Who decides when to call the Life Flight?
August 25, 2012 4:26 PM   Subscribe

I am unconscious, I've been in a terrible accident and I am in a rural area in the United States. Who decides whether I should be flown to the nearest city or taken to the local rural hospital that may not be equipped to handle my emergency?

I live in a rural area and I just found out our local hospital is not qualified to treat stroke or heart attack. Yet when we went in with signs of stroke we were not told this and not offered to be flown to the city. Should the paramedics have offered to make the arrangements? Or does the local hospital administration decide? And is it based on if you have insurance or not (we don't).
posted by cda to Health & Fitness (16 answers total) 4 users marked this as a favorite
What do you mean, not qualified to treat stroke or heart attack? If the hospital has an emergency room, it damn well better have that ability. That's pretty basic stuff.

The decision to transfer to a larger, more capable facility is made by the ER doctor or the specialst she consults. By Federal law, that decision cannot take ability to pay into account, and the hospital she calls has to accept the transfer without consideration of ability to pay, if they are capable of treating the condition.
posted by megatherium at 4:52 PM on August 25, 2012

Oh, and most often you will not get flown there, unless the larger facility is many hundreds of miles away. Overland via ambulance is the standard.
posted by megatherium at 4:54 PM on August 25, 2012

What do you mean, not qualified to treat stroke or heart attack? If the hospital has an emergency room, it damn well better have that ability. That's pretty basic stuff.

Some hospitals, especially rural hospitals, are not equipped for cardiac intervention.

Not all hospitals are primary stroke centers either.
posted by Fairchild at 5:06 PM on August 25, 2012

I was in a situation like this once, where it got to the point where the helicopter was actually ordered, and then canceled. Here's where decisions were made and who made them:

1) In Rainier National Park, when the rangers got me. They could have called in a helicopter there, but they decided to take me to an ambulance. They do, however, helicopter people out of Rainier National Park all the time, so this is a decision the rangers are used to making. I was just backpacking around the Wonderland trail, but climbers I believe both the weekend before me and the weekend after me had to get helicoptered out. These guys, though, they can't see that your organs are bleeding, say. It's not a perfect decision process.
2) The ambulance guys. They made the decision to take me to the hospital I went to.
3) The E.R. doctor when I checked in to the hospital said, "Nope, get this guy to Seattle." and he called a helicopter.
4) First, though, he also called a specialist to double-check with, who did some other doctor stuff, and said, "Wait…I'm gonna take a crack at this, cancel the helicopter."

Basically, the whole practice was pretty ad-hoc. Unfortunately, everyone has to make decisions with imperfect information, so they use rules of thumb like "his head fell off, so we know this is serious, call a helicopter" or "he's out of it but all his fluids are staying on the inside and he's in one piece. Drive him to the local hospital." As far as I can tell, the S.O.P. is whoever's got you uses whatever tools they have and makes the best call they can.

I wasn't asked for any sort of insurance or payment information until after they decided to keep me in the hospital I was in, for what it's worth. However, I think this varies. Another time I was taken by paramedics to some sort of mountain first aid station (I am very clumsy) and they wouldn't do anything without a credit card or insurance card. Also, a relative of mine was moved between hospitals in a normal ambulance just because we asked, so it's not 100% the doctors' call, every time. Now that I think about it, a third time, I was taken to a small rural mountain hospital, with a head injury, based solely on the ambulance guy's opinion, and they didn't bring up anything about insurance either. (That guy was kind of a flake though, he basically spent the ride trying to convince us to help him book DJ gigs in New York because the whole ambulance thing was "just a day job".)

So yeah, I'd say the general rule is "whoever's the most qualified medical person around at that point makes the best decision they can with the information they have, and they don't take your insurance status into the calculation, but they do on some level take costs into consideration. They don't helicopter every single person, for instance."
posted by jeb at 5:35 PM on August 25, 2012 [7 favorites]

Trauma/Injury is a bit different than triage/transfer for medical illnesses. As background, the development of designated trauma centers by the American College of Surgeons was in response to an initiative taken by a surgeon after he was traveling across the US with his family when they were in a major accident in a rural area. The different members of his family were taken to different hospitals, and I believe some died. Small hospitals in rural areas may not have access to general surgeons, orthopedic surgeons, and neurosurgeons for emergency call.

So, there are (in the US) recommendations for field triage (by the EMS/paramedics) and referral to designated trauma centers (which have different levels based on what services they have available). Being unconscious should get you transported from the field to a trauma center because you may have a brain injury that needs a neurosurgeon. The development of field trauma networks and coordination is a function of each state's department of health, so there will presumably be some inter-state variation, but the idea of field triage is endorsed nationally.

Having said that, if you are brought directly into an emergency room by family, the ER doc on call should be familiar with the basic principles of trauma assessment and stabilization (its part of their training as ER docs), and you would be evaluated for possible transfer, which that doctor would then arrange.
posted by artdesk at 5:38 PM on August 25, 2012 [3 favorites]

Someone will probably chime in with a better, more specific response, but I'll offer a broad outline based on what I know from my experience. Your questions is kinda broad, so I'm going to offer a lot of background information.

