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.

17,000
“No thanks is necessary ma’am, just doing my job.”

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.

helicopter educational standards
National Emergency Medical Services Education Standards Page 49

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.

  1. 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.
  2.  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.
  3. http://www.nytimes.com/2015/05/06/business/rescued-by-an-air-ambulance-but-stunned-at-the-sky-high-bill.html?_r=0
  1. https://www.ems.gov/ficems/june2012/Draft%20Manuscript%20for%20HEMS%20Evidence-based%20Guideline.pdf
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32 thoughts on “EMTs Should Not Be Allowed to Decide On Scene Flight Helicopter Use.  

  1. I don’t know where you work, but we arrive with anyone making that decision and/or recommendation. Your article is divisive at best and indicates the prejudice between being a Paramedic or an EMT that should not exist.

    The people I work with are EQUALS whether or not their patch is red or blue (TX). I just have advanced care capabilities if needed. Most of our care is BLS and my guys/gals have it down pat. I’ll put them up against any of you and your coworkers any day.

    Do not disparage EMT’s, they are our lifeline and ultimately make things happen when the shit hits the fan! This is a poorly written Op/Ed as far as I’m concerned!

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    1. It’s not disparaging to EMT’s to make observations concerning areas where they could improve; it’s condescending to assume that they are incapable of this. Lot of good points in this post, from medical evaluation to cost analysis to patient informed participation and consent. Many of the largest transportation providers have no interest in any education, ethics or skilled evaluation that reduces the number of transports. If you work for an agency that reviews HEMS use for over-triage, and commends medics for ethically processed refusals, count your lucky stars: you’re in the minority.

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    2. My freeken bitch with flying EMS follows: (1) I deal and have dealt with Crew Members who are what I call Pansy waste chicken shits.. (I’ll explain in a bit) (2) I am sick to death of fricken med crew members getting into by business. I am the PIC (hey med crews, remember, Pilot in COMMAND), Its my job to get you to the hospital or scene, NOT your job, I have the final word and remember this. Get your heads out of my ass, I am tired of this crap, I have been flying helicopters for 37 years, I’m old enough to be your father and even grandfather. (3) I deal with crewmembers who look for any excuse to NOT fly at night, Oh I see haze in the tower beacon, did you check the weather? No AHole Thanks for reminding me, let me go see if we have legal weather, Oh, I see halo’s around the lights we better turn around…. REALLY STFU …….. I say look bro we have legal weather and are expected to have it for the next 5 hours….. Then I say to these pansies, look, you know my policy, 3 to go, 1 to say no….. If anyone isn’t comfortable then I will turn around. and if they snibble I tell them fine then I call dispatch and advise them we have weather related issues and I RTB (return to base) then I write a detailed report and the name of the pussy medic who should be canned or placed on an ambulance, That’s why I am retiring on my 67th birthday…. I have had it with these babies and arrogant POS’s….. I think some of you know exactly what I am talking about. I would like to take these douchbags (the pathetic medics) into combat and then scare the crap out of them…… I have almost 30 years in the military flying helicopters….

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  2. We might take you more seriously if you’d leave the profanity out of your article. It’s unnecessary and unprofessional. Just sayin

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  3. I get the point of the article. I agree that as a whole, EMS overutulizes helicopters. Air med services over advertise themselves. Training in the use of helicopters can be less than desired. The problem with your article is that you single out basic EMTs in the title and first few paragraphs as incompetent. How does this help your article? The article would pass in a college course, but in the real world, your opinion stopped mattering at the title.

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    1. The truth is one can make a very strong argument that EMS is incompetent in correct helicopter utilization when 50% of patients flown are discharged within 24 hours with minor injuries.

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  4. # 1 – Class Action suit against Air transportation is now going for “750% profit margins”…..
    # 2 – It’s your card in our area if a patient dies in the back of an ambulance that met Major Trauma / Medical Criteria and you didn’t make the call regardless if you are over protocol time or not or the Air transportation was available or not.
    # 3 EMT – Paramedics are part of a chain of care that has set policy and procedures for the best outcome of the patient, not their wallet.
    #4 According to all protocol guidelines EMT’s are trained to recognize ALS level needs for their patient and request resources as necessary.
    #5 How dare you insult a National and State education system that has set the standards for Field treatment and have no choice in some cases in utilizing BLS Systems which is all that is available in certain areas.
    #6 Until the people are educated enough to assume the financial responsibility and understand the ALS providers should be the standard of care, you will have to deal with the fact, that it is this way, due to none other than the almighty dollar. Which means BLS providers will be around for a long time because they can pay them less or are still willing to volunteer. If you don’t think this is true go ask any commercial agency why they don’t have 100% ALS staffing. You will most likely hear because “we can’t afford it”
    So no matter how you look at it people’s lives are put at stake for a difference of a few dollars per hour. (Simply put) Rather than the spirit of volunteerism that has, by the way, supported this Nation for the last 100 years or so.

