Thursday, September 30, 2010

Art imitates life in the not-so-hilarious-world of EMS helicopters

So when my son walks into my office and sees me in front of my computer watching an animated short film, I can’t expect him to believe me when I say, "Really honey, mommy's working."
Animated stories of the FREEWAY PATROL
In fact, I was working, watching this You Tube video sent to me by a gentleman in Texas who found himself in practically this same situation, the latest victim of an epidemic of overuse of medical helicopters.  

In the video, a young driver is hit from behind and when she gets out of her car there descends upon her a virtual army of first responders insisting she’s seriously injured and in need of medical attention. No amount of eye rolling or shoulder shrugging can change their minds, and so whiplash collar firmly around her neck, and safely secured to a stretcher, the driver is airlifted from the highway to the hospital -- across the street from the accident site. 

“What’s this going to cost me?” she asks the ambulance attendant. 
“Let me ask you this” he answers, “wouldn't you say your life is worth a mere $17,000?” 

As the credits roll, I’m not laughing and my son, Joseph, asks why not.  “Because it too true,” I tell him, right down to the budget-breaking price tag. 

I’m sometimes told that questioning the use of EMS helicopters is on par with encouraging people to play Russian roulette.  “Wouldn't you say your life is worth a mere $17,000?” 

But who, faced with an expensive medical procedure they will pay for from their own pocket, doesn’t want to know “How much will it cost?” and “Do I really need it?” 

There are too many instances where medical helicopters are called for people who are not critically injured or do not have time-sensitive medical need. (Read my previous posts on this here  and here.) They will be shocked when the bill arrives. If you’ve got a few minutes, I urge you to watch this excellent investigative report by Amy Davis of KPRC in Houston exposing the unethical arrangement between EMS provider PHI and a Houston-area fire house.

According to her report, PHI made a deal with a local emergency service provider in 2008 in which PHI would build a helipad and crew lounge, provide a helicopter, pilots, a mechanic and pay $77,000 per month to the Harris County rescue district. In exchange, PHI would have the exclusive right to carry patients and bill for its services. 

Davis interviews Jason Boatswain - one of the patients transported by the PHI helicopter under the new agreement. Like a character out of a YouTube video, Boatswain, injured in an auto accident, was loaded into a helicopter for the hospital, even though he was not seriously injured. The bill he received for his short ride by air was $12,400. A ground ambulance would have cost less than $700. 

The year prior to the partnership between PHI and the county, the rescue unit moved 12 people by air, according to Davis’ report. With the PHI contract in effect, it moved 106.

I wouldn’t be rehashing a scandal from 2009, if I hadn’t heard of two eerily similar stories, one just a few months ago, also in Texas, about which more later.

The Association of Air Medical Services will hold its 2010 Air Medical Transport Conference in Ft. Lauderdale in a few weeks. Between viewing the product displays, whooping it up at the MASH BASH banquet and enjoying the MedEvac Foundation Charity Golf Classic, let’s hope attendees spend some time trying to figure out how to rein in an industry eager to know “Recovery Marketing after an Air Medical Accident” (Tuesday session 9:45) and intent on “increasing flight volume” (Monday session 11:00) whether patients need those flights or not.


Anonymous said...

I am a Board Certified, practicing Emergency Physician and have served as a flight physician, sending physician, receiving physician, EMS quality assurance director and have been the lowly emergency medical technician faced with making life and death decisions in time compressed and adverse circumstances. Its great to Monday morning quarterback appropriate utilization of HEMS but your reality is so skewed an misinformed that its hardly worth commenting on. It comes down to sensitivity and specificity. A highly sensitive system for identifying who may have a significant problem requiring a helicopter will never be specific enough to eliminate overuse. If it were you, Christine, that crashed with your son on a dark Texas road and had a EMT with 100 hours of first aid training, faced with bloody faces, hysterical mothers, well meaning but distracting bystanders, and a life or death decision that you make once every 5 years...what would you do? As a victim what would you want? Where would you want to be taken? The ability to say ground would be cheaper, faster, available, is best known by the person calling. Municipalities are more cost effective when AIr Medical Transport is if the helicopter got used more frequently after it became available...there are a myriad of reasons you haven't considered. Appropriate training, a change in destination policy so that the only local ambulance resources could remain local and not be taken out of service for hours on a rare but significant transport, or simply no availability of ground ambulance.

