#Helicopter medevac, a complicated industry

After World War II, the medical industry and hospitals grew rapidly because of new knowledge gained in the war. We learned how to do surgeries that we never did before, and developed new antibiotics, new medicines and new and expensive equipment. Over the years, we experienced an economy with spiraling costs for everything from cotton balls to hospital beds, and high tech equipment that is used to practically keep tabs on every cell in the body. This has made it difficult for many smaller hospitals to keep pace. When hospital beds are not full, revenue is down. Added to this are new ways of treating patients on an outpatient basis as opposed to inpatient. New medicines and technology has also tended to shorten hospital stays; even patients who have undergone surgery no longer stay in the hospital very long. All of these factors have made for a climate in which many hospitals and practitioners have literally had to fight for survival.

The general helicopter industry had comparable experiences in their growth and decline. Historically, helicopters have been a vehicle of the military, and later metropolitan police departments for use in traffic control and surveillance. One of the largest users of helicopters has been the oil industry for exploration. A worldwide slump in oil prices managed to drive many helicopter companies out of business. However, helicopter vendors who refused to become a dying statistic flocked to the medevac industry.

Since 1980, there has been a boom in EMS helicopter services as new programs have sprung up to get in on what has looked like a lucrative market. Where there had only been one or two services there are many. This sudden change of events caused the helicopter medevac industry to grow up Willie Nillie with no particular design or guidelines. Standards were not determined for conduct, staff qualifications, or equipment for air ambulances.

On the medical side, there was no legislation to clearly designate trauma centers and enforce health standards and conduct.

In 1980, only 30 helicopter medevac programs existed in the United States. According to Hospital Aviation Magazine, the first five years of the ‘80s saw the creation of more than 80 new programs. Today, in 2014, there are over 800. This has made for a climate of cutthroat competition for both helicopter operators and hospitals who were eager to cash in on what looked like a lucrative market. Those who have been able to enter the medevac industry have been able to keep their ships flying. At the same time, hospitals have a highly visible marketing tool and the capability of increasing their sphere of influence to take on many more patients. Fast and furious competition forced hospitals to develop a helicopter service just to keep a toehold in their own area.

A virtual explosion in growth created an industry with an almost total lack of federal or state regulations in either the medical or aviation arena. This resulted in minimal control over who flies, what they fly, or where they take the patient.

It can cost a hospital $60,000 or more a month to operate a helicopter. At the same time, severe trauma cases can draw $18,000-$26,000 in revenue for direct patient services. For a hospital to enter the trauma care arena under the best of circumstances, it can easily cost a million dollars. Not all hospitals with helicopter programs have elected to go into the business of being a bona fide trauma care facility. Further, it would not be cost effective for every hospital to become a trauma center. Still, it is difficult for some to forego the temptation to pick up trauma revenue.

Helicopters are secondary responders called in by another authority who has determined that a helicopter is necessary. Very quickly, which helicopter service is called to the scene, and where the victim is taken becomes a crucial issue for those wishing to gain their share of the market. This is a highly controversial issue whether one is concerned about economic survival or the best interests of the victim. Many have reared up in protest to demand that standards be met before a hospital can be designated as a trauma center capable of ministering to the needs of the critically injured.

On the helicopter side of things, is the question of who is qualified to transport a critically ill or injured patient. What kind of personnel and equipment is on board, and where is the patient taken. If competing helicopter services are within the same general vicinity, the situation can become more complicated. Paramedics and EMTs who arrive at the scene first suddenly become very powerful. Social, political and economic variables can run rampant, and have an impact on how a trauma case is handled.

The marriage of the helicopter to the hospital industry has not been without passion, controversy, and irony. Just about every helicopter medevac program carries a name that conveys benevolent motives of the highest order. Still, it is in the public’s best interest to ask: Are they really as good as they sound? Do they serve the best interest of the critically ill or injured?

After World War II, the medical industry and hospitals grew rapidly because of new knowledge gained in the war. We learned how to do surgeries that we never did before, and developed new antibiotics, new medicines and new and expensive equipment. Over the years, we experienced an economy with spiraling costs for everything from cotton balls to hospital beds, and high tech equipment that is used to practically keep tabs on every cell in the body. This has made it difficult for many smaller hospitals to keep pace. When hospital beds are not full, revenue is down. Added to this are new ways of treating patients on an outpatient basis as opposed to inpatient. New medicines and technology has also tended to shorten hospital stays; even patients who have undergone surgery no longer stay in the hospital very long. All of these factors have made for a climate in which many hospitals and practitioners have literally had to fight for survival.

The general helicopter industry had comparable experiences in their growth and decline. Historically, helicopters have been a vehicle of the military, and later metropolitan police departments for use in traffic control and surveillance. One of the largest users of helicopters has been the oil industry for exploration. A worldwide slump in oil prices managed to drive many helicopter companies out of business. However, helicopter vendors who refused to become a dying statistic flocked to the medevac industry.

