How Air Ambulances don't work

Wow... very interesting to say the least...
 
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The market force bit 13 minutes in is poignant to the conversation when discussing high medical costs..
 
This is a well known issue in the medical field. I’ve testified in court and written letters on behalf of some of my patients who were transported by air ambulance for dubious indications, and were unable to pay their bill. My most recent case involved an 80 mile flight for which the patient, who did not have an acute life threatening injury, was charged $55,000.
 
My brother who recently passed from a stroke caused by out of whack blood thinners was transported between hospitals and the bill was over 50K. The 2 weeks in ICU surgery and such was over $250,000.

I am a volunteer fire fighter and our area is serviced by both not for profit and for profit. We generally call the not for profit (they have a bigger copter). I don't know what their prices are. I have heard the for profit guys say feel free to call us for anything even if it isn't a big emergency or if you are short an ambulance. :rolleyes:
 
Well, the images shown for the "Sprawling university of Maryland Medical center" is not only not what's shown, nobody in their right mind would call the UofM medical school/hospital sprawling.
What they're showing is the main College Park campus. The UMAB (the medical school, the hospital, and R Adams Cowley's ShockTrauma center... officially called the Maryland Institute for Emergency Medicine) is a compact set of buildings in downtown Baltimore.

In the 1980's I was a paramedic in Baltimore County, MD. I was responsible for calling ShockTrauma and ordering up helicopters when things were necessary. Later I moved from one of the finest EMS systems in the country to NJ which was not only in the dark ages, but politics were forcing it to stay that way. Fortunately, I'm pretty impressed with the system down here in my county in NC other than the distances involved are pretty long.

The problem with they point made here is they MISSTATE the golden hour. The golden hour is NOT just the time to transport the patient to the hospital. It is the time to get certain necessary (usually surgical) interventions started. If you fly the guy in five minutes to a hospital that is not a full-up trauma center, you're no better off than if you drove him there in an ambulance. THIS WAS THE BATTLE COWLEY WAS REALLY FIGHTING. It was relatively easy to get the State Police to go in on helicopters with him. THe bottle was the fiefdom of the local hospitals that mandated all patients go to the nearest hospital and then only after they realized (or not) they couldn't handle the patient tried getting to a specialty center.

Now in Maryland there's a multifaceted decision as to where to send a patient. Multisystem traumas go to ShockTrauma (or one of its satellites). Simpler trauma to a hospital with trauma capability. Burns, pediatrics, ophthalmic, etc... all have their own specialty destinations built into the system. If time and distance is a problem, a helicopter is used. There's still time (IFR) that you can't get one. I've been both the driver and the guy in back on some pretty high speed transports when I couldn't get a chopper.

Coordinating this is a comm center located up in the top of a centrally located hospital that manages a bunch of radio and telephone links. It allows the guys in the field, the state police medevac, and doctors in the various ERs to be in instant communication.

It doesn't do any good to add just one facet (air transport) unless you have everything else to back it up.
 
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Some his explanations on how the trauma system works are in my experience incorrect. I do agree with the general point on how screwed up this entire HAA system is at this time. As much as I hate regulation, given that the 'customer' in this case has no real say in how his money is being spent, this IS an area that requires some rulesetting.
I have worked in two environments:
- Level I trauma with based hospital operated HAA
- Level IV community hospital with IHT provided by the referral centers
and
- Level III trauma with scene flights provided by the state police and IHT provided by the referral centers

Both have their warts, but neither has the problems of the free-for-all for profit system. If our clinicians decide to fly a patient to a referral center, that decision is based on the medical needs of the patient, not any kind of financial consideration related to the HAA provider. Most of the fly-outs from my current level III facility are medical for things like stroke intervention. On the trauma side, patients may get referred out for complex facial injuries and spine trauma that exceeds what our community spine-surgeons are willing to tackle. There is definitely stuff where you want to be at a facility where the director of the SICU is a trauma surgeon and where you have ortho surgeons with specialty training in trauma. That benefit may not be reflected in raw mortality numbers, it matters for issues like length of stay and long term disability.

There should be some repercussions for non-indicated inter-hospital transfers, particularly if those happen within the same health system. The racket my wife works for is kind of known for this. Patients that could be transported either by ground ambulance or personal vehicle at times get flown, more for the convenience of the sending facility. I would be a-ok with a rule that says that if after a review it is found that a transfer doesn't fulfill HAA criteria, the hospital system has to eat the bill.
 