    Finally, This concern needs to be redirected to the originators and powers that be that are responsible for creating and administrating the current system we now have. Not the provider who is faithfully executing what he/she has been instructed to do by their superior officers and/or Management all based on the concept of “Best Practices”.

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    1. # 2 – It’s your card in our area if a patient dies in the back of an ambulance that met Major Trauma / Medical Criteria and you didn’t make the call regardless if you are over protocol time or not or the Air transportation was available or not.

      That might possibly be the dumbest thing I’ve ever heard of. Not to mention dangerous.

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      1. “#5 How dare you insult a National and State education system that has set the standards for Field treatment and have no choice in some cases in utilizing BLS Systems which is all that is available in certain areas.”

        How dare you sir….How dare you! You believe that our national EMS educational standards are beyond reproach?

        Look at the data on EMS flight utilization and get back to me. If you are fine with >50% of people being flown by EMS from scenes by helicopters not needing to be flown, I think we need to examine that.

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  5. This also ignores the areas of operation across the country, southern VA or MD for example, where county fire departments staff EMT units, which vastly outnumber often single-provider ALS QRVs. On the size up those EMTs have to decide the distance of their resources – by the time you get an ALS ground unit, could the bird be there? If, by the time the ALS provider begins interventions there is the realization that the patient is already racing the clock and air medical will get them to definitive care faster? That same EMT has to decide whether to load and go by ground accounting for the resources available. Like most things in our field it’s a gray area, but the fact of the matter is, ALS providers are not always the first there, but the outcome of the patient may depend on those who are and who they request in the first few minutes. Should there be more training? Yes. Should there be criteria to activate an air medical response? Absolutely. Should all EMTs be disallowed to request those resources due to their credential? In my opinion, no.

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  6. The whole foundation of your article is that an air ambulance Bill can bankrupt someone. Where I live we have 7 aislyn ambulances within a 20 minute flight. Of those I know the bills for 4 are less than 20k. Maybe do some more extensive research. Their 20k air bill, my 1600 ground Bill, and their 1.2 million Hospital bill. Where do you think the problem truly lies?

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    1. If they need a 1.2 million dollar icu bill they might have needed the helicopter.

      The point of the article is EMS needs to consider the financial consequences of a $40,000 flight and make sure the cost is worth the benefit.

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  7. I am an insurance nurse. I routinely review air ambulance claims for medical necessity, utilizing an established criteria set. If the patients situation does not meet criteria, I send the claim on to the physician reviewer for determination. My point is this: all insurance companies have a mode to access their medical policies online. Pull up a few– say, BCBSA, United Healthcare, Anthem, Aetna — you will find they are strikingly similar and can form the basis for opening a cost-based discussion within your decision making chain of command. It might be worth the time for the folks writing the syllabus to do this as well.

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  8. In NJ, as of recent 1 public helicopter remains, state funded, affordable by healthcare standards. As more for profit helicopters show up, the sky gets crowded with dollar signs. Why does a patient get flown? Not for an inter-facility at 02:00 with no traffic that takes 15 minutes, but for a long extrication of other horrific medical problem. In my experience, the ground EMT does not always have the needed experience or training to make this call. Best done by a Paramedic.

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  9. My feelings are hurt due to profanity of others. Not yesterday not tomorrow right now. Oh where’s my unicorn? I love false sense of environment. Yaaaaaaay.

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  10. The Author admitted the title of the article is click bait. Heck, I bristled initially. Cool off, take a breath and relax. Read it again objectively from a mindset of “What can I glean from this to make me a better practitioner?” Perspective which, by the way, we should take with every industry related article. We are In a dynamic career field. Things are constantly changing and evolving in every level of medicine. EMS is slow to respond to these challenges. The author is not bashing EMTs, but rather calling attention to the neglect of the national standard insufficiently educating and equipping these dedicated individuals. What I hear is “EMTs deserve better!” Our patients deserve better. Good prehospital does not just include the right, diagnosis, the right treatment, the right destination, but also the right mode to definitive care.
    The burden of Unwarranted transportation cost to the post hospital patient is NOT good patient care. That stress, that burden has detrimental health effects. There needs to be better training so that articles like this don’t need to be written. Unfortunately, as many rural hospitals across the nation are closing their doors the burden of transportation decisions prehospital will have to make will ever increase. Subsequently, this situation is going to get worse. I’m an FP-C for a large HEMS company. I see the amazing job so many dedicated EMTs do across the country. Over worked, under paid and underequipped to do the job and make the decisions that the patients and the prehospital practitioners deserve.

