>>>> smaller JetRangers and AStars of the day were not.
>>>> I have some friends who work with an ambulance service in Northern
>>>> Louisiana- this outfit has both fixed and rotor wings, and the most
>>>> common use of the fixed wings is to take cancer patients from the
>>>> Monroe/Ruston catchment areas into Houston for care.
>>>> (While aircraft flying with "Lifeguard," "DUSTOFF," or "MEDEVAC" call
>>>> signs have relative priority over any other aircraft in the sky *except*
>>>> balloons and unpowered gliders, past practical experience has indicated
>>>> to me that it's not really smart to try to insert a KingAir or smaller
>>>> aircraft; or any rotorwing craft into a busy traffic pattern full of
>>>> 'heavies' short of a truly emergent patient!)
>>>> without drawing the ire of Dr. Mattox (with whom I have locked horns
>>>> with in the past on this matter), there is a time and a place for every
>>>> form of transport, from a blanket drag to a LearJet or Gulfstream....and
>>>> consideration of the distance, patient, weather and available staff all
>>>> need to be considered to provide the best and most appropriate transport
>>>> for any given patient.
>>>> ck
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