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Never been impressed by the Wendover videos. The couple that I've seen where I know something about the topic are poorly researched with lots of flash and no substance. It's all about getting the clicks.
 
donjohnston said:
Never been impressed by the Wendover videos. The couple that I've seen where I know something about the topic are poorly researched with lots of flash and no substance. It's all about getting the clicks.
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Lots of stock footage (as previously noted often irrelevant or even incorrect) with no real point (loved the shot of Venice at the end where he's carping about the guys "quality of life" gone because the of the medical costs). Dead is pretty bad quality of life.

In a lot of places even ground transport is going to cost you dearly. A lot of local governments have learned they can shift the costs of EMS from the taxpayers to the insurance companies (of course, modulo some additional profit drifting goes right back to the taxpayer's backs).
 
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donjohnston said:
Never been impressed by the Wendover videos. The couple that I've seen where I know something about the topic are poorly researched with lots of flash and no substance. It's all about getting the clicks.
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This video was a little light on specifics, but I think the general concept is on point. One of the take home messages is that private equity firms and hedge funds have penetrated health care and are driving up costs substantially for the benefit of very wealthy individuals at the expense of community health.
 
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Those things used to be insanely dangerous. Lots and lots of crashes. I think most of it was long duty cycles for the pilots. I bet they're still dangerous. VFR flight really doesn't mix well with medical emergencies. If you have to do it to save the patient Ma Nature may not cooperate.
 
steingar said:
Those things used to be insanely dangerous. Lots and lots of crashes. I think most of it was long duty cycles for the pilots. I bet they're still dangerous. VFR flight really doesn't mix well with medical emergencies. If you have to do it to save the patient Ma Nature may not cooperate.
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At one point, air ambulance crews had the highest on the job fatality rate of any job in the US.
 
The state police helicopters mentioned in the initial part of the video hand some real problems. Being "public" aircraft they were not subject to some of the FAA oversight and there were some serious maintenance corners cut. Indeed in the early days, they weren't IFR. There isn't an overall point because landing in the field IFR isn't going to happen without an approach, so even IFR you're going to have to break out and scud run in most places. We lost a unit (and the two police officers, pilot and ATT) when they tried to return from ShockaRama to their base in foggy conditions. My lieutenant found them in (fortunate for those on the ground) isolated park area in the city.
 
The principal I never felt comfortable with is how a first responder bumblef*** can make the determination if a helicopter is “necessary” for a trauma patient. My work-partner and I have turned away the whirlybirds in the past and determined that the 20-min ride to the level 1 trauma center would be just fine.
How the outrageous billing practice has been allowed to go out of control is bizarre. Past Congressmen haven’t cared and I surely don’t see the new DC kabuki theatre show moving on this either.
I later moved to a rural area and actually paid Air Methods/Guardian Flight the $85/yr membership for coverage. Seemed worth it as I was driving 35,000 miles a year, engaged in outdoor sports, and other high risk activities.
 
YooperMooney said:
The principal I never felt comfortable with is how a first responder bumblef*** can make the determination if a helicopter is “necessary” for a trauma patient. My work-partner and I have turned away the whirlybirds in the past and determined that the 20-min ride to the level 1 trauma center would be just fine.
How the outrageous billing practice has been allowed to go out of control is bizarre. Past Congressmen haven’t cared and I surely don’t see the new DC kabuki theatre show moving on this either.
I later moved to a rural area and actually paid Air Methods/Guardian Flight the $85/yr membership for coverage. Seemed worth it as I was driving 35,000 miles a year, engaged in outdoor sports, and other high risk activities.
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Congress is moving on this.
https://verticalmag.com/features/surprise-medical-bills-ban-could-reshape-air-ambulance-industry/

Air Methods canceled their flight membership program a couple years back. They now claim their new “patient advocacy program” amounts to just over $200 in out of pocket costs to the patient.
 
donjohnston said:
Never been impressed by the Wendover videos. The couple that I've seen where I know something about the topic are poorly researched with lots of flash and no substance. It's all about getting the clicks.
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Agreed. It's a 23 yr old that uses the google machine and puts a video together meant to be somewhat controversial.
 
Cervieres said:
One of the take home messages is that private equity firms and hedge funds have penetrated health care and are driving up costs substantially for the benefit of very wealthy individuals at the expense of community health.
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Agree 100%. Back in the day when all helicopter programs were hospital based (owned/paid for) the system worked and did what it was intended to do. When the market shifted to community based helicopter programs everyone jumped in and it went to chit operationally, financially, and destroyed the initial purpose of it. But so long as the EMS aircraft ops are protected by the Aviation Deregulation Act they will continue to charge $50K for their service. However, some states have changed tactics and are now taking legal action at the receiving facilities trying to force them to pay for the ride then the state can regulate what the facility can charge back to the patient for that ride.
 
steingar said:
Lots and lots of crashes. I think most of it was long duty cycles for the pilots.
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FYI: CFIT/inadvertent IMC at night/spatial disorientation has been the leading collective cause for many years. And unfortunately still is. However, I do know of one accident due to fatigue/falling asleep a the stick. They caught it on a cockpit camera of the pilot drifting off which lead to the main cause CFIT. Take away night time scene work for VFR aircraft and the accident rate drops dramatically.
 