Its not all about the money, its about the people, but like every part of healthcare and every business in the US. We have a need to be profitable and profitability means playing by the rules of reimbursement. It may seem like a lot but compared to the alternative its cheap and 60 % are not paying or underpaying and we have no ability to screen based on ability to pay. We didn't create the payment system that encourages transport as the only way to get paid..we just have adapted to it keep the mission alive. I was the Medical Director of Life Flight San Diego..a program who died a financial death and vacated a community.

Your comment about the AMTC and specifically the MedEvac Foundation International is OFFENSIVE. The Foundation has promoted research, safety, scholarship and giving back to those who have lost there lives in this noble profession. We raise money from our community to support our community the and Golf tournament is but one way we do this.

I hope that you (or your son) are not the 1 out 1000 US citizens who get transported every year. I pray that you are not under-triaged to a ground unit and suffer increased morbidity and mortality. Rest assured if you are flown you will be given the best care and the best opportunity to get back to your computer to write another stupid article about an industry of dedicated professionals who cares about people and to do the mission must be profitable. No margin no mission...even the so called not for profit hospitals understand this.

Thanks for considering the big picture

Kevin Hutton, MD
Chair, MedEvac Foundation International

Christine Negroni said...

"If it were you, Christine, that crashed with your son on a dark Texas road ... bloody faces, hysterical mothers, ... life or death ...what would you do?"

Dr. Hutton, this is precisely the kind of emotional argument that skews the debate. These decisions are tough, no doubt.

But let me ask you this. If providing the best care was the honest-to-goodness operating philosophy because "gosh darn it, were saving lives here" then please explain why industry decision makers (in the unemotional atmosphere of their corporate boardrooms) have consistently dialed-down safety by replacing twin engine aircraft with singles eliminating the possibility of operating with two pilots or IFR equipment? Why are so few of these aircraft fitted with terrain avoidance and wire detection systems?

Dr. Hutton, this HEMS business model, fly as much as possible spend as little as possible is not safe and it is not working. The HEMS safety record is abysmal.

Before you dismiss my knowledge on this subject, please read the paper I presented to the 2009 annual meeting of the International Society of Air Safety Investigators which was then published in its respected publication, Forum, which you can find here.

I have the utmost respect for pilots and aviation medical professionals. You deserve better.

OV said...

I would like to applaud Christine for posting this blog issue. She does not deserve the abuse she gets from some of her readers.

My family happened to experience a situation very much like the one described in the satirical video of EMS and air ambulances. In fact, I forwarded the video to her because it represents my situation extremely well. Even down to the $17,000 bill.

The only reason EMS chose to send my daughter by air ambulance is because they feared something unknown may still be wrong with my daughter. She was stable and fully awake and with NO obvious trauma. Using this type of EMS protocol, I would assume that every patient needs to be sent by an air ambulance.... since something unknown "could be wrong". A friend of mine who worked as a paramedic, said that in his day an air ambulance was only used if a patient could not be stabilized. That makes sense to me.

The ironic thing in my situation is that it took much more time for my daughter to get to the emergency room via helicopter then if EMS just drove her to the hospital (EMS spent a lot of time sitting around waiting for the helicopter to show up). If you considered there were major hospitals even closer than the one with a helipad, the transport time issue is even more ridiculous.

It gets even worse. When you look at the EMS documentation, its has major errors. Every time I talk to the EMS people they have a different explanation. The last one was that it was a simple computer error. Errors that no one with EMS seemed to previously notice. I have had three separate trauma professionals who work with air ambulances look at the EMS paperwork and all three voiced serious questions about why air transport was used.

I have spent almost three months trying to get Air Evac Lifeteam to review the case using any impartial authority. Instead I get the typical propaganda type comments like "hindsight is easy" or "monday morning quarter backing" or "isn't your daughter's health worth the cost".

My wife in particular was quite upset with the entire air transport issue because of the inherent risk. I brought this issue up to Air Evac and their employee crowed about their safety record. Its ironic because the next day on Aug. 31, 2010, Air Evac had a helicopter crash in Arkansas. Everyone on board died.

Until air ambulances and EMS actively and critically look at every air transport and the need for it, this is a business ripe for abuse. Right now my family happens to be the one getting abused.

Dr. Hutton, as the Chair of MedEvac Foundation International, you may be able to influence protocols being used in the air ambulance industry. I hope you work towards that end. Air transport "victims" need to at least have some avenue where they can have an unbiased authority review questionable use of air transport.

Anonymous said...

"No margin, no mission" Look at a map of the US HEMS coverage.

There are areas in KY,TN,PA,OH,MO that have an incredible numbers of helicopters -not out of medical need but due to making $$. There are other states that are grossly underserved ( obviously not profitable due to climate -cant make money in predominatly IFR weather)

20-25% of the 950 EMS helicopters in the US could just go away with little if any effect on patient outcome

Christine Negroni said...