Since 1980, there has been a boom in EMS helicopter services as new programs have sprung up to get in on what has looked like a lucrative market. Where there had only been one or two services there are many. This sudden change of events caused the helicopter medevac industry to grow up Willie Nillie with no particular design or guidelines. Standards were not determined for conduct, staff qualifications, or equipment for air ambulances.

On the medical side, there was no legislation to clearly designate trauma centers and enforce health standards and conduct.

In 1980, only 30 helicopter medevac programs existed in the United States. According to Hospital Aviation Magazine, the first five years of the ‘80s saw the creation of more than 80 new programs. Today, in 2014, there are over 800. This has made for a climate of cutthroat competition for both helicopter operators and hospitals who were eager to cash in on what looked like a lucrative market. Those who have been able to enter the medevac industry have been able to keep their ships flying. At the same time, hospitals have a highly visible marketing tool and the capability of increasing their sphere of influence to take on many more patients. Fast and furious competition forced hospitals to develop a helicopter service just to keep a toehold in their own area.

A virtual explosion in growth created an industry with an almost total lack of federal or state regulations in either the medical or aviation arena. This resulted in minimal control over who flies, what they fly, or where they take the patient.

It can cost a hospital $60,000 or more a month to operate a helicopter. At the same time, severe trauma cases can draw $18,000-$26,000 in revenue for direct patient services. For a hospital to enter the trauma care arena under the best of circumstances, it can easily cost a million dollars. Not all hospitals with helicopter programs have elected to go into the business of being a bona fide trauma care facility. Further, it would not be cost effective for every hospital to become a trauma center. Still, it is difficult for some to forego the temptation to pick up trauma revenue.

Helicopters are secondary responders called in by another authority who has determined that a helicopter is necessary. Very quickly, which helicopter service is called to the scene, and where the victim is taken becomes a crucial issue for those wishing to gain their share of the market. This is a highly controversial issue whether one is concerned about economic survival or the best interests of the victim. Many have reared up in protest to demand that standards be met before a hospital can be designated as a trauma center capable of ministering to the needs of the critically injured.

On the helicopter side of things, is the question of who is qualified to transport a critically ill or injured patient. What kind of personnel and equipment is on board, and where is the patient taken. If competing helicopter services are within the same general vicinity, the situation can become more complicated. Paramedics and EMTs who arrive at the scene first suddenly become very powerful. Social, political and economic variables can run rampant, and have an impact on how a trauma case is handled.

The marriage of the helicopter to the hospital industry has not been without passion, controversy, and irony. Just about every helicopter medevac program carries a name that conveys benevolent motives of the highest order. Still, it is in the public’s best interest to ask: Are they really as good as they sound? Do they serve the best interest of the critically ill or injured?

#Trauma center designation

In 2013, Dr. Christopher Urbina, former executive director and chief medical officer of the   Colorado Department of Public Health and Environment announced that the criteria for Level I designation as a trauma center would be reduced to treating 320 critically injured patients per year.   Research has demonstrated that centers that treat 600 critically injured per year have the best outcomes because it keeps their skills sharp. As other hospitals gear up to be designated trauma centers, this may be another case of too much competition at great expense.   The over designation of trauma centers would require Level I and II service to have to pay to have surgeons and other healthcare providers on call to assure that each hospital is prepared to provide intervention for the seriously injured 24 hours a day/ 365 days a year.   In essence the proposed change would simply increase competition and result in a duplication of services that drive up costs and dilute the quality of trauma care for Coloradoans.   Most trauma experts believe a population of 2.5 million in the Denver metro area justifies just a single Level I Trauma Center, not the three that we presently have.

In 2009 the American College of Surgeons conducted a comprehensive review of the Colorado Trauma System and completed with the assessment that it “likely reflects an excess of trauma centers that are competing for patients, reducing the volume at each center, and duplicating expensive resources.”

#Helicopter transport and #obesity

The National Center for Health Statistics reports obesity in America has reached alarming rates. It is one of the biggest drivers of healthcare costs that are estimated to range from $147 billion to nearly $210 billion per year. 68.5% of adults are overweight and 34.9% are obese. Obesity among children and adolescents has escalated. 31.8% are overweight and 16.9% are obese. This is alarming and preventable. Certainly obesity has a negative effect as it increases diabetes and other health conditions.