YooperMooney said:
The principal I never felt comfortable with is how a first responder bumblef*** can make the determination if a helicopter is “necessary” for a trauma patient.
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And that’s the problem. It takes a medical determination/decision for the helicopter to transport. The hospital based programs had a doctor make the call or there was one that flew with the helicopter. Enter community based with no hospital affiliation the only way for the system to work was to allow any on scene first responder (properly trained of course) to call for the helicopter.
 
Bill said:
I subscribe to AirMedCare every year, I think it a no brainer considering my hobbies.
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Be careful of those member programs. Most EMS flights would still be covered without one. And while all the member programs state they will accept the insurance payout you may want to read the fine print. If you receive a settlement from the transported incident the program reserves the right to seek those settlement funds to fully settle the bill. Or in some memberships if they determine you are a “person of means” will exempt you from that clause and seek the full bill.

flyingron said:
Being "public" aircraft they were not subject to some of the FAA oversight and there were some serious maintenance corners cut.
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FYI: After the 2008 accident MSP was “forced” into obtaining a Part 135 certificate. But in classic political fashion to make things good for that they powers to be bought them brand new IFR aircraft. But I dont think it helped the mind set much though.
 
YooperMooney said:
The principal I never felt comfortable with is how a first responder bumblef*** can make the determination if a helicopter is “necessary” for a trauma patient.
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Your point would be made better if you could refrain from profane insults. This first responder expended considerable effort getting his certification, roughly the equivalent of a couple of full time semesters, PLUS having to work along side of various areas of the hospital including the ER. I ain't no bumbledfark, thank you.

The decision is not made just by some gut instinct. We've got defined protocols defined by the state medical head under whose authority we operate. It specifies where we transport the patients and by what means. The helicopter only gets called for multisystem trauma cases. Broken bones and some serious bleeding wouldn't cut it. When you've pulled a few bodies out of wrecks, you don't have a hard time deciding when it is appropriate or not.

Despite the "inaccurate" statements in the video, there's no "stabilizing" of a multi-trauma patient in the field. We may stop the external bleeding and start fluids and perhaps even mast trousers, but we can't perform surgery in the field and these cases NEED surgery rapidly (that's what the golden hour is all about). Not only do you have to get them to the trauma center fast, but the trauma center has to be ready to start cutting.

Most of the other cases, for example, cardiac cases, we carry a lot of things that we can do (in coordination with the doctor in the ER) on the scene. We can do CPR, administer oxygen, adminster fluids, epinephrine, bicarb, monitor and diagnose arrhythmia, perform defibrillation and cardioversions. In that case, transport is wasting time. The patient needs certain intervention (defib, CPR) more than he needs to be in a hospital, even if he does end up needing angioplasty or the like.
 
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The issue that I see the most is helicopter transfer of stable inpatients from an outlying hospital to a tertiary center, i.e. not a particularly time sensitive situation. I totally agree that second guessing a field assessment from a good first responder is not appropriate.
 
Medevac, well I got my first flight in a Lear 31, 3 months ago. Industrial accident, causing sever injury to eye. Local hospital had no way to treat a trauma eye injury. Nearest trauma unit was Seattle. Not sure how long the flight was about 2 1/2 hours.

I know several of the flight crew for the medevac operation that flew me to Seattle. One of them came up to me last week and said he had no Idea I was the patient, he was flying as copilot on that flight.

Not sure what the bill was, company paid the bill guess. Hopefully I get sight back in the eye. I will not know if I will get sight back in the eye until the final surgery, 4 to 5 months down the road. Until then I'm working on the Sport, and getting it ready to sell...:(
 
Bell206 said:
And that’s the problem. It takes a medical determination/decision for the helicopter to transport. The hospital based programs had a doctor make the call or there was one that flew with the helicopter. Enter community based with no hospital affiliation the only way for the system to work was to allow any on scene first responder (properly trained of course) to call for the helicopter.
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This points no another issue. There is lack of sub specialty care at community hospitals, and often the transferring physician may not understand the acuity of the disease process. It is a defensive and somewhat understandable move to choose helicopter to avoid liability for events that could happen en route during ground transfer.
 
