It’s 3 am on a dark winding stretch of road a father, husband, son is driving home from work to rejoin his family after a long nightshift. His eyes begin to tire as his trunk slowly drifts off the road. The tones drop as you rub your eyes wishing for just a few more hours of sleep. But as you listen to the radio you begin your scene size up, one driver off the road way possible entrapment. So do you call for help now or wait?
As most things go in EMS we see a cyclical pattern in helicopter air ambulance services (HEMS) and scene call volume. In the late 1980’s into the 1990’s we saw the inception of wide spread helicopter usage to decrease time and provide patients with an opportunity to arrive at a trauma center within the golden hour. Now after several decades of accidents and deaths within the HEMS industry, wide spread education and regulation has in many areas restricted the likelihood of aeromedical usage. Coupled with an ever-increasing amount of lower level 3 and 4 “trauma” centers appearing, providers have continued to utilize HEMS less frequently with the idea that the golden hour stops when they arrive at a trauma center. But if that level 4 isn’t capable or willing to conduct the surgery, what have we done? We have actually slowed definitive care of the patient and blown the golden hour.
From an aviation stand point increased FAA scrutiny and regulation continues to make HEMS safer. More programs are conforming to the common safety standards found in the Commission on Accreditation of Medical Transport Systems (CAMTS). These have led to a decrease in accidents as well and an overall more reliable and safe system. Also, within this time we have seen tremendous growth in the scope of care that is capable of being provided by HEMS crews. Gone are the days of just flying fast with a cool suite. It is now the standard of care to be able to provide rapid sequence intubation, TXA, Blood administration, and antibiotics. Many HEMS agencies are even able to carry I-stats, ultrasounds, or perform chest tube insertions.
With this improved safety culture and ever-expanding scope of practice you have ask yourself why wouldn’t I fly my sickest patients to the most appropriate hospital. Ask yourself what can a level 4 trauma center provide that a HEMS crew can’t? A level 4 can provide imaging. But at what cost? For instance, if a patient has no airway and is actively bleeding does it help to take 15 min and drive to a level 4 trauma center that may or may not be able to rapidly treat this patient. In other words is it going to take 15 staff members and 20 min to get that patient intubated? How much blood do they carry for rapid release, 4 units, 8 units? OR I can call HEMS, they arrive pull the drugs out of their bag and intubate the patient within 5 min? Hang blood and then move the patient to a level 1 trauma center for definitive care all within 25 min. So here lies the dilemma will the level 4 provide surgical services immediately to the patient or will they spend hours trying to “stabilize” and do imaging then eventually transfer the patient by HEMS to a level 1 for actual surgery and ICU level care.
This all boils down to knowing your local capabilities and paying attention when you are conducting your interfacility transfers. Do they always transfer their surgical patients, can’t complete an appendectomy, transferring all of their intubated patients within 24 hours? If you bring in a STEMI do you notice the HEMS crew landing an hour later to move the patient? Strong providers being good patient advocates will have a positive outcome for many critically injured and sick patients by simply recognizing that most community hospitals do not have the ability to provide the care that is needed for our sickest patients, expeditiously moving these patients with capabilities that are already very similar to community hospitals to definitive care can be the difference between life and death.
Back to our 3am MVA with entrapment. Your patient is a 42-year-old male who is responsive to painful stimuli, has an intact gag reflex, ventilates with assistance and requires oxygen to maintain an SPO2 WNL. He is hypotensive at 70/30 (map= 43) with a ridged abdomen and concerns for internal bleeding. There are no obvious fractures or external injuries. You are 45 min away from a level one by ground, 15 min from a level 4 or have a 15 min eta for the helicopter which would you choose? This is an answer I can’t tell you directly what to do. But I can offer this thought what is your local community hospital/Level 4 going to provide the patient, an airway, blood products, TXA, imaging, and then more than likely a flight to definitive care. So why not cut out the middle men and send the patient where they are going to wind up anyway. Below I list out some of the standing orders than many HEMS programs use for giving blood, TXA, and STEMI’s.