In a critical care situation where a helicopter is called for transport, it is estimated 5,000 US patients are denied helicopter transport each year because they are too heavy or large to fit in an aircraft. This has created a dilemma for air transport providers. In an NBC report, Craig Yale, vice president of corporate development for Air Methods said, “It’s an issue for sure. We can get to a scene and find the patient is too heavy to be able to go.”    If a patient is too large or heavy to fit in the helicopter, they may not be able to receive the urgent care they need in a fast enough manner. In some cases patients simply cannot fit through the doors. In some instances, an overweight person may be able to fit into the aircraft, but their weight can sometimes prevent a helicopter from lifting off the ground.  This can pose a dangerous risk to all on board. A helicopter crashed in New York’s East River in October 2011 because it was over capacity by 50 pounds.

Americans seem to be sleep walking as they go about getting larger and larger compromising their health and setting poor examples for their children.   Helicopter transport services face having to deny service or invest in larger helicopters.   Obesity is something we need to address in schools and various healthcare facilities by focusing on the problem and teaching sound nutrition.   It can be difficult because when you attempt to mention the problem, a person may feel insulted and defensive. Still, programs need to be set in place to prevent this condition. It’s in everyone’s best interest.

 

#helicopter transport

Student in Murrysville Pa  at Franklin regional high school suffered a head injury in physical education playing volley ball.  Medics in the interest of “abundance of caution”  had him transported by helicopter.  In this instance,  possibly erring on the side of caution was a good thing.  Potential brain injury is a critical concern.  Other questions to consider:  Time and distance to critical care and the ability of the facility to deal with this kind of injury.  If all that is in line, it is good the medics had the ability and courage to make the right call. .

#medical helicopter transport

News update:   A student  injured in a physical education class at Franklin Regional High school in Murrysville , Pa Medics called for helicopter transport as a precaution.  This will be an interesting case to follow.  No further information at this time.  Sometime back, I asked the question:  Are medics in the field trained to a level to make accurate assessments?    Reportedly, the student was playing volley ball.  Wow!  Didn’t think  this game could create life threatening injuries.  I have read that sometimes medics do call for a helicopter in order to keep their ambulance in the field.  Do follow this story and give comment.   Share and Retweet

#Hospital Safety

Thursday, July 17, 2014

WASHINGTON, July 17 – Preventable medical errors in hospitals are the third leading cause of death in the United States, a Senate panel was told today. Only heart disease and cancer kill more Americans.

“Medical harm is a major cause of suffering, disability, and death – as well as a huge financial cost to our nation,” Sen. Bernie Sanders (I-Vt.) said at the outset of the hearing by the Senate Subcommittee on Primary Health and Aging.  “This is a problem that has not received anywhere near the attention that it deserves and today I hope that we can focus a spotlight on this matter of such grave consequence,” added Sanders, the panel’s chairman.

The Journal of Patient Safety recently published a study which concluded that as many as 440,000 people die each year from preventable medical errors in hospitals. Tens of thousands also die from preventable mistakes outside hospitals, such as deaths from missed diagnoses or because of injuries from medications.

The new research followed up on a landmark study, To Err is Human, conducted by the Institute of Medicine 15 years ago, when researchers reported that as many as 98,000 people die in hospitals each year due to preventable medical errors. Experts now say that figure was too low and hospitals have been too slow to make improvements.

There has been some progress, Dr. Peter Pronovost of Johns Hopkins University testified. Yet thousands of patients still are dying unnecessarily from infections, preventable blood clots, adverse drug events, falls, over exposure to medical radiation and diagnostic errors. “We need to declare right now that preventable harm is unacceptable and work to prevent all types of harm,” Pronovost said.

Compared to the rest of the world, the United States is about average. “While average is OK, given that we spend more on health care than any other country we should be a lot better. Our high spending is not buying us particularly safe care,” said Dr. Ashish Jha of the Harvard School of Public Health.

Other reports have examined the impact of medical mistakes on segments of America’s patient population. A Department of Health and Human Services report in 2010 said 180,000 Medicare patients die each year from preventable adverse events in the hospital. The Centers for Disease Control and Prevention in 2011 said 1-in-25 hospital patients get an infection from being in the hospital; 700,000 of them get sick as a result and 75,000 die.

In addition to deaths and injuries, medical errors also cost billions of dollars. One 2011 study put the figure at $17 billion a year. Counting indirect costs like lost productivity due to missed work days, medical errors may cost nearly $1 trillion each year, according to a 2012 report in the Journal of Health Care Finance. Lisa McGiffert of Consumers Union spoke about the everyday impact on individuals and families. “People who are harmed lose their jobs, their homes, their insurance. Many go bankrupt trying to pay the medical bills that they would not have had if they had not been harmed by a health care provider,” she said.

 

 

#EMS pilots on the job

EMS pilots can be on the job for 70 plus hours a week with only 10 hours of flying.  Long periods of nothing in particular to do, but wait for a call can be stressful.  There is the boredom of having many hours, without stimulation or challenge, and most likely having one’s mind on outside activities. While it may not be uncommon for corporate executives to spend as many hours involved with their jobs, there is on important difference:  Executives are for the most part, actively engaged in constructive activity and receiving    constant stimulation.  The pilot, on the other hand, must make a swift transition from inactivity to the jarring experience of responding to the critical needs of a victim.  Pilots can be tensed up enough that sleep is not really restful; this kind of anticipation has been likened to sleeping with one eye open.