I’ll take a helicopter ride any day to a better facility and I live in a decent sized city. The video is whack.... Yes, some doctors call a chopper for no reason but for the most part around here, when it’s called, it’s needed. I carry an annual membership and proud to. It supports an aviation asset and covers my ass in case something fire happens. Fairly intimate with the local air ambulance and I would never trade it’s benefits.
 
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flyingron said:
Now in Maryland there's a multifaceted decision as to where to send a patient. Multisystem traumas go to ShockTrauma (or one of its satellites). Simpler trauma to a hospital with trauma capability. Burns, pediatrics, ophthalmic, etc... all have their own specialty destinations built into the system. If time and distance is a problem, a helicopter is used. There's still time (IFR) that you can't get one. I've been both the driver and the guy in back on some pretty high speed transports when I couldn't get a chopper.
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"Mountain Maryland" side of the state (I'd call it western Maryland but you folks call Frederick that) seems to send their traumas to Ruby at WVU/Morgantown or rarely Pittsburgh. I guess that makes sense geographically though if the next best option was Baltimore. That said I wouldn't want to get in a bad wreck on 68 or 40 no matter what, wx almost always sucks to get a bird in there, and that's a long ride over many hills if it's ground transit.
 
AKBill said:
Medevac, well I got my first flight in a Lear 31, 3 months ago. Industrial accident, causing sever injury to eye. Local hospital had no way to treat a trauma eye injury. Nearest trauma unit was Seattle. Not sure how long the flight was about 2 1/2 hours.

I know several of the flight crew for the medevac operation that flew me to Seattle. One of them came up to me last week and said he had no Idea I was the patient, he was flying as copilot on that flight.

Not sure what the bill was, company paid the bill guess. Hopefully I get sight back in the eye. I will not know if I will get sight back in the eye until the final surgery, 4 to 5 months down the road. Until then I'm working on the Sport, and getting it ready to sell...:(
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That’s a whole other can of worms where you are...no ground transport options to another city.

I had an acquaintance up in Yakutat who had an eye injury. The weather was such that they couldn’t get him out until the next day, which in his case was fortunate because the injury stabilized enough that he didn’t need surgery. If they had gotten him to the hospital on the day of his injury, they’d have done surgery and probably lost at least some sight in that eye.
 
steingar said:
Those things used to be insanely dangerous. Lots and lots of crashes. I think most of it was long duty cycles for the pilots. I bet they're still dangerous. VFR flight really doesn't mix well with medical emergencies. If you have to do it to save the patient Ma Nature may not cooperate.
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Similarly driving ambulances fast hasn’t got the greatest safety record either.

It’s technically illegal for emergency responders to speed here, not that you’d know it. Or that anybody cares.

But a fire engine managed to squish someone in their car last week in a fatal.
 
denverpilot said:
Similarly driving ambulances fast hasn’t got the greatest safety record either.

It’s technically illegal for emergency responders to speed here, not that you’d know it. Or that anybody cares.

But a fire engine managed to squish someone in their car last week in a fatal.
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That is the truth. #2 killer of firefighters is vehicle accidents. #1 is cardiac events. As a guy that has spent 14 years driving big red things with flashing lights, I can often get to a scene or hospital faster without the lights and noise. Other drivers freeze up when they hear sirens and just stop in the middle of the road.

As for the original topic, protocol around here is to auto-launch the hospital helicopter for any severe trauma injury out in the county. I sometimes wonder on the life flight transports though. By the time we wait for the helicopter to launch and arrive on scene, the ambulance could have been halfway to the hospital already. Not to mention there is a lot more room to work on the patient in the back of an ambulance than inside the helicopter.
 
Bell206 said:
FYI: After the 2008 accident MSP was “forced” into obtaining a Part 135 certificate. But in classic political fashion to make things good for that they powers to be bought them brand new IFR aircraft. But I dont think it helped the mind set much though.
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I dont think they ever obtained the 135 certificate. Political winds in the state changed and the people interested in fixing the aviation division lost the platform they could use to make their case. MSP hired a consultant to help them file an application, but in the end that effort apparently fizzled.

The new choppers and double-crew hopefully fixed the issue that caused the 2008 crash. In the years that I have been dealing with them as a 'customer' on the ground, I found them to be quite careful about the weather that they launch in. With the havy wheeled choppers, they have also become quite picky in terms of landing zones. They have basically a few known locations where they meet the ground unit to take the patient the rest of the trip. We are an hour and 10 or so drive from the next trauma rated hospital, so the for a higher priority patient, the HAA transport makes sense.
 
