Maryland ACEP Maryland ACEP Medevac UpdateMedevac Update

Robert R. Bass, MD, FACEPRobert R. Bass, MD, FACEPMaryland Institute for EMS SystemsMaryland Institute for EMS Systems

September 28, 2008 September 28, 2008 Crash of Trooper 2Crash of Trooper 2

• KilledKilled

*Pilot Steve BunkerPilot Steve Bunker

*Trooper/EMT-P Mickey LippyTrooper/EMT-P Mickey Lippy

* EMT Tanya MallardEMT Tanya Mallard

*Patient – Ashley YoungerPatient – Ashley Younger

• InjuredInjured

*Patient - Jordan WellsPatient - Jordan Wells

Medevac IssuesMedevac Issues

• Expert Panel - November 24-25, 2008Expert Panel - November 24-25, 2008

• Trends in helicopter utilizationTrends in helicopter utilization

• Number and location of basesNumber and location of bases

• Fleet replacementFleet replacement

• SafetySafety

Expert Panel MembersExpert Panel Members

• Robert C. MacKersie, M.D. – Chairman, Expert Robert C. MacKersie, M.D. – Chairman, Expert Panel; Professor of Surgery in Residence and Panel; Professor of Surgery in Residence and Director of Trauma Services, San Francisco General Director of Trauma Services, San Francisco General Hospital, San Francisco, CA.Hospital, San Francisco, CA.

• John A. Morris, M.D. – Professor Surgery, John A. Morris, M.D. – Professor Surgery, Director, Division of Trauma & Surgical Critical Director, Division of Trauma & Surgical Critical Care, Director, Trauma, Burn & LifeFlight Patient Care, Director, Trauma, Burn & LifeFlight Patient Care Center, Vanderbilt University Medical Center, Care Center, Vanderbilt University Medical Center, Nashville, TN. Nashville, TN.

• Ellen MacKenzie, PhD – Professor and Chair, Ellen MacKenzie, PhD – Professor and Chair, Department of Health Policy and Management, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health – Johns Hopkins Bloomberg School of Public Health – Baltimore, MD.Baltimore, MD.

Expert Panel MembersExpert Panel Members• Tom Judge, CCT-P – Executive Director, LifeFlight Tom Judge, CCT-P – Executive Director, LifeFlight

of Maine, Bangor, ME; Past-President, Association of Maine, Bangor, ME; Past-President, Association of Air Medical Services and volunteer paramedic.of Air Medical Services and volunteer paramedic.

• Stephen H. Thomas, M.D., M.P.H. – Associate Stephen H. Thomas, M.D., M.P.H. – Associate Professor of Surgery, Harvard Medical School, Professor of Surgery, Harvard Medical School, Department of Emergency Medicine, Massachusetts Department of Emergency Medicine, Massachusetts General Hospital, Associate Medical Director, General Hospital, Associate Medical Director, Boston MedFlight Boston, MA.Boston MedFlight Boston, MA.

• Bryan Bledsoe, DO – Clinical Professor of Bryan Bledsoe, DO – Clinical Professor of Emergency Medicine, University of Nevada School Emergency Medicine, University of Nevada School of Medicine and University Medical Center, Las of Medicine and University Medical Center, Las Vegas NV. Vegas NV.

• William R. Metcalf – Chief, North County Fire William R. Metcalf – Chief, North County Fire Protection District, Fallbrook, CA.Protection District, Fallbrook, CA.

Expert PanelExpert Panel

• Maryland continues to be a model systemMaryland continues to be a model system

• Trauma outcomes are at or exceed national Trauma outcomes are at or exceed national normsnorms

• Field trauma triage protocol c/w national Field trauma triage protocol c/w national guidelinesguidelines

• Overtriage appears to exceed other areas of Overtriage appears to exceed other areas of the countrythe country

• MSP aviation has good safety recordMSP aviation has good safety record

• Syscom is unique and a national model Syscom is unique and a national model

Expert PanelExpert Panel

• HEMS is an essential component of an system HEMS is an essential component of an system and can contribute to improved outcomesand can contribute to improved outcomes

• MSP should change to FAA Part 135 and MSP should change to FAA Part 135 and becomes CAMTS accredited becomes CAMTS accredited

• Continue and enhance helicopter utilization Continue and enhance helicopter utilization reviewreview

• Should do an in-depth analysis of the number Should do an in-depth analysis of the number of helicopters needed and their overall role in of helicopters needed and their overall role in the EMS system beyond traumathe EMS system beyond trauma