Many new programs have not been too concerned with the issue of understaffing.  In these times of inflation, it is easy to take the position:   ‘If you’re not able to handle the job, we’ll find someone who can.’  Pilots need their jobs to take care of care of their families and meet financial obligations.  This leaves them in a subservient position with essentially no bargaining power, and in the position of flying regardless of weather conditions.  Most EMS pilots are contracted out to hospitals by a helicopter company.  Many are in new air ambulance programs trying to prove themselves.  These programs want to show their communities that they can save lives; this can put incredible pressures on the pilot to perform when a call comes in.  Emotions and tension can run high with the pilot having little apparent authority to decline to fly, even if in his best judgment, conditions do not permit.

What’s it like in your world?

 

Evaluating regional trauma concept #trauma

While just about everything in the medevac industry seems controversial, it is not surprising that some who argue that there is not much validity in establishing regional trauma centers.  Any attempt to evaluate the impact of a regional trauma center is uniquely complex due to the large number of variables that must be taken into account.  It was the intent of the 1985, Trunkey study to demonstrate that preventable death could be used to evaluate the impact of regional trauma programs in reducing mortality.  Salmi, Williams, Guibert et.al. from Montreal, Quebec and Germany has challenged the validity of United States studies on preventable death rates.  They profess that “preventable death rate” studies have major flaws.

By thorough review of design and research strategies, selection of subjects these researchers have come to the conclusion that “unless results from two or more studies are based on comparable data, the comparisons may reflect systematic information biases.”  They cite the following basic flaws in preventable death studies:  1) Time trends in trauma severity unrelated to care are not taken into account.  2)  Selection bias occurs when there is a restriction of cases by region hospital, type or cause of injury, time of death, or other variables.  3)  Other problems arise if clinical and post mortem data are drawn inconsistently from varying sources.  4) Also, the choice of criteria for consensus about preventability could by itself explain observed differences in preventable death rates.”  They also point out a more serious flaw of not accounting for those patients who would have died, but actually survived because of adequate care.

A trauma system can only be as effective as the services provided to designated communities.  Effectiveness is dependent upon quickly identifying the victims and dispatching EMS services; immediate and accurate diagnosis of severe injury; compliance of ambulance services, emergency rooms, hospital specialists and providing all victims with the highest standard of treatment through all stages of care.  Further consumer awareness, acceptance, and use of services plays an important role.  There is also the possibility that the quality of care may be related to differences in circumstances completely unrelated to care.

Death at the scene may or may not be preventable.  However, delays in response can result in “preventable deaths.”  Failure to provide basic or Advanced Life Supports at the scene or in transit may contribute to DOA (Death on Arrival).

#Flight Nurses

Today’s civilian flight nurse evolved out of the need to meet patient needs where they exist–in a pre-hospital environment. She/he represents a new breed of nurses who’ve taken to the sky to bring the highest quality Medical Care to the critically ill or injured.

Becoming a flight nurse can be fraught with untold stress and challenge as a fledgling flight nurse will tell you. The most heard phrases are: ‘It’s scary; it’s a lot to get your act together, or I didn’t see anything but the patient.’ A new nurse can wait for hours in anticipation of that first call. It is check and recheck the medical supplies to make sure all that is required in the field is in place. In nervous gesture, she may scratch down the dosage on her cheat sheet while her mind loads up with: “Will I save a life? How will I deal with triage (setting priorities)? What if I mess up? What if I forget something really important? Dear God will I make it? What if I can’t? When the call finally comes, and she lifts off, there is a prayer on her lips: “Lord, give me the strength to do what I need to do. Let me do no harm.”

The flight nurse knows that she takes on a great deal of responsibility for the life of others. At the same time, she is in the spotlight for all to see, criticize, and hold accountable, praise or support. It is not always easy to feel supported in the field because the environment can be chaotic and demanding. All she has is herself and the best possible medical training. Support will have to come later.

Each time a flight nurse goes into the field, she must be cognizant of her surroundings (what personnel are on the scene, where is the family, who is most critically injured, what decisions must be made quickly). Even if the nurse is trembling with fear, she cannot allow herself to be overwhelmed at the scene because so many are depending on her critical medical expertise. Oftentimes, the victim will be unconscious and healing has to start with family members who are devastated. A loved one is on the verge of death or may never walk or speak again. While the victim is of primary concern, family or significant others cannot be forgotten. A kind word, squeeze of the hand, and a brief explanation of what is going on helps to assuage a sense of isolation of helplessness.