Good point. Thank you for making it.

Anonymous said...


Hindsight is always 20/20. Fortunately, there apparently was nothing wrong with your daughter. Don't get me wrong, I am not condoning calling for a helicopter based solely on mechanism of injury as was so poorly portrayed in the video. I do however wonder what would have happened if the helicopter showed up and the crew decided that your daughter didn't warrant air transport or what if ground EMS had decided to transport by ambulance and your daughter had an occult injury and deteriorated. I wonder then if you would be corresponding with Ms. Negroni or instead with a lawyer seeking restitution for the poor decisions that were made by the air ambulance or ground EMS providers. In this litigious society, this is a damned if you do, damned if you don't situation and no where do I see anyone trying to tackle that aspect of this problem. Very few air medical operators continue to market their operations based solely upon mechanism of injury but once they show up, it becomes cheaper for them to maybe eat the cost of the inappropriate flight versus the risk of litigation by not transporting the victim.

Anonymous said...

Ms. Negroni,

Your generalizations about the air medical industry is highly prejudicial and shameful. The issues and economics are far more complex than the picture you paint. Are all air medical operators of the same poor caliber and have the same disregard for safety? AMTC is all about golf and parties and lectures on recovering customers after a crash and how to get more flights? I guess you missed the rest of the agenda which includes workshops on Threat and Error Management, Just Culture, Safety Management Systems and the multitude of educational courses aimed at improving the quality and safety of patient and flight crew safety and medical care. Should I generalize and say that all female aviation bloggers are inept? No, that would be inflammatory and demeaning to you and your colleagues as a whole. Not to mention highly inaccurate. When you post such future blogs about air medical transport, I would suggest you consider the bigger picture rather than low road journalistic sniping.

Anonymous said...

"I do however wonder what would have happened if the helicopter showed up and the crew decided that your daughter didn't warrant air transport or what if ground EMS had decided to transport by ambulance and your daughter had an occult injury and deteriorated"

Thats great!! Lets fly every MVA pt with minor injuries because they may have an "occult injury"

There has to be some basic level and skills for the folk who make these $17,000 desicions.

Anonymous said...

"Thats great!! Lets fly every MVA pt with minor injuries because they may have an "occult injury"

Wow...totally missing the point. No we shouldn't fly every minor MVA patient with a possible occult injury and we also shouldn't be held accountable for those very few that do have an occult injury and weren't flown!...that is the point. There is currently a very real liability given the current tort system in the U.S.

Anonymous said...

OV said...

I was the one who reposted the two anonymous comments shown for Oct. 6. Apparently the original comments from anonymous were sent to my email but NOT posted on the blog…maybe a software bug.
Dear Anonymous,

You would not believe how often I hear the "hindsight is 20/20" comment. All the more reason to just look at the facts! If we get into discussing "what if your daughter had a more serious occult injury" then we also have to discuss "what if the helicopter had crashed".

Can you tell when is it acceptable for EMS and air ambulances to be held accountable for bad decisions? Is there ever a situation where EMS can make bad decisions? What recourse does the customer (the patient) have for dealing with issues like this? Litigation? I think, just like you, I would prefer to not use that approach and I have made that statement to all parties.

I have tried to discuss my situation with EMS and Air Evac, hoping we could come to a resolution. They have been unwilling to discuss in an honest and fair manner but instead try to make me feel like I should feel privileged for the $17,000 service they provided. They also like to use the “hindsight is 20/20” cliché.

The documentation I have from EMS and Air Evac, is very clear in showing that the need for air transport was questionable (unless all 911 calls require air transport). Three different trauma experts who work in the air ambulances industry have reviewed the facts (as shown by EMS and Air Evac documentation) and all three have encouraged me to dispute the charges from Air Evac. Just the fact that these experts were willing to speak with me gives me hope that the industry will eventually improve its business practices.

So, should a for-profit, private, business, be accountable for making poor decisions? Should they be regulated in some manner? I think they should! Especially if they are doing a poor job of regulating themselves! I would hope you agree?

I have thought about this a lot in the past several months. It is ironic and disheartening to know that I have more protection from a tow truck company inappropriately towing my car then I have from an air ambulance company inappropriately transporting my daughter.

Individuals who have experienced situations like I mine, need to speak up. However, fighting an injustice like the one I have experienced takes an enormous amount of time and effort. More than you would ever imagine!

OV said...
This comment has been removed by the author.
Anonymous said...

