January 14, 2011

Ground ambulance Vs. HEMS

This will be the rare blog in which I discuss a profession with which I have been associated for 30-odd years. There are enough EMS blogs out there to chew up and spit out any conceivable splinter of the practice of pre-hospital medicine... and in much more eloquent fashion than I... so I tend to leave it to them.

However, while scanning the news I found one of those splinters upon which I feel compelled to comment. It was almost buried in all the other claptrap... and I almost missed it. 

Like everyone, I've followed the story of the tragedy in Tucson since it happened last Saturday. In the immediate aftermath I learned three helicopter ambulances were dispatched to the scene; with each transporting a wounded patient to University Medical Center. Knowing the city as I do, I wondered why helicopters were used and why we didn't simply transport by ground.

HEMS proponents will tell you that speed gained by utilizing air transport is critical in saving lives. Perhaps true in certain patients and in certain logistical settings. Transporting a CVA patient to a regional stroke center in the next city, or the victim of blunt, abdominal trauma in a rural setting 40 or 50 miles out... these could be candidates and likely would benefit from transport by helicopter. In Tucson all of the patients were gunshot victims, which under the correct circumstance would certainly qualify for air transport.

But that Safeway store is a ten minute leisurely drive to University Medical Center emergency room driveway, all  the way over congestion free city streets. 

So why the helicopters?

Rep. Gabby Giffords, one of the most critically wounded, survived. She was shot at 10:10 AM and arrived at UMC emergency department 31 minutes later. The pace of her recovery is being hailed as "miraculous" by UMC physicians. Efficient pre-hospital care, rapid patient packaging, and a short transport time to an appropriate trauma center can be credited with giving Rep. Giffords her chance for recovery.

It was therefore interesting to learn that Congresswoman Gabrielle Giffords was transported by ground ambulance

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17 Comments:

TenMile said...

Of course somebody liked it. Point well taken. Photo ops aplenty. And one 911 responder reuested "All or as many as possible EMS be dispatched, there's body's all over the place."

The 911 operator can only do the responders the best they may.

Anonymous said...

That Safeway is not 10min away from UMC, obviously you don't know Tucson very we'll. Its people like you who are costing HEMS staff their jobs. You suck !!

Anonymous said...

I think you hit a nerve...I agree that HEMS has its place in prehospital ems but I also think that there are times when it is utilized inappropriately...no one is trying to cost anyone their jobs. Relax

Anonymous said...

It is costing people there jobs... flight volumes are low becaues people like you are not calling Helos.. which causes bases to close down.

Mule Breath said...

Interesting. I suck and I'm costing jobs because I ask the question "why the helicopters?" Now that is quite the extreme leap there, Anonymous.

Assuming the base closure claim has any validity, and I've certainly seen no evidence of it, you don't suppose the reason might be that HEMS in major urban settings is being demonstrated excessively expensive and mostly ineffective, do you?

Far more of the evidence would support that than your superfluous assertion, I think.

Anonymous said...

Being in HEMS I am embarrassed by the "you suck" comments. They are unnecessary.

According to Google Maps the La Toscana Village is an 18 minute drive from UMC.

Looking at previous EMS articles showing Lights and Sirens save about 43 seconds (MD, EMT-P Robert A De Lorenzo, MD, FACEP Mark A Eilers; Lights and siren: A review of emergency vehicle warning systems, Annals of Emergency Medicine
Volume 20, Issue 12 , Pages 1331-1335, December 1991).

Twenty minute transport time seems to be a standard for calling HEMS. One could argue the point either way. Bottom line - is there going to be a significant delay waiting for the helicopter? What is in the best interest of the patient?

Mule Breath said...

The "You suck!" genre of responses are more infrequent these days, but just a few years ago when some of us started questioning the efficacy of HEMS in many of the calls, those comments were a chorus. Ceding turf to science has always been difficult in EMS.

I'll not split hairs on the drive time. LE logs indicate a 10 minute transport time. Stipulated that could be an estimate. None the less, by ground it was 31 minutes from trauma to hospital door. It would be interesting to contrast that with HEMS times.

Mule Breath said...

... and now I find a McPaper report quoting UMC doctors, saying that the Congresswoman was in surgery 38 minutes post trauma.

Ambulance Driver said...

