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Alright, I’ll Say It

EMS1.com News

June 12, 2008


The EMS Contrarian
by Bryan E. Bledsoe

Alright, I’ll Say It

Editor's note: A fatal Medevac crash on Sept. 28, 2008, in Maryland has once again placed a critical spotlight on the air transport system. As officials and the media delve into this controversial debate, EMS1 columnist Bryan Bledsoe offers his stance on the feasibility of air transports and the safety concern for these crews.


AP Photo/Jim Harrington
The charred wall near the helipad atop Spectrum Health Butterworth Hospital is shown in Grand Rapids, Mich., May 29, 2008. A medical helicopter crashed on the roof of the hospital, catching fire moments after the two people on board escaped with minor injuries, a fire official said.

On May 24, 2008, the National EMS Memorial Service recognized 73 of our brothers and sisters who gave their lives in the line of duty. Interestingly, 37 of those individuals died as a result of a medical aviation accident. Stated another way, nearly 51 percent of the entire memorial is tied to medical aviation incidents. In the last few weeks, we have had four medical helicopter crashes:

  • The University of Wisconsin’s Med Flight crashed on May 10, 2008, killing three. They were returning following transfer of an elderly patient with an intracranial hemorrhage who later died.
  • On May 29, 2008, an Aero Med helicopter crashed on the roof of Spectrum Hospital in Grand Rapids, Mich. The FAA observer and pilot got out of the aircraft before it was consumed by fire. They were rescued by the Grand Rapids Fire Department. Jet A fuel leaked into the top few floors and most of the hospital was closed as a result.
  • On June 6, 2008, Lehigh Valley’s MedEvac 7 crashed into a freight yard in Pottsville, Pa. while en route to a motorcycle accident. Fortunately, the crewmembers suffered only minor injuries and were removed from the wreckage by citizens who came to their aid.
  • On June 7, 2008, a PHI helicopter from Bryan, Texas crashed in Sam Houston National Forest just a few minutes after leaving Huntsville Memorial Hospital in Huntsville, Texas. They were transferring a 58-year-old man with a ruptured abdominal aortic aneurysm to a hospital in Houston. The patient and the crew were all killed. Interestingly, Life Flight of Houston had originally started to make the flight, but aborted the flight when weather conditions deteriorated. The PHI team launched after conferring with the operations center in Phoenix, Ariz.

Some consider it bad taste to discuss an emotional issue like this so soon after these tragedies occurred. But, if not now, when? I have taken a beating for criticizing medical helicopters in the past. Those in the helicopter industry say, “Bledsoe doesn’t know what he is talking about.” I have to admit that I don’t know as much as many, but I know a lot.

First, I was a flight paramedic in Fort Worth in the 1970s. I spent a lot of time in the air and coordinated the program. Second, I was the first employee CareFlite (Dallas/Fort Worth, Texas) hired when they decided to get into the helicopter ambulance business in the late 1970s. Third, I was the medical director for Columbia One in the 1990s, a helicopter ambulance for north Texas operated by the now-defunct Columbia hospitals. Fourth, I am an active researcher with several peer-reviewed articles published on the topic.


Why were medical helicopters developed in the United States?

The medical helicopter developed in the U.S. differently than in the rest of the word (with the exception of the Maryland State Police and the New Jersey North Star and South Star system). In most countries, medical helicopters were established for patient rescue and, in a few situations, transport where ground ambulances were not available. In the U.S., hospitals got into the helicopter business to increase their patient census — plain and simple. Most established hospitals in the U.S. are in older parts of town — many in socioeconomically depressed areas. These particular hospitals did not want their local neighbors as patients — they wanted the people from the suburbs with insurance.

And what better way to get people to your hospital than a helicopter? It was fast, flashy and had an air of sophistication. In 1979, I sat in on several meetings where hospital administrators laid out their plans to open helicopter operations first and then open community hospitals later. Helicopters were always seen as loss leaders. The direct benefit was not worth the cost, but the indirect benefit was incalculable. In a Journal of Trauma article, researchers found that for fiscal year 2001, the University of Michigan’s Survival Flight helicopter cost in excess of $6 million to operate. But it generated more than $62 million in revenue (not counting physician fees). They found that helicopter patients were more likely to be insured and accounted for more ICU days. So, the evolution of helicopters was not some altruistic plan — it was always about the bottom line.


Medical helicopters save lives?

There is no discernible scientific evidence that medical helicopters save lives. Let me say that again: There is no scientific evidence that medical helicopters save lives. Even the most rabid helicopter proponent must admit to that. Sure, there are some studies that indicate that a part of the population may benefit (primarily those with an Injury Severity Score [ISS] > 30 or more). But they have to dig deep into questionable statistical analysis to come up with any evidence whatsoever. Many of the studies supportive of helicopter medical transport are frankly a priori. There is no evidence that the interhospital transport of patients improves outcome. The comparative studies show that patients transported by ground do just as well as those transported by air. Most honest trauma surgeons will tell you that, over the course of their career, they can count the number of patients who benefited from helicopter transport on one hand.