Helicopter UtilizationHelicopter Utilization

Total Trauma Patients Transported Total Trauma Patients Transported from Scene FY 1998 - 2007from Scene FY 1998 - 2007

Percent of Injured Patients Treated at Percent of Injured Patients Treated at Trauma Centers FY 03 - 07Trauma Centers FY 03 - 07

Medevac Transports Peaked in 2004 Medevac Transports Peaked in 2004 and Dropped 23% by FY2008and Dropped 23% by FY2008

(Graph = Scene and Total Transports)(Graph = Scene and Total Transports)

Number of Medevac Patients per Fiscal Year

1000

2000

3000

4000

5000

6000

98 99 00 01 02 03 04 05 06 07 08

Fiscal Year

Co

un

t

• Increased medevac utilization from 1998 – 2004Increased medevac utilization from 1998 – 2004

• Changed protocols to emphasize the general lack Changed protocols to emphasize the general lack of benefit when ground drive time to trauma of benefit when ground drive time to trauma center is less that 30 minutescenter is less that 30 minutes

Transport to Trauma Center or Specialty Center per Transport to Trauma Center or Specialty Center per protocol; alert trauma team; consider helicopter protocol; alert trauma team; consider helicopter transport if quicker and of clinical benefittransport if quicker and of clinical benefit..

Helicopter Utilization ProtocolHelicopter Utilization Protocol

Scene Transports to a Trauma Center Scene Transports to a Trauma Center Air v. Ground - FY 03 - 07Air v. Ground - FY 03 - 07

Post-Crash Medevac Protocol ChangePost-Crash Medevac Protocol ChangeCategory C (mechanism) and D (other)Category C (mechanism) and D (other)

Transport to trauma center; alert trauma team. Patients within a 30-minute drive time of the closest appropriate trauma/specialty center

shall go by ground unless there are extenuating circumstances. Receiving trauma

center medical consultation required when considering whether helicopter transport is of

clinical benefit.

Medevac Requests to SYSCOMMedevac Requests to SYSCOM Total By Week Post Crash Total By Week Post Crash

Total Medevac Requests to SYSCOM

0

10

20

30

40

50

60

70

80

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Week Since Crash

Co

un

t

Medevac Requests to SYSCOMMedevac Requests to SYSCOMOutcome: Fly versus No-flyOutcome: Fly versus No-fly

Medevac Requests to SYSCOM by Outcome - Percentage

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Week Since Crash

Pe

rce

nt

% Fly % No Fly

Post Crash StatisticsPost Crash Statistics(27 Weeks)(27 Weeks)

1259 Requests1259 Requests

• Fly: 65%Fly: 65%

• No fly: 35%No fly: 35% No FlyNo Fly

• 45% Directed - land45% Directed - land

• 27% Field cancelled27% Field cancelled

• 14% Field decision- land14% Field decision- land

• 14% Cancelled weather14% Cancelled weather

Medevac Requests to SYSCOMMedevac Requests to SYSCOMTransports by Patient CategoryTransports by Patient Category

Medevac Requests to SYSCOM by Trauma Triage Tree Category

0

10

20

30

40

50

60

70

80

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Week Since Crash

Co

un

t

Cat A Cat B Cat C Cat D No Category

Percent Enhance COMARPercent Enhance COMAR(ISS + ICU + OR + Death + Transfer)(ISS + ICU + OR + Death + Transfer)

Percentage of Patients Transported from the Scene by Air or Ground to a Maryland Designated Trauma Center Meeting the

Enhanced COMAR Severity Definition Source: Maryland State Trauma Registry

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 Oct - Dec,2008

Air

Ground

Air + Ground

Number of Medevac Patients per Fiscal Year

1000

2000

3000

4000

5000

6000

98 99 00 01 02 03 04 05 06 07 08 09

Fiscal Year

Co

un

tEstimated Medevac Transports Estimated Medevac Transports

2009 Based on Current Utilization2009 Based on Current Utilization

80% of the estimated decline is the result of less medevac requests80% of the estimated decline is the result of less medevac requests

2009??2009??

Fleet ReplacementFleet Replacement

• Proceeding with RFP for multi-Proceeding with RFP for multi-mission aircraftmission aircraft

• Flexibility in number purchasedFlexibility in number purchased

SafetySafety

• Safety is “Job 1”Safety is “Job 1”

*FAA 135FAA 135

* Safety equipmentSafety equipment

*Two pilotsTwo pilots

*CAMTSCAMTS