Re: Closest vs. Most Appropriate Facility

May 2, 2005

Here is the evidence that burn patients less than 200 miles from a burn

center should be transported by helicopter. Where is your supportive

evidence to the contrary?

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J Trauma. 2004 Jul;57(1):57-64; discussion 64. Related Articles, Links

Regional air transport of burn patients: a case for telemedicine?

Saffle JR, Edelman L, SE.

Department of Surgery and the Intermountain Burn Center, University of Utah

Health Center, Salt Lake City, Utah 84132, USA. jeffrey.saffle@...

BACKGROUND: Air transport of burn patients is plagued by frequent

" overtriage. " We examined the use of air transport and the feasibility of

using alternative methods such as telemedicine to assist in evaluation and

treatment of burn patients within our region. METHODS: We reviewed all burn

patients transported by air during 2000 to 2001. Each patient was classified

as being most appropriate for air, ground, or family transport. In addition,

a decision was made regarding whether telemedicine evaluation of the patient

before transport could have significantly altered initial treatment

decisions. RESULTS: Two hundred twenty-five acutely burned patients were

transferred from referring hospitals in nine states, at a mean distance of

246 air miles. Mean burn size calculated by burn center physicians was 19.7%

total body surface area, whereas referring physicians' mean estimate was 29%

total body surface area. In 92 cases, over- or underestimation of burn size

by referring physicians of as much as 560% or decisions regarding

performance of endotracheal intubation suggested that telemedicine

evaluation before transport might have significantly altered transport

decisions or care. Air transport charges exceeded hospital charges in 21

cases. CONCLUSION: Frequent discrepancies in burn assessment contribute to

overuse of air transport. The ability to evaluate burn patients by

telemedicine may have the potential to assist decisions regarding transfer,

avoid errors in initial care, and reduce costs. We are currently attempting

to develop and test such a system.

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Burns. 2002 Feb;28(1):70-2. Related Articles, Links

Helicopter transportation of burn patients.

Slater H, O'Mara MS, Goldfarb IW.

The Western Pennsylvania Hospital, 4815 Liberty Avenue, Pittsburgh, PA

15224, USA. hslater@...

Analysis of 437 consecutive acute burn patients transported to our burn

center revealed 339 transported by ground and 98 by helicopter. There were

18 air transport patients from within a 25-mile-radius, and 80 flown further

than 25 miles. Mean age was the same in all groups (P>0.05). Percent total

body surface area (TBSA) burned was 8.26% in ground transport patients,

significantly less than the 20.35% (within 25 miles) and 21.40% (greater

than 25 miles) seen in helicopter transports (P<0.0001). Three percent of

ground transport patients and 28% of helicopter patients had inhalation

injury (P<0.0001). There was no difference in incidence of inhalation injury

among helicopter groups (28 vs. 29%, P=0.8). In patients with coexistent

inhalation injury, the mean TBSA burned was significantly larger when

compared with the TBSA of burns without inhalation injury (P<0.001). Air

transported groups contained patients whose status was not critical based

upon lack of inhalation injury and small burn size, and who could have been

transported by ground. Non clinical factors such as insurance status, desire

to keep ground ambulances in their community, and competing helicopter

services reluctant to refuse to transport a patient appears to be factors in

choosing air ambulance transportation. Regional single helicopter services

and regional cooperative ground ambulance services should reduce use of

helicopter transport of burn patients when it is not clinically indicated.

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J Burn Care Rehabil. 2000 Nov-Dec;21(6):535-40. Related Articles, Links

Cost-effective use of helicopters for the transportation of patients with

burn injuries.

De Wing MD, Curry T, son E, Palmieri T, Greenhalgh DG.

Shriners Hospital for Children, Northern California, Sacramento 95817, USA.

