RE: Ground versus air

["Paul M. Wright, Jr." <pmwright@home.com>]

> It made a point to clarify an old saying that 'flying is safer than
> driving a car.'  Their data suggested that is not true for EMS
> helicopter flights.

To the best of my ability to determine, with specific regards to the risk to
the patient, the safety of ground ambulance versus air ambulance is roughly
comparable in terms of patient miles per fatal  incident.
An ongoing barrier to the determination of relative significance and
incidence is the problem of reporting bias.  Helicopter fatalities are
widely publicized while those involving ground ambulances generate only
local interest, if that.  Also, helicopter fatalities are widely publicized
without regard as to whether a patient was involved and the same is not true
of ground ambulances in my experience.

> Your post does raise several questions though.  You stated that the
> helicopter service was offering a "flat rate" for "all" of your
> "stable" transports.  Although the helicopter service is offering
> your facility a flat rate can I assume that this cost will ultimately
> be passed on to the patient?  Being a small/rural ED I doubt you have
> the resources to "eat" that cost nor is the helicopter service going
> to lose money.

This is a legitimate concern.  Particularly in a situation where the
majority of the patients are funded by a third-party government agency (e.g.
Medicare, Medicaid), it can be very difficult for both the clinic and the
flight operator to make a rational business model for air transport when a
ground option is feasible.  If the clinic guarantees payment, they are
assuming that their funding agency (or agencies) will permit inclusion of
those payments in their reimburseable cost structure and that can be a very
dangerous assumption.

> The fact that your ambulance service has had a bit of bad luck with
> loose animals on the roadway does not justify a helicopter transport
> for every patient that needs to go to a tertiary facility.  I also
> doubt that most of your patients are willing to pay that money out
> of their pocket when a ground ambulance transport was more
> appropriate and their insurance denied the reimbursement.  Many
> ambulance services do much farther transports than the 75 miles you
> spoke of.

But, Eric, you don't understand.  These are not just "loose animals on the
roadway" - they are genuine Arizona-bred Ambulance Eating Horses.  I've
encountered them and they are fairly frightening.  They look much less
intimidating from 500 ft AGL than they do eye-to-eye through the windshield
of your Type II van.

> My suggestion would be to carry good auto insurance on your
> ambulances and perhaps install a large cow-catcher on the front.
> Seriously, if the ambulance service is concerned with safety during
> ground transports there are several courses out there that train
> personnel for emergency driving.  Emergency Vehicle Operations
> Courses are taught by many law enforcement, EMS and fire departments.

In fairness, there are a number of other challenges beyond driver
competence/horse avoidance.  If the patient requires a level of care beyond
that of the ambulance crew (a common scenario in rural areas), the rural
facility ends up committing a staff nurse to the transport.  For a transport
to a hospital 75 miles away, the round trip represents half a shift of
coverage.  Administrators of these clinics have a very difficult time
balancing resources and the demand for those resources and outsourcing the
transport function to another provider might be an entirely rational
workaround.  If the financial model can be made to work....

The other factor to be considered is whether it makes sense to keep the
flight program viable by throwing them some lower-acuity transports so they
are still around when you really need them.  I could name some very large
flight programs that at some point in their history have subsidized their
emergency traffic by doing transports on some other basis than strict
medical necessity.

Whatever the outcome, Connie has raised some interesting issues and I
appreciate your perspective on them.

regards!

paul

Paul M. Wright, Jr.
Mesa, AZ