We in EMS continue to promote the use of helicopters by not questioning the practice. The actual number of “lives saved” is quite few. But how can you argue with somebody who says, “The helicopter saved my baby” or “My momma would not be alive had it not been for that crew”? When science and emotion cross, it is not a pretty picture. But science, if done correctly, is without bias (or has limited bias). The word “emotion” and “bias” can almost be used interchangeably. We must abandon the emotion and seek the science.


Frequent arguments

Most helicopter and EMS crews know the system is being abused. But when confronted, responses are always similar:

We are just following the air medical dispatch criteria. This is a good argument because, in many situations, paramedics must closely follow protocols. The current helicopter usage criteria are so broad that virtually every patient will qualify for transport. Heck, I should have had about three helicopter transports during my childhood (fractures of two or more long bones). The current helicopter usage criteria were written by the air medical industry. That is akin to asking Starbucks to write the criteria for who should drink coffee. These criteria are heavily based upon “mechanism of injury criteria.” Interestingly, there is no scientific evidence supporting the use of mechanism of injury with the exception of ejection from a vehicle. That single criterion is the only one that is linked to increased mortality. Yet we follow these blindly.

We are trying to get the patient to the hospital within the “Golden Hour.” The so-called “Golden Hour” has been debunked as a criterion for transport times. It was coined by Dr. R Adams Cowley to market his Shock Trauma Center in Baltimore. We don’t know what the critical interval is. In fact, we treat trauma patients differently than we did 30 years ago — so comparisons are useless. Even Prehospital Trauma Life Support (PHTLS) has changed “Golden Hour” to “Golden Period.” We have followed suit in our textbooks. The “Golden Hour” argument just does not hold water.

We use the helicopter to keep a ground ambulance available in our county. This seems like a good idea on the surface, but look deeply. Mrs. Smith calls 911 because of dizziness and chest pain. EMS responds and finds her in mild to moderate distress. She needs admission, but nothing emergent. If EMS takes her to the hospital (a 50 minute trip each way), then the only ambulance in the county will be unavailable for almost 2 hours. Instead, let’s call Angel Flight and let them carry her and the ambulance will be back in service. What is happening here is that Mrs. Smith is getting penalized for calling the ambulance. She does not need helicopter transport. But she will receive helicopter transport and pay the exponentially higher cost and take an extraordinary risk, simply because she is sick. She is being asked to bear an undue financial and safety burden to ensure that her county is covered by EMS. EMS is a county responsibility to be shared by all citizens — not just the most ill, like Mrs. Smith. It is a non-sequitur.

We use the helicopter because our local hospital is poorly staffed. First, having been on both sides of the fence, I can say that most ambulance crews are incapable of judging the limitations of a hospital and its medical staff. Second, you choose where you live. I choose to live 20 miles from a hospital and 12 minutes from an ambulance. Should I expect the same level of EMS in rural Ellis County, Texas that somebody would receive in downtown Austin? No, and I would never ask that. We are all concerned about the inequality of EMS, but we can’t fix it ourselves. Some areas of the country will have lesser quality than others. Besides, there is some evidence that shows that stopping at Level III and Level IV hospitals before ultimate transfer to a Level I or Level II actually improves outcomes. However, there is literature to the contrary.

We use medical helicopters because “we’re not doctors” and our job is to get the patient to the hospital as quickly as possible. I am not sure what paralysis of intellect led to this statement. Let’s carry this argument to the logical conclusion; if that is the case, we should respond a helicopter to every call. Or, a better idea, abandon all medical training and return to the days of high-top Cadilliacs that can move a patient comfortably at 100 mph. The preponderance of the evidence shows that response times (unless 4 minutes or less) have little, if any, effect on outcomes.


Who is to blame?

The blame for overuse of medical helicopters can be laid at the feet of many. First and foremost, we must blame the physicians. As the highest level of health care providers, we control the health care system. We control the research. Most importantly, we sign the documents that verify that a medical helicopter transport is necessary. I would love for Medicare and the private insurance companies to start auditing each helicopter transport. Those found inappropriate (and studies have shown the majority of helicopter transports are inappropriate) would be kicked back to the approving physician and would be charged to them or against their billings. In my experience, the rank-and-file physician does not truly understand the risks and limitations of helicopter transport. They simply want the patient moved and moved now. Physicians don’t lament the lack of evidence behind medical helicopter usage because we are not taking the risk — the crew and patient are. If it affected us personally, we would have all sorts of guidelines, best practices and clinical pathways established.

