Monday, October 20, 2008

To Fly, or Not to Fly?

That is the question.

There's been a lot of talk on various sources about the pros and cons of HEMS. Don't get me wrong. I'm all for it in the right circumstances. I have flown several patients out myself. Five, in fact. In the 10 years I've been an EMT. Three were peds cases, two were adult traumas. In all 4 cases, I had (as did the medics with me) every reason to believe that time was of the essence. Both peds cases were head injuries, and while one of them could have been driven, it was rush hour in the metro area, and getting to the Big Children's Hospital would have taken over an hour, if not closer to 2 hours. The second peds case I flew was a status epilepticus secondary to a fall down the stairs. The third was a toddler who had been 'run over by a car' and while he didn't appear to have any obvious injuries, there was a large patch of hair missing from his head, which lead both me and the medic to believe the by-standers story that it was his head that was in contact with the tire. How much? Who knows, but I'm not really one to take chances with a toddler.

The first kid actually ended up only having a moderate concussion and depressed skull fracture (after pulling a fully loaded bookcase on himself!) and spent 2 nights in hospital, only because mom wanted him to stay the second night just in case. They stopped by about a month after it happened to say thank you, with cookies. Lucky kid.

Both adults were head injuries from an MVA, with altered mental status and other injuries like bilateral humerus fractures or a femur fracture, etc. In one case I was driving home from work and came on scene before the FD. Luckily, I knew the Lt on the engine, and when I said that the guy was going to need a helo, he listened to me. Granted, the guy could have gone by ground, but again, it was rush hour and even with lights and sirens, it would have taken over an hour to get to the Level II trauma center.

I got my EMT certification in a state with a lot of rural areas, and I happened to work in a semi-rural area (some small cities, with LOTS of emptiness and the closest trauma/burn/anything bad center was about an hour away on the state turnpike). The closest helo was about 45 minutes away by ground, and had to be called special by the county to the state in order to get them going. I can't remember EVER flying someone when I was up there. Granted, I didn't have much of a chance to most of the time, but the mentality up there was to get a good assessment and learn to deal with a lot of shit yourself, because the helo was only for REAL emergencies. Good, bad, or indifferent, that was the way it was.

Then I move to a smaller state with a much higher population, in one of the most populated areas in the country. The HEMS around here is run by the state. No 'helo shopping' around here. And a federal police service has medics on their helos, so they can help out when we need them to. Their AC are also larger, and can carry more people/patients. I see a lot more patients being flown to various places here than I ever saw in Rural Area state. One would think it would be the opposite, with my primary call area being within spitting distance of 3 hospitals, one of which is a Level II Trauma center, and within an hour (in good traffic) of 3 Big City Hospitals. I've had an opinion about this proliferate use of HEMS when you are so close to relatively definitive care, and a recent call I went on before my surgery only cemented that belief.

My EMT instructors HAMMERED us on assessment. How can you decide what is best for the patient when your assessment is lacking? And in areas where the closest hospital may easily be an hour away, assessment is key. Continuing assessment is also key. And by having a good assessment, and KNOWING your assessment is good, you have confidence. Confidence that you haven't missed anything glaringly obvious, and confidence that what you write on your run sheet will stand up.

When you lack confidence in your abilities, you are more likely to call for someone with more skills to help out. This can be a good thing sometimes. But when that someone is a flight medic who comes on a big whirly bird, this can be a bad thing. The flight medic is unlikely to refuse the flight, because flights mean money and continued existence (and jobs) for him or her. In private companies, that money comes in the form of billing the patient (and a helo flight is VERY expensive). In public, like where I'm at, that comes in the form of state and federal monies, which are given based on this case, usage of the service. So, because of the lack of confidence of the medic, and a poor report to the doctor (which does not paint an accurate picture of the patient) and a doctor afraid of 'zebras' and the extra money it will cost the hospital if the patient really IS a trauma who needs to be at a trauma center and has to be flown by private HEMS, a helo is dispatched, extra flight hours are put on the helo, taking it out of service faster, and in general, risk is run to everyone.

Equal to the lack of confidence, (and perhaps, and indirect result of lack of confidence) is the 'what if' scenario. 'What if' the patient has serious trauma injuries that are being masked by EtOH? 'What if' the patient really is hurt and deteriorates while we're taking them to the lower level trauma center? Constantly looking for the stampeding hordes of zebras doesn't make you a better provider. I've heard of doctor's with this same problem. I blame the lawyers and policy makers for making every medical provider from EMT up to surgeon uber-paranoid about lawsuits for 'what if' situations, so we over-treat in the hopes that the zebra will be caught. In the meantime, all those extra costs (or risks) are being passed down to the patient and public. But in reality, is this really totally the fault of the lawyers and policy makers? Why are some providers comfortable in treating patients as they present and others want to do everything under the sun 'just in case?'

In my opinion, it comes down to confidence. Confidence in assessments, abilities, and documentation. If you are confident in your ability to assess and treat, and then document EXACTLY what you did, the times you did it and why (not always needed, but it helps), then there should be no reason for you to call for a higher level provider unless it is truly needed. If you can back up what you did, why worry? Sure, something may slip by. But I was always taught that if you are acting within your scope of practice, and with the best interests of the patient in mind, and you document why you did what you did, then you should be covered.

Sadly, for so many, this is no longer so. Perhaps I just haven't gotten bit by the lawsuit bug yet, or been trampled enough by zebras to have this worry. Hopefully I never will.

1 comment:

Rogue Medic said...

the mentality up there was to get a good assessment and learn to deal with a lot of shit yourself, because the helo was only for REAL emergencies.

Almost as if EMS were something that mattered.

My EMT instructors HAMMERED us on assessment. How can you decide what is best for the patient when your assessment is lacking?

Assessment is more important than HEMS, intubation, or anything else.

Assessment vs. What if...? - I'll take assessment every time.