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.
I guess I’m in an odd situation. Really the only thing we call HEMS for is a faster ride to a tertiary facility. Anything they can do, chances are I’ve already done for the patient by the time they get there. But in my rural setting, there’s absolutely no point taking them to the community hospital who will just transfer them out by fixed wing an hour later. Plus some of these roads we have will be horrible to take a trauma patient down.
But I fully agree that ground CCT needs to mature and take a better place than where it is. Even if it’s like my service where the 911 is a CCT agency.
A lot of my co-workers around these parts seem to think I hate helicopters. Actually, I don’t, and I think they have their place. I even have lots of HEMS patches, pins, and have had lots of HEMS t-shirts at different times. And I know a lot of the people and they’re pretty darn smart.
In my home area we have a level I trauma center within 40 minutes of anywhere in our county. We have three more level I trauma centers about 30-40 minutes further away. And while the “Golden Hour” is more likely the “Golden Period”, I will agree that a severely injured patient, or a severely ill patient, needs to be at definitive treatment sooner rather than later.
My biggest concern is that over and over, by the time we call for HEMS, they respond to where our ambulance is (or we transport the patient to our local airport where a helicopter is based), they accept the patient and conduct their assessment and prepare the patient, load the patient onto the aircraft, ‘spool up’ and take off (even when we ‘hot load’ a patient while the rotors are still turning), and even taking into consideration their 120-130 mph transport time to one of our local trauma centers, our ground ambulance can (or could have) consistently (and this has been reviewed over and over and over and verified) arrive at the level I trauma center, PCI center, or burn center in about the same time, give or take five minutes. In several years, we have had less than three situations where more than five minutes was saved, but the vast majority of time, it actually took longer to fly the patient than it would have to have just put them in the ambulance and drove. Consistently. Sometimes by 10-25 minutes. Yes, you read that right- 10 to 25. Minutes.
We do have a network of ground based CCT units around here (five or six separate providers), but our system is fortunate to be in close proximity to specialty care centers, so we just go direct except in the rare case of a deteriorating airway or something like that. With the exception of blood products, our personnel can manage a sick patient. And even then, with the extra time it takes for us to get the patient on an aircraft, we really do not see a clinical advantage. For us or our patients.
Granted, not everyone is as progressive as our system is. We don’t thump our chests very often nor do we take out press releases very often, but I will apply the 4077th’s motto, “best care anywhere”, to that provided by our folks.
Until such time as the laws of physics are repealed or we can “beam” patients directly to trauma centers, there will be a need for HEMS in some places and come instances.
The tricky part is trying to figure out when those circumstances exist. Guess wrong and you run the risk of endangering the crew and/or the patient.
All of which makes me glad that I worked in the city to which the HEMS service flew and not one of the ones FROM which they flew.