Whipped Cream Difficulties

From the Austin American Statesman:

Amid concerns that STAR Flight is being underused, Travis County officials have asked Austin-Travis County Emergency Medical Services to review why a ground ambulance was dispatchedinstead of a helicopter to take patients to the hospital in a handful of incidents.

It isn’t clear to me exactly who these “Travis County officials” are. However:

According to emails between county and EMS officials obtained by the American-Statesman, [STAR Flight program manager Casey] Ping aired concerns to EMS medical director Paul Hinchey and other EMS and county officials in February about “multiple cases” in which he said STAR Flight had responded to a call and was overhead when it was canceled. Meanwhile, he said, additional ambulances were requested or it took an ambulance a long time to get to the hospital.

Is there any evidence that these decisions compromised patient care?

Ernie Rodriguez, who heads EMS for the city, said he doesn’t know of any situations in which STAR Flight, which provides air ambulance service for the agency, should have been called but was not.

Let us consider some of the situations in question:

The county has made written requests to the city to review six incidents or issues regarding what resources were used to respond to a call, Ping said.

That’s six out of how many?

STAR Flight has flown patients in the county and the city about 600 times since fiscal 2009, according to county data, with the number of flights dropping slightly over the years. In fiscal 2009, STAR Flight took patients about 170 times. In 2010, there were about 160 such trips, about 130 in 2011 and 120 in 2012.

Let us talk about specific incidents.

One such incident, [Danny] Hobby [“who runs emergency services for the county”] said, was a lightning strike in Bee Cave on April 29 that injured three people. Medics took the three patients, two in critical condition, to University Medical Center Brackenridge, about 30 minutes away not accounting for traffic. He wondered why multiple EMS units stationed in the county were dispatched to respond to the call when STAR Flight could have been used.

This is kind of useless without knowing the actual transport time, as opposed to the 30 minutes without traffic estimate. I’m not an EMS guy; what I know about EMS I’ve picked up from reading AD’s blog and listening to “Confessions of an EMS Newbie“. But I’d be willing to bet that by the time you get STAR Flight dispatched, it gets on scene, you get a safe landing zone cleared, STAR Flight lands, loads up, leaves and gets to the hospital…you’re probably looking at close to 30 minutes, at least.

Again, note that there’s no indication that anyone believes patient care was compromised by the decision to use ground ambulances instead of STAR Flight.

In early February, Ping received an email from a STAR Flight paramedic wondering why it took 45 minutes to get a baby in serious condition to Dell Children’s Medical Center.

Man. Sick babies. That’s terrible. And 45 minutes to get one to a hospital?

Austin-Travis County EMS sent medics to the baby’s home at 5:11 p.m., according to the email, which doesn’t specify a date. When medics arrived, the baby’s condition was a “priority 1 trauma,” the email says. They left the home about 20 minutes after getting there, and 25 minutes later pulled into the hospital, where a trauma team took over.

Oh. So it was actually 25 minutes to get the baby to the hospital, not 45? And it sounds like the first 20 minutes were probably evaluating the baby’s condition and stabilizing it for transport.

(Again, no suggestion that patient care was compromised by taking 25 minutes instead of…well, how long would STAR Flight have taken, under those circumstances?)

Now this is interesting:

Considering rush-hour traffic, the STAR Flight paramedic asked the responding EMS medics why they hadn’t requested the helicopter, according to the email. They said it was because the computer-aided dispatch system EMS uses wouldn’t let them since it calculated the transport time — the time it takes medics to arrive at a scene — at less than 20 minutes.

In asking several EMS officials to review the incident, Ping said he was most concerned by “the perceived comments about what authority ATCEMS personnel have or do not have to make transport decisions. This is not the first time we have been told they aren’t allowed to request STAR Flight.”

This is a place where I’m on Ping’s side, and the side of the paramedics. As you know, Bob, I’m very much in favor of letting the guys in the field make decisions. If their decisions about whether STAR Flight is appropriate are being overridden because of decisions by some automated system, then let’s review that. But:

Jasper Brown, an acting assistant chief for EMS, said that the system recommends STAR Flight respond to calls flagged as having the highest and second-highest priorities if the closest ambulance is more than 20 minutes away from the scene of the call. But once medics arrive at the scene, they can request STAR Flight regardless of the call priority, Brown said, a decision that’s based on the patient’s medical condition, among other factors.

And, hey, who doesn’t love a cool helicopter ride? Buried in the final few paragraphs of the Statesman article is one good reason why paramedics may not want to call out STAR Flight:

A STAR Flight trip costs $3,400 plus $85 per loaded mile for Travis County residents and $7,500 plus $85 per loaded mile for people who don’t live in the county, Ping said. Insurance could cover those costs, he said, or patients can set up a payment plan, with some paying $20 per month.

Can I point out that you can get a decent used car for $7,500? Can I also point out that if I do some rough calculations based on someone I know who lives outside the county being STAR Flighted to UMC Brackenridge, I come up with a rough estimate of $8,945 for the trip? (I’m figuring about 17 miles by helicopter at $85/loaded mile.) At $20/month, they’d have that bill paid off in 447.25 months, or 37.27 years.

So that’s reason one why EMS may not want to use STAR Flight if patient care isn’t compromised; because it is freaking expensive.

Reason number two: helicopters are dangerous compared to ground transport. Kelly Grayson has been sounding alarms about the overuse of helicopters since I first started reading his blog, and that was a long darn time ago. Quoth the man himself:

I believe helicopter EMS is useful. I believe it saves lives. I also believe that it is vastly overused, inherently dangerous, and that the overhwelming majority of the people we fly don’t need a helicopter. I believe that a significant chunk of them don’t even need a trauma center. And I believe that we owe it to the HEMS crewmembers who make those flights, not to endanger them needlessly by sending them out for silly shit.

Going back to that lightning strike in Bee Cave, I don’t remember what the weather was like that day, but I suspect it was pretty sorry if people were getting stuck by lightning. Doesn’t do a whole lot of good to transport people by helicopter to get a better outcome if your outcome is that the helicopter is forced down by weather and everyone onboard dies.

That happens. More often than you might think.

So are “Travis County officials” worried that patient care is being compromised by paramedics avoiding STAR Flight? Or are they more worried that STAR Flight is not being used enough to justify the cost of maintaining it, for what may be very good reasons? You make the call.