Map of life expectancy at birth from Global Education Project.

Monday, April 20, 2009

Rescue me?

My employer has recently been certified as a Level 1 trauma center. While our bosoms swell with pride, the principle consequence for me has been an increase in the frequency of helicopters landing on the roof just down the block from my 10th floor window. It is mighty impressive, I must say. If you haven't been close to these things, they are very powerful machines and they make one hell of a racket.

Unfortunately, in the process of saving lives, they sometimes crash killing not only the original trauma victim but the helicopter crew and the EMTs. Quite a few of these incidents have been in the news of late. I also presumed these flights cost a lot of money so I naturally started to wonder, is it really worth it?

It turns out a lot of people have been wondering the same thing. Alas, the only serious discussion I could find of this is in subscription-only medical journals, so I can't give you a link. JAMA reporter Mike Mitka discusses the issue in the March 25 issue, as does Jan Greene in the March Annals of Emergency Medicine. I have to conclude that this is yet another example of how we Americans spend big bucks and do aggressive, high tech stuff in medicine without the slightest idea of whether it's actually worth it or does more good than harm.

In 2008, 9 medevac crashes killed 35 people. Now, that doesn't mean your odds are necessarily terrible. According to one expert, Ira Blumen M.D., there were fewer than 25,000 patients transported by helicopter in 1980, but more than 275,000 in 2007, which means that the rate of fatalities actually declined to 2/100,000 flight hours. On the other hand, a helicopter ride costs about $8,000, compared to $800 for an ambulance ride, and nobody has actually figured out when the cost and risk might actually be worth it. Basically, we just do it.

As the Natasha Richardson tragedy reminds us, it's often difficult or really impossible to assess the urgency of trauma cases, so it would be challenging to write guidelines. A further complication is that diverting an ambulance from a rural area for a long ride to a distant trauma center would deprive the region of adequate ambulance coverage for the duration.

Still, we have guidelines in place for all sorts of difficult medical situations and the bottom line is, just doing more and spending more does not necessarily translate into a benefit, not only for society, but also for the individual who gets the service. It turns out the federal law assigns regulation of medical air transport to the Federal Aviation Administration, which pre-empts any efforts at regulation by state or local authorities. The FAA completely lacks relevant expertise and pretty much does whatever the industry wants it to, which is nothing.

So, as much as I would miss all those helicopters, it might must be that we could save some money and some lives if we you know, violated the sanctity of the free market with some sensible cost-benefit analysis and rationing. As in rational. As in smart.


C. Corax said...

One of those pilots was the brother of a friend of mine. Not knowing the details of the situation (except apparently the conditions were such that three other units refused to fly this particular rescue), I can't offer an opinion on the necessity.

Cervantes said...

One of the practices that are condemned in the pieces I cited is helicopter shopping -- when one company says conditions are unsafe to fly, the docs will call others until they get someone who will agree to do it. Everybody wants to be a hero, but you aren't doing trauma victims any favor by putting them at high risk for even worse trauma.

kathy a. said...

i think there must be local procedures in place, both with emergency responders and with hospitals seeking to transfer critical patients who need to be elsewhere. surely the FAA is not deciding who can and cannot take a couple hours on the road?

the medevac stories i hear about locally generally involve terrible freeway accidents; and the local freeways can be horrible during commutes.

kathy a. said...

c. corax, i'm sorry about your friend's brother.

Anonymous said...

Since when is a helicopter "high tech equipment"??

I'd presume it was 'really worth it' if the facility the patient was transported to saved the patient's life. How many of the 275,000 so transported in 2007 lived because of treatmemt they got at a specialized medical center?

There's little doubt if Natasha Richardson had been seen and treated by a neurologist in a trauma center instead of languishing in a medical clinic for hours that she probably would have lived.

Would the eight grand for a helicopter have been worth it? I bet Richardson would've thought so!

Cervantes said...

Well, a helicopter is definitely high tech equipment compared to a truck. And anonymous, I'm not arguing against helicopter transport in general, I'm just saying that we need to make sure we're using it wisely. I invoked Natasha Richardson precisely to make the point that we should err on the side of caution in evaluating the urgency of trauma. Given her remote location and the length of time it took for her to reach a trauma center, she indeed might have been a candidate for helicopter transport. But many people who are transported by helicopter do not have head injuries. I'm just saying we need to study the question better, right now it's a mess.

And yes, unfortunately, the FAA is the only agency with power to regulate this and the courts have ruled that their authority pre-empts state and local authority.