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      1. Really – that’s your contribution. The theory of ‘you don’t know what you don’t now’ comes to mind.

        Some day, when your average ground EMS unit has the training, experience, and autonomy to function to the level of your average HEMS unit, your statement may be true.

        Today is not that day.

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  11. Your complaint could just as well be about the cost of any medicine in today’s market. From a 300 percent markup on a minor er visit, to the costs of complex surgeries.
    Ground ambulances aren’t a bargain today either, having bills that try to recover standby and overhead costs.

    Using a tool when no other resources are available, or anti compete rules shut sown resources is not the responsibility of the field provider.

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  12. The “Golden Hour” even with air medical pretty much goes out the window in the area where I’m from; 90 minutes by ground to a Level III Trauma Center and 180 minutes by ground to a Level I Trauma Center. Air medical has a huge impact on these times for trauma patients, very few medical patients are airflighted from our area. The ERs (Level IV Trauma Centers) in our area are staffed by GPs, and the comment of “get ’em out of my ER, I don’t want them dying here” has been heard more than a few times. Comforting words to an EMS ground crew to hear immediately prior to transport.

    Training and more training is a good thing, but even the docs with a LOT more training than EMTs will ever have, don’t always get it right. Unless the docs are Clark Kent, they do not have access to the toys they use in the hospitals to make a diagnosis on scene.

    Air medical in our area has an insurance plan that costs less that a cup of coffee a day ( a lot less if you’re buying Starbucks) which will accept whatever your insurance provider pays for air medical transport, or if you forgot to sign up for Obama Care, will pay the entire bill.

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  13. ” over triage a patient” what is that suppose to mean ? We have protocol for a reason. 1 I have never called out the bird with out contacting medical control first there for its a joint decision between feild personnel and a doctor. 2 if you don’t follow protocol that was set up by a board of doctors that can leave you open to lialibilty. 3 I can only say that follow up is not possible in every case. Out all the patients I flew out I only got to know the out come of one and that is because the family wrote a nice letter thanking me for doing everything I could to save their loved one . Even though the patient had died on the or table I knew I did the right thing.

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    1. Over triage is when you think a patient is sicker than they are, for example when an EMT or Paramedic puts someone with a minor injury on a helicopter.

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      1. True say a drunk driver with a broken leg…life flight was called they crashed…my son the pilot lost his life for a broken leg, when paient was loaded and ready for transport not ambulance 7 miles away….who makes the call for air transfer and Why….what training do they to make this call.

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      2. Hellen,

        I’m sorry about the loss of your son, one of my great friends is a flight medic for REACH out here in CA, we (the EMS community) just lost a LifeFlight fixed wing plane to a crash (patient, pilot, staff all perished). Accidents happen. Parts fail. There is a joke that goes around the Military Medivac community regarding helicopters. “A helicopter is 10,000 parts rotating around an oil leak, waiting for metal fatigue to set in.” Fly Heli’s long enough and you’ll have one fail on you. Hopefully you can autorotate down and everyone’s ok. Sometimes that doesn’t happen.

        Your information regarding the call is lacking. What part of his leg was broken, was it an upper femoral break? Was there internal bleeding? Was there head trauma? Was there airway complication? Would the Helo ride be faster than ambulace (slow twisty roads). There are many factors that are considered BEFORE air is called. Air isn’t called until someone at the scene says “We need air”. You seem to be asking the question “Is a drunk worth my son’s life?” While most of us would snap to the “NO” answer, you have to understand also that the business is inherently dangerous, weather it be EMS, Fire, or Law Enforcement; Injuries, Accidents, and Death happens. It’s a risk that we all know and accept. While it’s “Shitty” that your son was killed in a crash going to the scene of a drunk’s wreck. That’s what he signed up for. I don’t know the circumstances surrounding his crash. Was it an engine failure? Tail rotor failure? Did he clip power lines or a tree? Did a truck crash into the Helo as it was landing? Did they have a birdstrike?