Twin engine helicopters will do nothing for safety, most HEMS accidents are NOT due to engine failures. IFR equipment on HEMS helicopters. Ms. Negroni, I understand you used to be a pilot or flight engineer or someone that took up space in a cockpit. How would you recommend we go about shooting an Instrument approach to the middle of the woods? Or how about all those hospital pads with ILS? Mentioned before, mentioned again, your opinions are nothing more than to spread fear and propaganda. Your opinions are extremely biased and poorly researched. Because of your status as a "journalist" you should put more insight into what you say. Your words very well may end someones life one day.

helicopter flying lessons said...

That was a nice post..You have a point but we should not totally blamed them. To be fair with the authorities involved..EMS helicopters are mainly for medical purposes..

Anonymous said...

For the woman that is complaining about the HEMS operator that took her daughter. The paramedics on the ground were probably privied to information that you are not willing to share on this post. Her daughter was probably thrown from the back seat into the windshield due to the fact that she was not wearing her seatbelt. Although, and thankfully, her daughter was alright from such a violent impact; ground EMS made the prudent decision to fly the young girl. As head injuries can take time to manifest themselves, when they do, it is usually a rapid onset and progression into death or serious irreversible brain damage. Although that story is clearly an account made off the top of my head, there may be some amount of truth to it. EMS will not do these things unless there is a reasonable justification to believe that there may be a more serious condition that can suddenly pop up. On a serious note, what if your daughter had a bleed in her cranial cavity? What if the helicopter did crash? To answer that question, the helicopter had less of a chance of crashing than your daughter did of a serious injury that had not shown symptoms yet. Do not let Ms. Negroni's attempt to instill fear in you close off the fact that HEMS is safer than any form of ground transportation, including ambulance. Your daughter would have been subject to a greater risk of death due to a ground ambulance crash.

Christine Negroni said...
This comment has been removed by the author.
Christine Negroni said...

Listen, I am not going to allow this comment about how much safer helicopters are to ground ambulances to go unchallenged anymore. The relative safety of air to ground IS NOT KNOWN.

No statistics are kept on the total number of transports by either mode, and when it comes to ground, there is no record kept of the total number of accidents.

Without this data it is impossible to know the accident rate per xx of either kind of medical transport, so please don't keep regurgitating this "factoid" that helicopters are safer than ground ambulances because you can not know it to be true.

Randolph Mains said...

Christine. You're right on all counts. When I read through your blogs and articles detailing the appalling safety record in helicopter EMS in America and then see how irate most of the respondents are to your views, I cannot fathom how they can defend the indefensible. They just don’t get it. As a former HEMS pilot and the first recipient of the Golden Hour Award recognizing me for my contribution to furthering helicopter EMS, who, for 25-years, has been trying to convey the same message you are trying to get “out there” when I wrote my book The Golden Hour in response to the senseless carnage I witnessed back then, I applaud your efforts to try to bring about change. There are too few of us in number who are desperate to stop the senseless loss of life. It is all about greed pure and simple and anyone who thinks otherwise is just plain wrong. Over the years I have noticed with much sadness that there are no new helicopter EMS accidents, just the same ones occurring over and over again. I have witnessed the same tired rhetoric being bantered back and forth for a quarter of a century and still the blood of HEMS crews continues to flow at an alarming rate. There seems to be a willingness to sacrifice lives because of an unwillingness to address the real safety issues because it will cost money to do so. That lack of commitment, in my mind anyway, isn’t just wrong, it’s immoral. As you know and I know, the system is broken. To fix it will need the commitment by all the decision-makers or, barring that, it will take such a strong outcry from a general public who will not tolerate the bloodshed any longer that they bring pressure on their representatives in government to do something. There is a fix to our broken system and the wheel wouldn’t have to be reinvented to fix it. All one has to do to find the answer is to look north over the border to Canada or to Europe or to England or Germany or Switzerland for the answers. It really is as simple as that. Why is it they have such a sterling safety record and America does not? If you ever need someone to stand with you in your corner, Christine, I will be glad to stand by your side. Keep up the good work. Don’t become discouraged. Perhaps, one day, you and I will see a system free of greed and an industry that doesn’t resemble a war zone with the senseless loss of life that comes with it. Randolph Mains

Anonymous said...

Ms. Negroni, they do have statistics on both accidents and transports of HEMS and ground actually. You slipped up in another post elsewhere in your blog and showed how you search for things. You don't actually search for the story, you search for what supports you view. If you look a little harder you will find the stats that you don't want to see apparently.