Todd82 said:
"Mountain Maryland" side of the state (I'd call it western Maryland but you folks call Frederick that) seems to send their traumas to Ruby at WVU/Morgantown or rarely Pittsburgh. I guess that makes sense geographically though if the next best option was Baltimore. That said I wouldn't want to get in a bad wreck on 68 or 40 no matter what, wx almost always sucks to get a bird in there, and that's a long ride over many hills if it's ground transit.
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I am at the little level III facility that sits half way out on that road. The transport decision is up to the medic on the helicopter, and they are biased to go to the closest appropriate facility that they can reach from the scene or pickup location. And most of this area is a much shorter flight to Ruby (I) or Altoona (II) than anything in Baltimore or DC. If after they arrive at the scene they decide that all the patient needs is level III, they send them to us. If the weather is unflyable or the MSP helo is unstaffed due to budget issues, higher level trauma tends to end up on our doorstep (III) with little warning. Those patients get worked up and stabilized, if they need services we dont have, they get an inter-hospital transfer.
 
weilke said:
I dont think they ever obtained the 135 certificate.
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I don't know if they completed the process, but I was indirectly involved in putting togather some maintenance documents for their initial 135 attempt. Regardless, I do believe MSP does operate the 139s at Part 135 standards as the maryland based private 135 EMS operators made an issue of that at one time.
 
Bell206 said:
I don't know if they completed the process, but I was indirectly involved in putting togather some maintenance documents for their initial 135 attempt. Regardless, I do believe MSP does operate the 139s at Part 135 standards as the maryland based private 135 EMS operators made an issue of that at one time.
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They were able to make it an issue because for a while they had a listening ear in state government and the legislature.

There have been attempts to force the state to contract it out on a statewide basis, the snag with that is that by doing that, they would lose the exclusive grip on the business. The state can do what they are doing now and just say 'we do all scene flights, end of story' because it is considered a 'government function'. What the state couldn't do would be to establish a monopoly of a preferred provider. The only way to do this in a more cost effective manner would be to contract a 135 provider but then to have them operate as 'public use' the way the forest service contracts for some helicopter and spotter services.
 
Todd82 said:
"Mountain Maryland" side of the state (I'd call it western Maryland but you folks call Frederick that) seems to send their traumas to Ruby at WVU/Morgantown or rarely Pittsburgh. I guess that makes sense geographically though if the next best option was Baltimore. That said I wouldn't want to get in a bad wreck on 68 or 40 no matter what, wx almost always sucks to get a bird in there, and that's a long ride over many hills if it's ground transit.
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There's a level III trauma center in Cumberland MD too but if you've flown into that valley it's certainly sporty enough in good weather. :D
 
Pugs said:
There's a level III trauma center in Cumberland MD too but if you've flown into that valley it's certainly sporty enough in good weather. :D
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It's bad enough driving down Savage mountain into that LaVale/Cumberland valley sometimes let alone flying.
 
weilke said:
The only way to do this in a more cost effective manner would be to contract a 135 provider but then to have them operate as 'public use' the way the forest service contracts for some helicopter and spotter services.
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But that creates its own set of problems and issues. I had/have a direct connection to one of the private 135 EMS operators in Baltimore and the few times I was involved in the VA, MD, NJ corner of things was always amazed at "intricacies" of operating in that part of the country.
 
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Bell206 said:
But that creates its own set of problems and issues. The old day job company is one of the private 135 EMS operators in Baltimore and the few times I was involved in the VA, MD, NJ corner of things was always amazed at "intricacies" of operating in that part of the country.
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From where I live, I could hit three different medevac helos with a forcefully thrown rock yet neither of them would routinely respond to us. To make it more interesting, any incidents on the river up to the 'ordinary high water mark' belong to MD, anything that happens in a 'creek'* that branches off the river is VAs responsibility. The US Park police responds out into the surrounding states, I think they just like flying ;-)





* a 'creek' in this context is something anyone looking at it would call a 'bay'.
 
weilke said:
I am at the little level III facility that sits half way out on that road. The transport decision is up to the medic on the helicopter, and they are biased to go to the closest appropriate facility that they can reach from the scene or pickup location. And most of this area is a much shorter flight to Ruby (I) or Altoona (II) than anything in Baltimore or DC. If after they arrive at the scene they decide that all the patient needs is level III, they send them to us. If the weather is unflyable or the MSP helo is unstaffed due to budget issues, higher level trauma tends to end up on our doorstep (III) with little warning. Those patients get worked up and stabilized, if they need services we dont have, they get an inter-hospital transfer.
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I can see Altoona getting socked in from time-to-time around this time of year as well, sitting down in the valley.
 
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