We performed a retrospective review to analyze the use of helicopters for

the transportation of patients with burn injuries to determine whether a

more cost-effective approach could be developed without impairing the

quality or delivery of health care. Charts were reviewed for all patients

with burn injuries who were transported by helicopter to our hospitals

during a 2-year period. Patients with inhalation injuries, with burn

injuries received more than 24 hours before admission or more than 200 miles

from our burn center, with more than 30% total body surface area (TBSA)

burned, or with associated trauma injuries were excluded. Control patients

with burn injuries who were transported by ambulance were identified and

matched to the patients with burn injuries transported by helicopter for the

percentage of TBSA burned, the percentage of third-degree burns, transport

mileage, and age. The outcome was evaluated by comparison of length of stay,

days on ventilator, and mortality rate. Comparisons were performed with

Student t test. The transportation charge was determined for the patients

transported by helicopter who we believed were eligible for transport by

ambulance. Forty-seven of 85 patients transported by helicopter matched the

inclusion criteria and had survived. There was no statistically significant

difference between the percentage of TBSA burned, the percentage of

third-degree burns, length of stay, days on ventilator, age, or transport

mileage. There was, however, a significant difference in the time from the

injury to admission to the hospital, as well as in the charge for

transportation. Patients who had less than 30% TBSA thermal cutaneous

injuries without evidence of inhalation injury, and who are less than 200

miles from a burn center may be safely transported by ambulance. Ambulance

transportation may take additional time; however, stricter protocols for

helicopter transportation of patients with burn injuries will result in

potentially substantial savings without affecting outcomes for patients.

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J Burn Care Rehabil. 1991 May-Jun;12(3):229-33. Related Articles, Links

Helicopter transport of the patient with acute burns.

Baack BR, Smoot EC 3rd, Kucan JO, Riseman L, Noak JF.

Division of Plastic and Reconstructive Surgery, Southern Illinois University

School of Medicine.

Helicopter transportation of acutely injured or ill patients has become

common practice at most major medical centers. However, its specific

effectiveness in the transportation of acute-condition patients with burns

has never been critically assessed. This study, for the period 1984 through

1988, evaluated the use of the helicopter for transportation of

acute-condition patients with burns to a regional burn center for a rural

area. It is concluded that helicopter transport within a 180-mile radius in

a non-hospital-based system is not appreciably faster than is ambulance

transport, and does not clinically benefit most burned patients.

Consideration such as safety, cost, and working space are discussed. It is

recommended that at least one of three criteria be met before helicopter

transfer is considered for patients with burns: the surface area involved

should be enough to require a formal fluid resuscitation, an inhalation

injury should be present or suspected, or there should be a possible need

for an escharotomy.

PMID: 1885639 [PubMed - indexed for MEDLINE]

May 2, 2005

Tow-long bone fractures qualify for helicopter transport in most systems.

There are EMS systems that are facing financial peril because of revenue

losses from flying every little thing. Their argument is that it keeps the

ambulances in service. Well, if the ambulances never transport, they have no

chance of billing for revenues.

E. Bledsoe, DO, FACEP

Midlothian, TX

Don't miss EMStock 2005 (http://www.EMStock.com)

RE: Closest vs. Most Appropriate Facility

OK, I may be a little off base here, but the immediate concerns for the care

of a burn patient will be respiratory compromise, either from airway

injuries, smoke inhalation or from severe (3rd or 4th degree) burns

impairing chest wall movement, or circumferential burns to the chest. Severe

burns to the abdomen which would impair the diaphragmatic movement. Fluid

loss. Circumferential burns to an extremity that impairs circulation. There

are many, MANY other long term issues that need to be dealt with, so don't

assume that I didn't take that into consideration.

Of those, corrective action to airway and fluid loss should be undertaken by

the crew on the scene, and worst case scenario is that an escharotomy is

necessary to relieve constriction to the chest/abdomen/extremity. If the

latter is the case, should it not be done as soon as is reasonably possible?

And again, if that is the case, would that not qualify the patient to go to

the closest facility which is able to accept and perform measures necessary

to sustain life? That facility may not be prepared to offer long term care

to the patient, but it could well be able to, and should be able to offer

immediate life saving care.

Often (not always) respiratory and/or perfusion will become restricted with

circumferential 3rd and/or 4th degree burns, not with 2nd.

My point is that as with other injuries and illnesses, the entire scenario

comes into play, a gunshot would in and of itself will often cause many

services to fly a patient to a trauma facility, even if it were a gunshot

would to the foot.

Biased against the use of helicopters? No. Biased against the current abuse

and over use of helicopters? Oh yeah.

Hatfield FF/EMT-P

May 2, 2005