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Rural Challenges in EMS

Air Medical Transport

Jeffrey Coughenour MD FACSAssistant Professor of Surgery and

Emergency MedicineMedical Director, Mitchell Trauma Center

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Disclosures

Industry supported research

Reflectance Medical, Inc. and ZOLL Medical

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Objectives

History

Utilization and scientific evidence

Safety, quality measures and performance

St. Anthonys Hospital, Denver, CO 1972First civilian air medical service

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Beginning

US Army Air Corps

Nicaragua to Panama, 1926

Korea 22,000 Vietnam 800,000

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Common Theme

Care under fire

Far-forward surgical care

Rapid transport to higher echelon of care

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Civilian Adaptation

Dual role aircraft

Civilian aircraft exclusive patient care andtransport: 1972

R. Adams Cowley, Golden Hour

Lerner EB, The golden hour: Scientific Fact or urban legend?

Acad Emerg Med 8(7): 758-760

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Missouri

1978 The Spirit of KC Life Flight

Followed by St. Louis in 1979, MARC(ARCH)

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Missouri

6thin the nation with 30 aircraft

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Why HEMS?

Presumed superiority of care

Time to definitive care

Local resource utilization or availability

But which patient actually benefits?

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Utilization

Joint Position Statement

Air Medical Physician Association

American College of Emergency Physicians

National Association of EMS Physicians

American Academy of Emergency Medicine

Appropriate and safe utilization of helicopter emergency medical services: ajoint position statement with resource document. Prehosp Emerg Care2013

Oct-Dec;17(4):521-5

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Position Statement

Patients benefit from the appropriateutilization of HEMS

EMS and regional healthcare systems musthave and follow guidelines for HEMSutilization to facilitate proper patientselection and ensure clinical benefit

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Position Statement

Clinical benefit may be provided by:

Meaningfully shortening the time to delivery ofdefinitive care to patients with time-sensitive

medical conditions Providing necessary specialized medical

expertise or equipment to patients before

and/or during transport Providing transport to patients otherwiseinaccessible by other means

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Position Statement

That the decision to utilize HEMS is amedical decision, separate from theaviation determination whether a transport

can safely be completed

That HEMS must be fully integrated withinthe local, regional, and state emergency

health care system

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How are we doing?

EMS and regional systems should have andfollow guidelines

Medical decision, separate from aviationdetermination of safety

Integration with local, regional, stateemergency care system

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Guidelines

Trauma Task Force, TCD System

19 CSR 30-40.790

Transport Protocol for Stroke and STEMI

How well are they followed? I have no idea

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Literature

Silicon Valley, CA, 947 trauma patients

22.8% potential benefit, 33% DC from ED1

LA pediatric trauma

189 patients, 85% minor injured, 33% DC fromED2

1Shatney CH. The utility of helicopter transport of trauma patients from theinjury scene in an urban trauma system. J Trauma2002, 53:817-822

2Eckstein M. Helicopter transport of pediatric trauma patients in an urbanEMS system: A critical analysis. J Trauma2002, 5: 340-344

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Literature

North Carolina

Small subset survival benefit1

Pennsylvania

3,048 penetrating trauma pts. over 8 years,helicopter longer transport times, no mortalitydifference2

1Cunningham P. A comparison of association of helicopter and groundambulance transport with outcome of injury. J Trauma1997, 43(6): 940-946

2Dula DJ. Helicopter versus ambulance transport of patients withpenetrating trauma. Ann Emerg Med 2000, 36(4): S76

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Literature

Inter-facility transports similar outcomes,no significant mortality differencecompared to ground transport

Arfken CL. Effectiveness of helicopter transport vs. ground ambulanceservices for inter-facility transport. J Trauma 1998, 45(4) 785-790

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Literature

Netherlands, 446 patients

Improved survival, estimated 5.4 additionallives saved per 100 HEMS deployments

Giannakopoulos GF. Helicopter Emergency Medical Services save lives: outcomein a cohort of 1073 polytraumatized patients. Eur J Emerg Med. 2013

Apr;20(2):79-85

.

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Cochrane Review

25 studies, considerable heterogeneity

Low quality evidence

an accurate estimate of overall effectcould not be determined.

Galvagno Jr SM, Thomas S, Stephens C, Haut ER, Hirshon JM, Floccare D,Pronovost P. Helicopter emergency medical services for adults with majortrauma. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.:

CD009228

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Utilization

Trauma

Physiology and injury pattern criteria

Stroke and STEMI

When GEMS transport to a capable facility maypreclude arrival within a therapeutic window(thrombolysis, PCI)

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Early or Auto Launch

Partially responsible for poor utilization

Over-triage

No literature support Business/PR tactic

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Operating Models

Public safety

Hospital-based service (HBS)

Community-based service (CBS) Hybrid or alternative

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Finances

Costs often fixed

Medicare reimbursement fee structurediffers rural and urban

Urban $3,308 per trip plus $21.53 per mile

Rural $4,962 per trip plus $32.30 per mile

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Safety

1988 1997

Average of 5 HEMS incidents/year

1998 2008

12.4 incidents/year

22 fatal injuries 2009-2010

Significant number of those related tohuman error

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Safety

Human error 77%

Weather, IIMC, CFIT

Mechanical 17%

Other 3%

Undetermined 2%

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NTSB

Scenario-based pilot training

Safety management systems

Flight data recording Aviation Digital Data Service (ADDS)

NVIS

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NTSB

Low-altitude infrastructure for HEMS ops

Autopilot/Dual pilot operation

HTAWS/TCAS

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Operations

$800K 3 million

Single engine

Single pilot only

Limited weathercapability

Limited weight carriagefor medical equipment,

fuel

$4-6 million

Twin engine

2 pilot capability

Instrument weathercapability

Autopilot

Longer range

Higher critical carecapability (e.g. balloonpumps, ventilation)

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Safety

What level does your provider operate?

Are the aircraft equipped with the NTSB-recommended safety features

Do you take an active role in knowing whois flying your patients?

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Canada

Funded by government

Centralized dispatch

Twenty aircraft serving 21 million people Required Dual pilot, autopilot, IFR capable

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Canada

ORNGE crash, northern Ontario

Inexperienced pilots, night operations

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Quality

Data analysis and benchmarking

Administrative and peer review

Medical control oversight

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74

21

SFL Helicopter 2014 Intubation Success 2nd Quarter

1st Attempt Success

2nd Attempt Success

Failed (king)

First & Second Attempt 95%

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Quality Measures

Advanced airways supported by mechanicalventilation

Bedside time for STEMI

BP management for hemorrhagic stroke

Glucose measurement in AMS

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Medical Oversight

Dont intubate profound shock

A, B, C B, A, C C, A, B?

Ketamine is amazing Septic shock from a critical access hospital

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Performance

Education

CAMTS requiring professional certification CFRN, FP-C

Mentorship program for new hires Live-tissue or simulation training

Clinical interaction

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Performance

Clinical Care

Cardiac augmentation

Transfusion

High-risk OB

Pre-hospital ultrasound

POC ABG/VBG, lytes, coagulation

Pharmacologic adjuncts

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Summary

Early, helicopters added patient care skills,interventions

Sophistication of EMS, may offer little morethan speed

Evidence showing clear benefit ?

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Summary

Safety, quality, performance allhelicopters and their operators are NOTcreated equal

Take an active role in knowing who is flyingyour patients

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