Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Why is air medical transport still killing us? Comment from Samuel Kordik

In the comments to Why is air medical transport still killing us? the following comment appears from Samuel Kordik

Without a doubt, something needs done to reduce the high risks for HEMS crews. But I’m not sure how enforcing the 1 hr drive radius would help.

A one hour no fly zone is one way of measuring distance. I did not state that there should be an absolute ban on flights within a one hour drive time of a trauma center. I stated, We should then require justification for any flight within that radius.

I think that we should require justification for all flights, but that it is essential to carefully review flights within what is a reasonable drive time for unstable trauma.

Where is the evidence that there is a benefit to unstable trauma patients from HEMS transport within an hour drive of a trauma center?

We definitely need to have ground EMS justify calling for helicopters.

Where I work, anything that could remotely justify transport to a trauma center is flown by some agencies only 10 minutes drive time from a trauma center.

Why?

Well, I am not sufficiently familiar with the DSM-IV to give an accurate explanation.

Why endanger flight crews and patients for no possible benefit to the patient?

As I stated, I don’t know how many of the diagnoses in the DSM-IV apply, but the DSM-IV does seem to be the place to look for answers.

I work on a rural MICU unit about 30 minutes from a Level 1 trauma center. My service also flys 3 helicopters, and holds us to account to justify every air transport in our documentation—which makes basic sense.

It makes basic sense to have to justify flights so close to a trauma center. Why do you need 3 helicopters when the trauma center is so close? Why even one helicopter?

If the patient needs it, and the helicopter would get them there faster than we could, then I’ll fly my patient in a heartbeat.

If the patient needs it,

Define needs it. Do you follow up with the trauma center to find out how many of these patients had immediate surgery, or had an emergent intervention in the trauma room, that saved the patient’s life, or made some other significant difference in outcome?

How many of these patients meet that criteria? HIPAA does not prevent the hospital from providing that information. This is a necessary part of any flight justification.

and the helicopter would get them there faster than we could,

How much faster?

The major benefit from HEMS is to make a significant difference in transport time.

A difference of only 5 minutes in transport time, or a difference of only 10 minutes in transport time, or a difference of only 15 minutes in transport time is unlikely to make a difference in outcome.

Yes, there will be the extremely rare patient, where a decrease in travel time of 15 minutes is important, but it is extremely rare.

That is the purpose of justification. There should be an explanation of the particular threat to the patient’s life, supported by EMS assessment findings, information from the trauma center supporting or refuting the initial assessment, and whether it was reasonable based on the limited information available to EMS at the time, to conclude that there would be a dramatically worse outcome if this patient were not flown.

A worse outcome is so rare, that the research on prehospital time periods does not show any effect of these differences in prehospital time on the survival of the most seriously injured patients.

This decision is not based on my desire to go watch TV or sleep, nor is it based on some kind of fear. It comes right out of my position of being a patient advocate and wanting the best possible outcome for said patient.

I did not mean that everyone will fly patients for the same reason. However, there are plenty of people who do fly patients for purely personal reasons.

Restricting unnecessary flights is entirely about wanting the best outcome for patients.

Although I’ll watch for weather and overhead hazards, I still rely on the HEMS crew to watch out for their own safety—weather, terrain, etc.

Perhaps the best way we can protect HEMS personnel would be to require ground EMS providers to justify the flight, and then provide education followup for those providers on patient outcome and whether or not the flight was justified.

Absolutely.

Help ground paramedics learn what is and isn’t a justified use of air transport, so that it will still be around when a patient legitimately needs it.

Agreed.

Let me emphasize what I believe is the most important part.

The risk to the patient is usually significantly greater when transported by helicopter.

The risk to the flight crew is definitely much greater when transporting by helicopter.

We need to decide when the benefit to a patient of a particular and significant difference in travel time is worth those risks.

There should be an explanation of the particular threat to the patient’s life, supported by EMS assessment findings, information from the trauma center supporting or refuting the initial assessment, and whether it was reasonable based on the limited information available to EMS at the time, to conclude that there would be a dramatically worse outcome if this patient were not flown.

We have at least that obligation to our patients and to the flight crews.

.