Can I get HEMS?

I’m back up in Ballarat at the moment, working in the control room, and one of the most common question I get is “can we have HEMS?”.  The answer is often, but not always “yes”, however there are a number of things that need to be considered before a helicopter is launched.  We will take a brief look at air operations in the post, however please bear in mind that this is from the point of view of me, a clinician.  I am not a HEMS medic, I am not a Flight Coordinator, so everything I write here must be treated as suspect.  Much like all my other posts…

Victoria has a fleet of 5 helicopters which provide a mixture of scene flights and retrievals.  2 helicopters live in Melbourne, one of which (HEMS01) is the primary craft for scene flights, with the other (HEMS05) set up for retrievals, especially paediatric retrievals.  However any craft can be reconfigured for different missions and it is not uncommon to have HEMS05 as the primary, depending on what is required.  There are also helicopters based in the LaTrobe valley (HEMS02), Bendigo (HEMS03) and Warrnambool (HEMS04).  Currently there are 2 different helicopters used: HEMS01 is a Eurocopter Dauphin, and the others are Bell 412s.  However HEMS will be transitioning to AW139s across the fleet shortly, which will make everyone at Air Ambulance very happy.

Aside from HEMS, Air Ambulance also runs a fleet of Beechcraft KingAirs, which are used primarily for routine transfer and retrieval work.  However it is not unheard of to use a fixed wing on a primary case in the field, depending on the situation.

So, what happens to get the helicopter crews out of bed and in the air?

First of all, in Victoria we do not automatically launch an air resource to a scene.  There are certain case types that will result in a notification page being sent to the Air Ambulance Flight Co-ordinator.   However, nothing will happen until the clinician has looked at the job and spoken to the flight co-ordinator.  Anyone who has been subjected to AMPDS will understand why this is so: recent cases I have seen sent to air have included “walked into a door” and “dropped scissors on foot”.  Clearly we will not launch an air mission for this sort of thing.  So first of all, the Clinician vets the call to see if it is appropriate to go to air.  We also send cases that haven’t had an automatic notification to air for consideration as well.

We then call the Flight Co-ordinator and speak with them regarding the case, to see what resources are available where, and how long they will take to get to scene.  Sometimes if we have enough information from the scene, or road resources are a long way away, we will ask for HEMS to be sent straight away, sometimes as the primary response.  For other cases we may wait until a crew arrives to give an accurate summation of the scene to see if HEMS is warranted.  It should be stressed that the Clinician is not the person who makes the final decision as to whether HEMS is launched or not: that is the role of the Flight Coordinator (and ultimately, the pilot).  HEMS are a precious (and expensive) resource, that come with significant risks in their use, so we need to be careful that we deploy them where they will provide the most benefit.

So what kind of cases will get HEMS?  Broadly speaking there needs to be something that HEMS can provide the patient that ground based EMS can’t.  That may be a clinical intervention, a time saving to definitive care, or an ability to access the patient.  One of the most common patient types HEMS will get sent to is the patient fitting the trauma time critical guidelines, where the HEMS paramedic can provide blood rather than salty water, and get the patient to a major trauma centre far quicker than road medics can.

HEMS is also sometimes used as a primary MICA resource to medical cases, such as cardiac arrest where road MICA will take longer to get there than HEMS, however this is relatively rare compared to trauma cases.  I think there is probably scope to use HEMS as primary to more medical cases than is currently the case.  There are no hard and fast rules as to what HEMS is used for at the moment so HEMS use basically comes down to gestalt of the flight coordinator.  I personally would like to see some more formal criteria in place, with room for variation based on individual factors, in order to remove some of the variability in dispatch.

The next question is, why didn’t you get HEMS?  Please be aware, none of us are here to stop you getting the resources you need to provide the best care for your patient.  The default setting we work on is send everything, always.  However, we need to triage cases, we need to consider costs and benefits, and especially with respect to HEMS we need to consider the risks involved.  I’m sure most of you are aware of the number of HEMS helicopters that have fallen out of the sky in the US.  We haven’t had that happen, and I have no doubt that careful consideration into the necessity of HEMS plays a part.

The most likely reason you didn’t get HEMS, is because there was none available.  It is not uncommon to have every helicopter in the state out.  If they are already tasked, they won’t be coming to you.  Well, usually.  There is sometimes scope to triage cases differently and divert HEMS from one case to another.  The most common time this will happen is if they are on a retrieval for a relatively stable patient in one hospital going to another.  Then we may be able to divert to you.

The other common reason is weather.  I am not a pilot and I have no idea about the weird meteorological phenomenon that they must consider before going up in the air.  But what we will never do is second guess their decision.  They too are here for the patient, and I know from experience that they will do their utmost to get to scenes.  However, if they determine that it is not safe, that is the end of the discussion.  Bear in mind as well, that just because it is lovely and clear where you are, that doesn’t mean it is where HEMS launches from, where they have to go to, or en-route to your location.

So those are the non-negotiable reasons to not send you HEMS: there is none, or it’s not safe.  That leaves a range of cases where you may or may not based on clinical/logistical reasons.  This is where I would like to see some criteria in place, as there is huge variability in whether HEMS get sent or not.  There is too much in this to be able to breakdown individual cases, however we will consider all the variables mentioned above – where you are, where the hospital is, what the hospital capabilities are, what your capabilities are and so on.  There is no one answer, but a bit less guess work would be good.

If you genuinely think that HEMS will be of benefit to you patient, please ask.  But make sure you have a very clear idea what that benefit is, a clear picture of what is wrong with your patient, and convey this succinctly to the clinician.  I am happy to go in to bat for you, but you have to give me something to work with.

So, that is HEMS from my point of view.  I will try to get Ben to give a bit more of a run down on life as a MICA Flight Paramedic to flesh this out a little.  I hope this was of use.  As always, happy to hear from you on this, or any other topic.




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3 Responses to Can I get HEMS?

  1. Derek Leggo says:

    Well written article. As a Flight Coordinator, I agree with all of your points and it’s great to see an article written that provides such a clear description and clarification of AAV so well. Thank you!

  2. Pingback: Can I get HEMS? | Prehospital and Retrieval Medicine - THE PHARM dedicated to the memory of Dr John Hinds

  3. Ben Hoffman says:

    Great article.

    It sounds like what Victoria needs is something broadly similar to the ANTS criteria used in New Zealand for helicopter response. Specifically, these are:

    1. Access: a helicopter is most appropriate method to access and extricate the patient
    2. Number: the number of patients exceeds road ambulance capacity (noting this is a rare indication to respond a helicopter)
    3 Time: a helicopter will allow the patient with a time sensitive condition to save a clinically significant amount of time in reaching hospital.
    4. Skill: a helicopter will allow a specific skillset required at the scene to be delivered with a clinically significant time-saving vs. responding by road.

    Just as I underestimated the amount of time it takes for the Fire Service to extricate a person from a crashed vehicle, it seems common to underestimate the amount of time HEMS takes to get a patient to hospital, that is, overestimate the time saving. The time to get airborne, fly to the scene, land, exit, receive handover +/- any treatment from HEMS, load, fly to hospital, unload and take to ED all adds up.

    Now having said that, in most areas of Victoria, the vast distances involved from hospital, and indeed I suppose more importantly from tertiary hospitals makes the above a little less valid unless you are say, an hour or so by road from hospital.

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