I tell ya, nothing makes me rethink my position better than an anonymous commenter lobbing verbal grenades like "You suck!"

If only you had used four exclamation points instead of two, we might all have come to realize that all helicopter transports are necessary, no matter how short the trip or how much quicker the ground unit beats them to the ED, and that if. it. even. saves. ONE. life!, it's worth all the deaths of our HEMS brethren every year.

All caps would be a nice touch, too.

ZerCool said...

According to my local helicopter service's published guidelines, I should have been flown when I wrecked my motorcycle. (Mechanism of injury: Motorcycle crash >20mph or with separation of rider and bike.)

I slid sideways leaving a stop sign, the bike went one direction, I went the other in a logroll, at perhaps 5-10mph.

It hurt like a sonofabitch, but I picked up my bike (causing myself an even more painful injury by burning my finger on the exhaust manifold) and rode home to wash off the minor road rash I'd acquired.

Anon up there would have me with a large-bore IV, c-spined, wrapped like a baked potato, and being flown to the trauma center... because the book says to!

Bull patties.

Look at your patient. I know you're not an x-ray machine or a blood lab, but open your damn eyes, put down The Book, and treat the patient, not just the mechanism.

Mule Breath said...

Taken to its fullest extent, the ground vs. HEMS discussion is necessary simply because it helps us improve our profession and ourselves as medical practitioners.

Bickering over peripherals such as jobs maintenance is shallow. The only valid reasons for the overuse of HEMS are threefold: (1) Major urban center hospitals receiving high value patients (2) HEMS operations have a much higher profit margin than ground; (3) An incorrect assumption that HEMS is a higher level of care than ground.

Truthfully, the lost jobs argument is irrelevant even if true.

Anonymous said...

I work for a suburban fire dept in central indiana. We have about a 25-30min transport time to our nearest level one TC. I have found that unless there is extrication involved, that even if we call for HEMS early I can usually get my pt's to the trauma center sooner than the HEMS. On more than one occasion I have transported a less critical pt via ground while more critical pt's went via air. I was done with my turnover in the trauma room before the other pt was in the ED. So I am going to transport via ground unless I know it was going be delayed.

Anonymous said...

I use air transport based on my patient’s presentation. If I think it will cause them more harm or injury to transport by ground or if they are a prolonged entrapment I usually airlift them. If we are greater than 25 to 30 miles out I will airlift priority 1 and 2 patients. If it is going to take me longer than 15 minutes to get back to a road so I can get them to town I airlift them if they are a priority 1 or 2 patient.
I have noticed that if we are working anything on an interstate or other major highway and the fire district or someone else calls air transport before I get there. The patients that my ground units take will get to the hospital 10 minutes at the average before the airlifted patients do. By this I mean in the ED and under a physician’s care. At most of the hospitals the helicopter lands on the roof or out in the parking lot. This adds to the time before the pt. is received in the ED and under a physician’s care.
Some of my crews call the air transport because of lack of confidence in their skills or the desire not to treat acute patients. This should never be a determining factor. Volunteer first responders and non-transporting fire districts will call them at the drop of a hat. My crews will get there and the patients will be stable. Thus the flight crew and the public have been endangered by a flight that should have never been initiated.
My biggest grief with air transport is that when I am working an MCI and have everything running smoothly with transport. They will land right in the middle of my means of egress and ingress essentially stopping all transport while they are on the ground. Law enforcement places them so I can not completely blame the helicopter crews. I have spoken with the crews and the pilots and they now place the ship as far out of the way as possible. Our last incident with multiple patients and using air transport went very well in that respect. Lastly the helicopter crews are sitting on the ground for 20 to 30 minutes retreating and redoing everything we have done to the patients. That in itself reduces the claim that they can get them to the hospital faster.
I never call air medical transport unless I feel that the patient will benefit from it. I am not one to put the crew of the aircraft or the public at large in danger from a flight that the patient could have gone in and ambulance. The only things the helicopter can do that my crews can’t are RSI and fly. I have been trying for years to get RSI but someone somewhere has been fighting it like it was some new diseases come to town. As far as flying my trucks will never do that unless we get a conversion kit like they had in “Back To The Future”.

Anonymous said...