        Again, I’m NOT belittling your loss, only you are allowed to decide how you feel about it. I hope my response doesn’t come across as callous, as even though I did not know him, he was a brother to the community, and his loss hurts us all. But even though he may have been a drunk, we in the EMS community will do everything we can to save that life. Even if it means risking one of our own. It’s what we do.

        In answer to your question about “What training do they have”
        Every Department, Company, Air Service, and Hospital have different guidelines regarding when you call for Air. “Usually,” a trauma center where the patient would be transported is consulted and given a rundown of the patients condition, and a higher level of care (RN, or MD) is the one to make the call. Sometimes in more rural departments they have a set number of criteria to follow, if more than 2 boxes are ticked you must call air, (distance, head trauma, facial trauma, airway/difficulty breathing, cardiac, etc) the only way to know what happened is to contact your sons employer and obtain the incident report and the NTSB report (all air crashes with fatality are investigated by the federal transportation administration). If you really want to know, you can find out. But this won’t be the place you find your answers. Here we are discussing the merits in general of allowing EMT’s vs ALS vs MD consultation, in the decision to call air as there is no “Set Standard.” And that’s the issue is that the conditions are different from district to company to state. There is no Standard so there will always be that question of “Was it needed”

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  14. I like discussions that ponder the extreme, “EMTs should not be allowed to decide on scene flight helicopter use.”

    The other end of the extreme might be, “Every EMT assessed patient gets flown by helicopter. ” That would be a fairly interesting way to run an EMS system .. no ambulances, all scene care based on stabilizing and monitoring patient until the helicopter arrives. Helicopters would be everywhere and flying much more often, perhaps driving the cost down per flight???

    So pondering the extremes seems inane. Then we are left to say, well the need for a helicopter depends on the patient’s condition. Some patients need it (very few) and some patients don’t (almost all). To determine the few likely requires more training and experience than we are currently providing EMS personnel at any level.

    Meanwhile, the more intriguing thought I ponder is the remarkable success of the air medical marketing machine to enlist EMS providers, paid and volunteers, to be their relentless, unpaid advocates. Kickback statutes/regulations likely forbid a referral fee, but it’s a remarkable return on investment when a box of pens, a couple of t-shirts, vital sign notepads, refrigerator magnets, and chip clips can turn into a $40,000 (give or take $20,000) charge to a patient.

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  15. I can say this is put 20 years in as a EMT in Kentucky most of it in rural areas I was trained by lexington ky fire major and we were trained to know when to to call for helicopter and the staff from health net air ambulance and from UK air ambulance gave most services in ky classes on when to call them so maybe were your from emt’s are not trained properly but here in ky I’d put most services up against anyone you got

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  16. The decision to call Air or not should be made by the person with the highest level of training at the scene. Sometimes, the way things work out, all you’ve got is an EMT and your closest Paragod is 25 minutes out still due to staffing, staging. or just bad luck. They have to make a judgement call. Should a 3 month EMT have that responsibility thrust upon them? No. But sometimes it is. Hopefully you have a veteran running the scene and they have the experience to back up the call, the knowledge and understanding needed to make the proper decision. YES, Money is a big deal in air calls. When I was picked up for my 25 minute flight after my motorcycle wreck (burst fracture t5-6-7, 45minute LOC, multiple rib fractures, no motor control below the spinal injury) It was the right call. It ended up being a tick over $20,000, but the closest level 1 trauma center was over an hour and a half away by “bus.” I’m a paraplegic now, but I’ve worked dispatch for EMS in Sacramento. And if a “3 month old” EMT decides to “err” on the side of caution for the benefit of the patient, I will not second guess him. I will call air and pray the right decision was made for the Patient. Because in the end, I will always choose to err on the side of the Patient rather than money. Could they use some extra training? SURE. Go for it. Training shouldn’t just stop once they get their NatReg#. Training should never stop. But if you’re going to make a mistake, I’ll always advocate for making the error in favor of Patient Safety and Care.

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  17. Several years ago I had to investigate a call where ski patrol in a small facility had summoned HEMS and did not even consult local EMS.
    Most HEMS I have worked with encourage being called and are only too happy to work on guidelines and protocols, reducing unnecessary flight use.

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  18. These assholes have too much butthurt. How dare you, you are terrible, blah blah blah. You are correct! In my opinion, if the patient doesn’t meet the criteria and is flown, the project should be responsible for the bill.

    Like

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