EMTs don’t possess the foundational knowledge in disease process, anatomy, physiology and pathology needed to decide who should and should not be flown by HEMS. I’m not faulting EMTs for this but the fact remains that they simply do not have enough training to know who should and who should not be put in a helicopter.
EMTs should not be allowed to decide on scene flight helicopter use with the current initial educational standards in place. The NHTSA and the NREMT need to increase the educational requirements on this topic. Perhaps they could replace a few hours of the spinal immobilization witchcraft that is obsessed over in EMT programs and talk about things that matter to patients and outcomes; cost–benefit analysis and risk versus benefit decision making, explaining what flights can and cannot do for a patient, financial, patient advocacy and the concept of patient autonomy in medical decision making.
Before your BP gets any higher and you round up your pitchforks, most paramedics are not good at this either and they need more training on this topic as well.
There should NOT be a difference in the initial education on this topic between EMT level providers and Paramedic level but unfortunately there is one. The National Emergency Medical Services Education Standards from the NHTSA (http://www.ems.gov/pdf/811077a.pdf) serve as a blueprint for what EMS courses must teach and there is clearly a difference between EMR/EMT/AEMT and what the Paramedic is taught about who to fly and when.
How much time was devoted to this subject in your class? When I took EMT it was a 30 second spiel about “life or limb” and that was it. I looked in a recent (2012) EMT text book to see how much of the text was devoted to information on when to use air medical resources. 3 paragraphs out of a 1284 page book were devoted to this topic. 3 paragraphs about a decision we make that can literally cost someone their home and ruin their life seems a bit light to me.
There needs to be sweeping reform of all EMS education, especially this topic.
If you have read this far I would like to apologize for the somewhat click-baitish nature of this post, but controversy drives people to posts way more than a post titled “NHTSA Needs to Make Sweeping Policy Reforms to Air Medical Resource Utilization Education in Initial EMS Training.”
Dunning – Kruger Effect
Over triage rates of patients sent to the hospital by HEMS ranges between 26% and 60%1,2. Dr Bledsoe et al produced an excellent meta-analysis of this in 2006 and it seems fair to say that the issue has not gotten better in the past 10 years.
EMS loves nothing more than to develop flow charts rules and protocols for things. There have been attempts to streamline who should and should not be transported by a helicopter. The NHTSA has produced a set of guidelines based on the 2011 CDC Guideline for the Field Triage of Injured patients3. The 2011 CDC guidelines are too broad and not specific enough to work unless common sense is applied. While a respiratory rate of >29/minute might be a problem, it might also be due to the fact that the person was just in a traumatic car accident, without clinical correlation the guidelines are worthless.
Primum Non Nocere
The number one cause of bankruptcy in America is medical bills.
Depending on the study or article you read medical bills account for between 17-62% of all bankruptcies in America. Medical billing is a major cause of bankruptcy and it is not just affecting the uninsured, many of the people forced to file bankruptcy because of medical bills have medical insurance.
The nation’s largest provider of EMS helicopters is Air Methods. A recent NY Times article states the average bill for a flight from Air Methods is around $40,000. There have been accusations that Air Methods has taken people to court over their bills and even put liens on people’s houses in order to get paid4. EMS needs to make sure that the ends justify the means when utilizing HEMS for a patient.
Patient advocacy needs to be one of the tenants of EMS practice and this has now extended to counseling those with decision making capacity on the financial aspects of their health care choices.
I’m not an idiot, there are some patients that simply need to be put on a helicopter and flown to a major hospital because the choices are A) be dead or B) be alive and bankrupt but this is not a justification for bad decision making; it is not a justification for the what-if game.
It is no longer acceptable to replace poor clinical judgement with an appeal to emotion of “well, at least they are alive to bitch about the bill.” It is also no longer okay to rationalize bad medicine to ourselves and others with another appeal to emotion of “THE LAWYERS” and the ever popular well what if I don’t fly them and they get worse and then I get sued.
You might be saying, “I’m just an EMT and shouldn’t have to make these decisions and wait a second here, the author of this blog post agrees I should not be making these decisions so why is he telling me to figure it out.”
Because I live in reality and know EMTs are going to be tasked with the decision of who goes to the ER by HEMS regardless of what a blogger says on the internet. It does not change the fact that it is not okay to routinely cost patients $40,000 because we as an industry have shit for educational standards.
Here is the thing that no one ever told you in EMT class – your decisions have consequences, mostly for the patients and sometimes for you. If you don’t want that responsibility then look in to another career.
What is a realistic goal then? Educate yourself, read everything you can on this, talk about it with your coworkers, supervisors, protocol writers, and medical directors. Discuss it on internet forums, think of scenarios, and understand what HEMS can and cannot do in your area. Strive to be a provider who uses clinical judgment with a solid educational foundation.
You are going to over triage patients and fly them, it is a fact and this is preferable to under triage but when you follow up on the patient you flew from scene (you do follow up on them right?) and find out they had only minor injuries and did not benefit from a flight don’t dismiss it, embrace it, look at your decision making pathway. Keep track of your rate of over and under triage. When you screw up sit there with those feelings and wonder if you are a shitty EMS provider, feel bad about yourself and your judgment for a bit. This is what good EMS providers do.
Bad EMS providers simply say some bullshit about lawyers, MOI, better safe than sorry, x-ray vision or some other non-sense and never internalize this lesson and grow from them.
Good EMS providers scrutinize their judgments and feel bad when they make a mistake. Feel bad about it for a while and then move on, realizing this is the path to becoming a better provider.
- Smith HL, Sidwell RA. Trauma patients over-triaged to helicopter transport in an established Midwestern state trauma system. J Rural Health. 2013;29(2):132-9.
- Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’keefe MF. Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis. J Trauma. 2006;60(6):1257-65.
- http://www.nytimes.com/2015/05/06/business/rescued-by-an-air-ambulance-but-stunned-at-the-sky-high-bill.html?_r=0
- https://www.ems.gov/ficems/june2012/Draft%20Manuscript%20for%20HEMS%20Evidence-based%20Guideline.pdf