There is no scientific evidence that medical helicopters save lives. Even the most rabid helicopter proponent must admit to that.
— Bryan E. Bledsoe

The insurance companies are to blame. The abuse of helicopter EMS has not been on their radar screen because it constituted a limited amount of health care expenditures. But, now with over 1,000 helicopters in the U.S., the money adds up quickly. In the 1980s, the fad was to develop boutique substance abuse and psychiatric hospitals. These popped up everywhere. They were plush, with dining rooms serving prime rib and cheesecake. Many physicians signed on because these hospitals paid well. Soon, virtually everybody had a mental health diagnosis, the hospitals filled, and the system was abused. The insurers soon figured it out and they all went away.

In the 1990s, the proliferation was home health care. Home health care offices opened on virtually every corner. Soon, everybody needed a potty chair, home oxygen, nebulizer, or a Jacuzzi. I received a form from a home health care agency requesting a motorized wheel chair for a patient with a Grade I ankle sprain. Physicians bought in again. The system was abused and the insurers stopped it.

In this decade, it is medical helicopters. We went from 300 to over 1,000 in less than five years. Everybody needs one. Everybody meets the criteria for one. In fact, I have heard (jokingly) that the indication for a helicopter is the presence of a patient. Some services actually sell subscriptions. However, unlike home health care or boutique hospitals, people can die from medical helicopters. It has to stop.

The helicopter companies are also to blame. They know that flying on a medical helicopter is fun and many paramedics would work for free. Some helicopter services in Texas pay paramedics $380 per 24-hour shift and nurses $450 per 24-hour shift. Would you work for the same money if the job was a ground transport unit? As the helicopter fleet has increased, the size of the helicopter has decreased — and in certain conditions, gotten older. There is a lot of peer-pressure in HEMS. There is a shortage of pilots, but no shortage of nurses or paramedics. Dare to say no when two want to go? Sure, it sounds good on paper, but, remember that nurses and paramedics are replaceable — pilots are not. Subconscious coercion exists.

Next, we have to blame ground providers. Many times we know that we can safely take a patient by ground (probably 99.5 percent of the time). I have spoken to several ground EMS people who simply call the helicopter so they can go back to bed. After all, they have to work the next day. We dump patients on helicopter crews and they can do nothing about it and we know it. If they say no, you simply won’t call them or will complain. They will be told to transport regardless and the cycle continues. So before you call a helicopter, first determine whether you could get the patient to the hospital quicker if you simply left then and now.

Finally, the Federal Aviation Administration shares a great deal of the blame. The Airline Deregulation Act of 1978 severely limited the ability of anybody other than the federal government to regulate helicopter ambulances. Both Texas and Tennessee tried to tighten state helicopter EMS standards, only to lose in court. Only the FAA has the ability and authority to evoke changes and they won’t. The National Transportation Safety Board has made several recommendations, but the FAA has ignored many of these. There are some moves afoot in Congress to regulate helicopters — but the wheels of justice move slowly.

I see flight nurses and flight paramedics as victims. These are great people who took these jobs because they like working on helicopters and they believe they are making society better. They are caught between their dreams and the realities of the job. I have received numerous emails from flight nurses and paramedics. They usually start, “Please don’t use my name or I’ll lose my job. I agree with you. We are transporting more and more non-emergencies. Keep fighting for us.” The job is dangerous — among the most dangerous there is — and although it hurts to hear this, the vast majority of patients will do just as well if transported by ground. We know that on ground EMS calls, we rarely “save lives.” The same holds true for helicopter EMS.


Summary

I had better bring this tirade to an end. While flying home today from Philadelphia, it hit me that I knew more people who have been killed in a medical helicopter accident than by virtually any other means. At some point in my life I have met or spoken with at least five people who later died in medical helicopter crashes. They were all great people and died doing what they loved. We owe it to their legacy to assure that not a single flight nurse, flight paramedic, pilot or patient dies unnecessarily.

The wise man does not expose himself needlessly to danger, since there are few things for which he cares sufficiently; but he is willing, in great crises, to give even his life — knowing that under certain conditions it is not worthwhile to live.

– Aristotle

About the author

Bryan E. Bledsoe, DO, FACEP, EMT-P is an emergency physician, paramedic and EMS educator. Dr. Bledsoe is the principal author of the Brady paramedic textbooks and others. He has more than 20 years publishing experience and has more than 900,000 books in print and has written more than 400 articles. He is a prolific writer, popular lecturer, and EMS researcher. Dr. Bledsoe is currently developing a distributive educational program for initial EMS education through the University of Nevada Las Vegas and online continuing education through Paramedic.com. Dr. Bledsoe maintains residences in Midlothian, Texas and Las Vegas, Nev. To contact Dr. Bledsoe, email bryan.bledsoe@ems1.com.
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