I use air transport based on my patient’s presentation. If I think it will cause them more harm or injury to transport by ground or if they are a prolonged entrapment I usually airlift them. If we are greater than 25 to 30 miles out I will airlift priority 1 and 2 patients. If it is going to take me longer than 15 minutes to get back to a road so I can get them to town I airlift them if they are a priority 1 or 2 patient.
I have noticed that if we are working anything on an interstate or other major highway and the fire district or someone else calls air transport before I get there. The patients that my ground units take will get to the hospital 10 minutes at the average before the airlifted patients do. By this I mean in the ED and under a physician’s care. At most of the hospitals the helicopter lands on the roof or out in the parking lot. This adds to the time before the pt. is received in the ED and under a physician’s care.
Some of my crews call the air transport because of lack of confidence in their skills or the desire not to treat acute patients. This should never be a determining factor. Volunteer first responders and non-transporting fire districts will call them at the drop of a hat. My crews will get there and the patients will be stable. Thus the flight crew and the public have been endangered by a flight that should have never been initiated.
My biggest grief with air transport is that when I am working an MCI and have everything running smoothly with transport. They will land right in the middle of my means of egress and ingress essentially stopping all transport while they are on the ground. Law enforcement places them so I can not completely blame the helicopter crews. I have spoken with the crews and the pilots and they now place the ship as far out of the way as possible. Our last incident with multiple patients and using air transport went very well in that respect. Lastly the helicopter crews are sitting on the ground for 20 to 30 minutes retreating and redoing everything we have done to the patients. That in itself reduces the claim that they can get them to the hospital faster.
I never call air medical transport unless I feel that the patient will benefit from it. I am not one to put the crew of the aircraft or the public at large in danger from a flight that the patient could have gone in and ambulance. The only things the helicopter can do that my crews can’t are RSI and fly. I have been trying for years to get RSI but someone somewhere has been fighting it like it was some new diseases come to town. As far as flying my trucks will never do that unless we get a conversion kit like they had in “Back To The Future”.

TOTWTYTR said...

Dear Anonymous, you are absolutely correct. That Safeway is 16 minutes from the ambulance dock at UMC, driving at normal speeds in a civilian car.

How do I know that, you ask? Simple, a friend of mine who lives about two miles from that Safeway and has been a paramedic likely longer than you've been alive, drove the route in his car. He obeyed all traffic laws and it took him 16 minutes to go the 8.3 mile from the corner of West Ina and North Oracle to the ambulance dock at UMC. Took him 16 minutes. No doubt it would take less time driving lights and siren, so let's say about, oh, 10 minutes. Wait, isn't that the number Mule Breath used? I often debate with Mule Breath, and have for 15 or more years. One thing I don't do is doubt his research and facts. It's not wise.

So, anonymous, take me advice and embrace the suck. Yours.

One thing I will say in defense of using helos is that there might just not have been enough ground ambulance capacity to transport everyone. I don't know if that's true or not, but it shouldn't be discounted as a possibility. After all, TFD only has 16 ambulances and I don't know what Rural/Metro brings to the game. Technically, the shootings happened in Pima County, not within the City of Tucson, so TFD would be responding on mutual aid is my guess.

Now, I figured all that out from 2500 miles away, just using Al Gore's Internet. Someone who lives closer should have a better degree of detail than I.

Other than the possible shortage of ground ambulances, I can't think of one reason that any patient should be flown 8.3 miles over a land area that has paved roads.

crispy said...

Mule Breath is right, we (street medics) overuse air ambulance. That is fact. I have argued that point with colleagues many times. I've seen fire do it. I've seen ambulance peeps do it. They usually point to MOI, I usually point to pt assessment! Meh, it is what it is. I work in the 'burbs. Some of our outlying areas are far from hospital. The ambulance guys out there use that as a reason to activate air ambulance all the time. Twelve YO M, closed tib/fib, no head trauma, no LOC they still call air. That's BS.

Anonymous said...

In the early 1980's my paramedic unit was second due on a fairly nasty auto wreck. We responded in a 1968 Crown 100 foot aerial ladder truck with a top speed of 58 mph. One patient was transported by helicopter and we followed the second in an ambulance, code 2, to the same trauma center. Our patients arrived in the ER within seconds of one another, ours clearing the doors first.
The time it takes to get airborne, the remoteness of the LZ to the scene and sometimes to the ED conspires to make aerial transportation impractical unless the distance is significant.