Monday morning thoughts

Just a couple of random thoughts to get your Monday morning started.

 

1) In EMS, we’re constantly making noise about going beyond blindly parroting and following protocols, but we continually apply the cookie cutter mindset to any legal issue in EMS. For example, if you don’t do exactly this, you’ll be guilty of abandonment, battery, or some other tort that the average EMS provider remains incapable of understanding, but is an expert because they sat through the PowerPoint slides on medical-legal issues.

2) Nursing (and other health care professions) have made a great deal of noise over the years about not taking abuse from physicians.  Rightfully so.   I’d like to remind nurses that respect is a two way street.  Especially the ED charge nurse who sarcastically asks, “Why’d you bring the patient here?”  That is an excellent question.  I will be sure to recommend the competing hospital network’s facilities, especially since my family uses said network, primarily because of the quality of the nursing staff.

3) Part of the reason, in my opinion, that private EMS gets a bad rap is because so many of the management types there give you the same feeling that you get from the finance guy at the car dealer who tries to convince you that without the rust guard and the extended warranty that you’re placing your family at risk.   Long term success and short term profits aren’t always the same things.  Successful businesses recognize that.

Some reasoned justifications in favor of jet fuel and flight suits

In the EMS world, it’s become almost fashionable to question the need for helicopter-based EMS (HEMS).   I personally believe that HEMS has been overutilized on occasion, probably even by me.  (I have a lovely snark-gram from the QA gremlin about that, in fact.)

Having said all of this, I think there are some reasoned, nuanced justifications for HEMS.  Allow me to share a bit, if you will.

1) The “Golden Hour” may not be evidence-based medicine, but there’s definitely a few cases where interventions are time-sensitive.  We can all agree that a multi-system trauma patient or a head injury is best treated in the operating suite, preferably sooner rather than later.  Likewise, there’s a specific window of time for thrombolytic therapy for stroke.  And we definitely know that reperfusion times matter for myocardial infarction.   HEMS adds a speed factor in these cases.

2) Most areas don’t have ground-based critical care transport program.  As such HEMS becomes our default CCT option.  Multiple drips and vent settings on the acutely ill patient, whether encountered on a 911 call or in a transfer to a higher level of care, require critical care transport.  In the vast majority of the country, flight medicine is the default critical care provider. If we want to cut down on HEMS utilization, we’re going to have to provide a ground-based CCT alternative. (And a 40 hour class intended to comply with Medicare regulations governing billing for “specialty care transport” just isn’t going to suffice.)

3) Especially in lower volume EMS systems, HEMS providers are a welcome supplement on critical and special needs populations.  As much as I try to enhance my knowledge and skills, I don’t always get to see enough truly “sick” patients or enough pediatric patients to have the comfort level that I’d like to have.  For providers in less populated areas, the ability to refer the sickest and/or rarest populations of patients to providers with (potentially) more experience and more comfort is not necessarily a bad thing.

4) In some EMS systems, HEMS does bring additional medical interventions and resources to bear.  Blood products and ventilators do provide a benefit in some cases.  In many cases, HEMS operations may have an expanded drug formulary as well.  Some HEMS providers are also using ultrasound and video-assisted intubation. Granted, the cases where a drug or a particular intervention may be truly life-saving and needed “RIGHT NOW” are few and far between, but knowing that the option is there is helpful, again for the sickest of the sick.

HEMS has a poor safety record in many instances. Some HEMS operators engage in questionable marketing practices aimed at both ground providers and the general public.  But until ground EMS steps up its clinical game and offers true critical care medicine, both in terms of provider knowledge and expertise as well as protocols, HEMS will be a needed, if occasionally overutilized, resource in the majority of the USA that’s more than thirty minutes away from truly comprehensive care.

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