Re: Helicopter risk/benefit

["Nick Nudell" <nick@glacierems.com>]

Bob

When a physician requests a certain mode of transport, that is all it is, a
request. It is not an order, as in a medication order. The physician is
responsible to determine the need for transport, stabilize for transport,
and ensure that the requested transporter is capable of providing the
necessary care. When that physician signs the COBRA form, they are
indicating that they have reviewed the method chosen and deem it
appropriate.

Medicare has very strict rules for determining the need for transport,
whether it be by air or ground, regular ALS or Critical Care, etc. There are
many flight programs, in particular, who are requested for flights that are
not reimbursable. This is also a major problem in my state, Montana. This is
not just a flight issue... ground transport systems must also receive an
additional signature on a Medicare approved form that indicates the need for
ambulance transport for every patient who requests transport by a method
other then 911. No form, no payment.

The 'standard' of care for transport is to transport by ground ambulance.
(not looking to insult anyone, this should just be a statement of the truth
as I understand it). If a determination is made to transport a patient by
air (an increased level of urgency in many cases), the additional expense
must then be justified to the satisfaction of the insurance/Medicare
auditors to receive payment. If they do not feel that the patients condition
warranted the expense, they will refuse to pay. So this is where my
questions are based. If the payer determines that a flight is unnecessary to
adequately care for a patient, then why is it appropriate for the hospital
staff to initially, then the flight crew to later incur this increased risk
of transport upon the patient. (I know we discussed the secondary issue of
whether it really is more dangerous to fly, subsequently to my posts). In
any case it is more expensive and in the case of our local programs, by
nearly 500% more expense.

When discussing about risks of transport... there is a risk of death or
injury no matter the mode chosen. Think about a patient being prepped for
surgery in the hospital. They will sign a hospital release when they are
admitted and then will sign an authorization for the surgeon to do the
surgery. They will then have to sign an anesthesia permit to allow the
anesthetist to provide that service. Why must so many forms be signed? This
I believe is the same point at issue here with transport. If the transport
crew does not provide escalating levels of information to receive a
continued informed consent for continued care, then they will be seen to
have breached their duty.

> How would it sound for a medical crew to question the referring MD's
decision about the
> form of transport.
This happens all the time. This is a very appropriate use of EMS providers
judgment in many cases. You have to constantly question decisions made to
ensure that you feel they are in the patients best interest. If you do not
feel that the MD made the appropriate decision, they you should not just 'go
along' with it until your concerns have been appropriately addressed!


I hope these points are more clear to understand.

Be safe.
Nick









----- Original Message -----
From: "Robert L. Carnevale" <cw5aso@erols.com>
To: <flightmed@flightweb.com>
Sent: Tuesday, October 01, 2002 3:50 PM
Subject: Re: Helicopter risk/benefit


> Nick,
>
> We don't transport a patient without a signed transfer form from the
referring facility.  The decision to
> fly a patient is made before you receive the call requesting the
transport.  So the potential risks
> associated with flight have been covered by the referring facility.
> I don't understand your question about deciding whether it is safe to fly.
Are you talking about weather
> issues?  If you are, then of course the pilot decides if there is
appropriate weather to conduct the
> flight.  What does most appropriate decision nor in the patients best
interest mean?  Are you referring
> to the MD who made a decision to fly?  Sometimes a referring MD will make
an inappropriate request.  This
> is where your medical director/medical control gets involved, not the
medical crew.  Talk about stepping
> on your toes.  How would it sound for a medcical crew to question the
referring MD's decision about the
> form of transport.
>
> Bob Carnevale
>




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