If, in moving through your life, you find yourself lost...go back to the last place where you knew who you were, and what you were doing, and start from there. Bernice Johnson Reagon.

08 September 2013

How long does it really take?


Dispatched for a motor vehicle crash (MVC), Upon arrival there is a patient who was riding an ATV and was struck. The patient was ejected and then part of the ATV landed on him. There are obvious patient care issues and such, but which mode of transport do you use? Air or ground?
Some things to consider-
1. You have a Level I trauma center 30 minutes driving time away (it could take longer- that depends upon traffic conditions).
2. It is clear weather.
3. Your patient meets CDC Trauma Notification criteria.

Should you fly the patient? After all, flying is quicker. Isn’t it?

Well…maybe not. There are a few things to consider.
First, how long before the helicopter gets to you, assuming that it was not requested until you arrived. If it was ‘placed on standby’ while you were en route, how long before it gets to you? Figure five minutes to get into the air (based on what I have seen while watching helicopters take off) and then whatever the flight time to your location is. Then there is the landing and the crew exiting the aircraft. And no, it is not like any DUSTOFF mission you have ever seen where the flight medics and/or crew chief jump from the aircraft and run to the medics.

Second, how long does it take to provide a patient report to the flight crew? My experience? Five to six minutes. What I have seen documented? Anything from five to twenty-four minutes (yes, you read that right).
Third, they have to load the patient onto the helicopter. Again, this is not like Vietnam or Afghanistan where they open the doors and the patient is rapidly placed into the aircraft. No, this is a process. I have never seen it done in less than five minutes. Maybe it can be done quicker, but sometimes it takes longer.

Then there is take-off and flight time and landing. Then the patient is unloaded and taken into the facility. At two of my local facilities, this is five minutes or so. And no, they are not running.
So how long did that flight actually take? Figuring in best case scenarios of five minutes for each phase listed above, and allowing for a twelve minute flight time, then we have taken about 27 minutes from the time of patient report to unloading the patient at the facility.

For a 30 minute trip, we have taken just under 30 minutes. In ideal conditions, we have shaved three minutes (maybe) from the transport time.
But, what if you have to take the patient to the landing zone? Depending on where that is located, we are talking maybe five minutes. Or more.

Based upon some research on call records I discovered the following intervals. Documented.
1. Travel to landing zone- 5-9 minutes.
2. Patient turnover to flight crew- 5-24 minutes (out of several flights, only one was 24 minutes; one was 18 minutes, the rest in the 5-9 minute range)
3. Loading the patient onto the aircraft- 5-9 minutes
4. Figure a flight time of 10-15 minutes.

Then, when you figure in timed observations at a couple of the local facilities for unloading the aircraft and taking the patient into the facility of 5-8 minutes, that short flight to the trauma center actually can take takes 30-50 minutes. Yes, you read that right.
At best, that 30 minute drive turns into a 30 minute flight.

So we have saved…what?
Now, don’t take this to mean I am totally against medical helicopters. I am not. I think they are a fantastic resource in certain circumstances. I also think it is pretty neat flying on a helicopter. And I think they just look cool.

But, I also think I have to do what is best for my patient. All the time. And if I can get the patient to the trauma (or STEMI or stroke) center in a reasonable time by ground, then I need to hit the highway.
Helicopters can save time in certain circumstances. If the landing zone is close by, and the helicopter is waiting for you when the patient is extricated, and the driving time to the facility is extended (40-45 minutes or greater, then maybe there is an advantage to cutting 5-10 minutes off of the time it takes to get the patient to the hospital.
A lot of the research says otherwise, but I know how some people feel about the research.
The 'romance', if you will, with medical helicopters grew out of the 60s. Many people have a memory of news video from the Vietnam war of Army UH-1's with red crosses emblazoned front and sides, landing ever so briefly in a rice paddy for the wounded, then hustling them off to army MASH units.
We became enamored with flashy terms like "The Golden Hour" and ""The Platinum Ten Minutes". But where was the research into those time frames? Sure, it is intuitive that a trauma patient gets to a trauma center quickly, but how quickly?
You can search the internet now and find videos of DUSTOFF missions from Afghanistan where UH60s swoop in, and after just a minute or two on the ground, hustle their wounded cargo off to field hospitals, bypassing the less-than-developed road system, laden with IEDs, that is Afghanistan.
But that is a different world than what we live and work in.

2 comments:

BadgerMedic said...

Having moved into HEMS in the last year and off the County EMS units, I totally agree that for the most part, anything under 30 minutes is generally equally as fast, if not faster by ground, barring certian circumstances… (Aircraft already in the air etc.)

Now, there are some circumstances that would benefit from HEMS even with the close proximity; especially if there are things/treatment that cannot be preformed by local EMS (i.e.: Trauma Blood administration). But for as close as you are (and we up in Forsyth are) to the Trauma Center/PCI/Stroke centers, it would have to be something very out-of-the-ordinary for me to call for a helicopter working at the county.

To further this conversation; say you do have a prolonged extrication, HEMS is dispatched and landed before the patient is out… but upon examination the injuries are insufficient to qualify for Trauma criteria… do you still package and fly the patient?

9-ECHO-1 said...

Me? No. I tell the flight crew is a nice manner "Thanks guys, but we got this". First, I do not want to tie up the resource that could do someone else some good. Second, I don't want to saddle someone with an $18,000 bill that they did not need.

I know of a situation just recently close by- helicopter called, patient extricated, aircraft had landed, patient transported by ground.

It was the right thing to do by the patient.