Why we F.A.L.T.E.R. on helicopter response
Air EMS should be called only when time really counts — here’s how to decide when that is
By Steve Whitehead
A recent story hit the news about two children who were flown by helicopter to a trauma center for minor injuries over the protests of their parents. The story ignited a new firestorm of debate in the EMS blogosphere as well as the local newspaper. Opinions ranged from “Suck it up and pay the bill” to “That’s child abduction!”
From the first-hand reports of the responders, parents and flight crew, the consensus was that these children didn’t need to be flown to the hospital. I share that opinion. I also think the story points to a larger concern. That concern is the frequent misuse of helicopters in EMS care.
The age-old debate on EMS helicopter use
The subject of helicopter misuse may ring familiar in your ears. Haven’t we addressed this before? Indeed we have. Helicopter misuse is a garden-weed issue. It rears its ugly head over and over again. Each time that the level heads in EMS education step up and pull the weed, it disappears briefly, only to reemerge again.
There are times when helicopter transport may benefit your patient. It’s up to you to decide when it’s time to fly the bird. The question is, are you using a logical reason for transporting your patient by air?
Let me take a shot at this seemingly never-ending issue with a brand-new acronym: F.A.L.T.E.R. This is a tool that you can use to remember the important considerations when deciding if helicopter transport is an appropriate option for your patient.
F is for Fear
Ask yourself, am I making this decision because I’m afraid to spend the next thirty minutes managing this patient in the back of my medic unit? Would I prefer to hand the patient off as soon as possible? Though we are loath to admit it, many times we call the helicopter because we’re scared.
We don’t feel adequate to manage the patient. The helicopter is our panic button.
Fear is never a reason to call for alternate transport. Overcome it, load the patient and transport. Bring additional help if you feel like you need it and get moving.
A is for Access
Does your scene lend itself to convenient helicopter access? If not, you may waste minutes or hours trying to move the patient to an acceptable landing site, or waiting for weather to clear. Bad weather and dicey landing zones make helicopter operations high-risk endeavors. You are often better off loading the patient and heading for the hospital. No landing zone, no helicopter.
L is for Lazy
Much like the fear factor, the laziness element requires a good, honest gut-check. That requires a high degree of self-perception and honesty. When the hospital is an hour away and your shift change is twenty minutes away, a helicopter may sound like a great option.
Helicopters allow us to dodge the time and the work of emergency transport. We can do the fun skills, hand off the patient on scene, restock the kit and go home. Sometimes we aren’t even required to do our standard documentation if the patient was handed off to a local air crew.
Helicopters aren’t a convenient dodge for doing the hard work of EMS. If your real motivation for calling the helicopter is because you’d rather not do the work, you may need to do some personal soul searching. Don't saddle your patient with a $7,000 or more transport bill. Load the patient and transport.
T is for Time
Is time really a factor for your patient? This is a huge question that we can’t just conveniently overlook. There are very few clinical emergencies that are proven to benefit from reduced time to definitive care.
Significant trauma, strokes and myocardial infarction may all benefit from a reduced transport time. Diabetic emergencies, minor injuries and stable patients with scary-looking mechanisms of injury do not benefit from decreased transport times. (And the first person to say, “What if…” gets a poke in the eye with a fence post.)
Don’t call the helicopter if you can't assure that the possible time saved will make a difference in outcome. Use your evaluation skills. If the patient doesn’t stand to benefit from rapid transport, load the patient and go.
I don’t want to hear a word about potential rapid decompensation. The diagnosis needs to support rapid transport right now, period. And the use of the helicopter has to actually accomplish that goal (see “R is for Real,” below).
E is for Extrication
Does the patient require extended extrication or extraction from their location? If the patient meets the requirements for rapid transport but is in a situation where their transport will be delayed, consider helicopter transport. This is one situation where having a helicopter waiting for the patient might be beneficial. Let’s call it the “sick and stuck” rule. If the patient is sick and they are stuck, consider calling a helicopter.
For example, if the patient is stuck under their dashboard, pale, cool and diaphoretic, with a rapid pulse and questionable blood pressure, consider calling a helicopter. Keep in mind that in most urban areas, a ground ambulance will still beat the helicopter to the hospital even if the air crew is waiting on scene for the patient.
R is for Real
When we consider the helicopter as an alternative to ground transportation, we have to consider the real time required for helicopter transport. This is probably the single biggest mistake we make when considering the appropriateness of helicopter transport. Consider this concept: Helicopter transport is often very slow.
Here's an example. Calculate your estimated ambulance transport time, from the point of loading the patient onto your gurney to the point of making contact with staff at the emergency department.
Now, calculate the time it takes to notify the helicopter crew, the time it takes for them to scramble the unit, go through their preflight routine and lift off, and their flight time to the scene.
Then add in the time it takes to land, power down the aircraft, disembark, and receive your patient. Once transferred, they prepare the patient for flight, clear to take off, fly to the destination, land and transfer the patient.
Sounds like a lot of steps — and that's true. But let's take a closer look at some of the steps.
Flying takes time
The crew’s preflight routine takes time. Rapid pre-flight shortcuts have been cited in several recent air ambulance crashes, and the FAA is considering changing the rules for these procedures to require even more time.
Once in the air, we need to add in the actual flight time to the scene. If the wind is blowing, the helicopters transit time may be considerably longer in one direction that the other. Once over the scene, the crew will need to assess the safety of the landing zone prior to landing.
Once they have landed, the pilot may require certain criteria before the crew can disembark (especially if the ground is not level). The crew may need to sit on scene and wait to exit the aircraft. Then, the crew will need to receive a hand-off report and package the patient. Based on the crew’s policies, they may also need to perform procedures (like RSI) prior to loading the patient. Space is limited inside the aircraft, so some procedures may need to be completed on the ground.
They will then take off again, fly back to the hospital, land the aircraft, wait to disembark again, transfer the patient into the hospital (sometimes using a second ambulance or a rooftop elevator) and hand off the patient to the staff.
Even in ideal situations, helicopter transport can take much longer to accomplish than you might expect. It is rarely quicker to fly a patient than it is to load them in your rig and transport them to the hospital.
Learn how much time it really takes for a helicopter to fly to your scene and transport a patient back to the hospital. When you’re selling the benefits of a helicopter to your patient (or their parents), make sure you consider the real risks, the real benefits and the real reduction in transport time.
My guess is that the children in that Kentucky store who were transported in the helicopter might have actually gotten to the hospital faster if the medic had simply evaluated their wounds, loaded the children and transported. It would have required more time and more paperwork, but he would have avoided finding himself on the pages of his local newspaper and various high-profile EMS blogs.
When you consider calling the helicopter, think realistically. Evaluate the patient. Be honest with yourself and never FALTER.