Giving patients emergency treatment outside the hospital is sometimes called pre-hospital care, and is part of a larger system known officially as Emergency Medical Services (EMS). Paramedics have responsibility to judge how severe an emergency is, and what the nature of the emergency is once they are 'on scene.' But paramedics are only one arm of EMS. In America, territory is divided up into different EMS Systems and each EMS system has their own dispatchers and medical directors in addition to the paramedics. Paramedics communicate to dispatch what's going on, 'on the ground' and one of the first decisions they make is whether they have enough tools or resources to deal with an emergency on their own, of if the patient needs a higher level of care. Then the paramedic will communicate with dispatch what is going on, and if the patient needs a higher level of care, they will discuss with the paramedic what to do next.

As an aside, I'm using 'higher level of care' as an extremely broad term. If a patient is suffering an allergic reaction from a bee-sting, the paramedics have enough tools to deal with that, at least for a little while. If a patient is having a heart attack, the patient needs to go to a hospital with advanced medications and a trained doctor. If the patient was hit by a mack truck and rapidly losing blood, they need more than just a hospital, they need a Level-1 Trauma center with special surgical personnel. Now, every emergency room can offer some interventions, and is required to meet certain standards by law. But certain treatments, like cardiac catheterizations to physically remove blockages causing a heart attack, are only available at certain large centers. This is not a bad thing, because not every heart attack needs a cardiac catheter, and stopping by the rural emergency department to see a doctor who can give initial treatments is an important step in many medical emergencies.

So who make this decision of where you go? Ultimately it's the Medical Director who I mentioned above. That's the doctor who takes ultimate responsibility for the treatment provided in an EMS system. But a lot of the time the medical director will set out directives that allow paramedics and dispatchers to get the process rolling before they consult an MD. If someone has had two legs amputated in a car accident the paramedic can declare the emergency a "level one" trauma and get the person started on the road to the nearest level one trauma center. If the nearest trauma center is 100 miles away and there's a helicopter available, then the dispatcher can go ahead and queue up the helicopter. The bigger decisions get double checked with a medical director, and if there's ever any debate every paramedic has the number of the MD's call phone.

In the hospital, the emergency room doc assumes care and then will make decisions in conjunction with consulting doctors. Like I said, not every stroke need an emergency CT scan or MRI (such as strokes that are already over six hours old) and not every heart attack requires surgery. Getting to the hospital is usually the right first step, even if it is a rural hospital. Helicopters can also land at the hospital and take the patient to the next level of care, which I've seen done before as well.
posted by midmarch snowman at 5:43 PM on August 25, 2012 [4 favorites]

Jeb: Your stories made me think of couple interesting points that are probably irrelevant but interesting to me.

The first step of your story, needing help in the wilderness, falls in the special portion of pre-hospital care that is search and rescue. I call it special because it's performed by a huge variety of agencies with policies that are much more variable depending on the resources available. Salt Lake City Search and Rescue is run through the sheriff's department and has an entirely different threshold for calling their helicopters than most non-wilderness care providers.

Second, paramedics work for a vairety of agencies and are not always employed by the EMS system. Ski mountains employ paramedics who operate seperately from EMS and thus can do things like ask for insurance cards in 'non-emergencies.' In true emergencies they may end up calling a state agency.
posted by midmarch snowman at 6:07 PM on August 25, 2012

most often you will not get flown there, unless the larger facility is many hundreds of miles away

The small town where I used to live was less than 100 miles from the nearest trauma center, and you'd hear about people being flown. Local hospital had a helicopter landing pad for that purpose.

How you get transported probably has a lot more to do with whether there are any helicopters available than anything else. Come in with something where you will die unless you can get airlifted to the trauma center, but all the copters are in use transporting people with less serious injuries? Bad luck.

This might have something to do with why they didn't rush you off in a helicopter. In the last few years we've seen some outcry over the idea that rationing for healthcare might be implemented in the future -- but it's already here. Limited number of hospital beds, ICU spaces, deciding who gets seen first in the emergency room -- the resources to give everyone the most optimum care simply aren't there.
posted by yohko at 6:10 PM on August 25, 2012 [1 favorite]

BTW, I always recommend to anyone in a rural area that they figure out in advance when they'd want to go to their local hospital, and when they'd want to have someone drive them elsewhere. Signs of stroke isn't going to be something you'd want to drive a few extra hours to see someone about, but things like broken bones in delicate areas like the hands -- you might be willing to be in pain for longer to see someone with more experience.
posted by yohko at 6:15 PM on August 25, 2012

Being "able to respond" to stroke does not require having the ability to do carotid endarectomies.
Ditto - "heart attack" - "open heart surgery".

That is why the question was "what do you mean"? No one can expect that every little hospital will be a tertiary care center. But every little hospital with an ER has to know how to be able to handle primary intervention and have a transfer protocol in place.
posted by megatherium at 7:02 PM on August 25, 2012

I can't speak to the US context but I suspect that there are some similarities with the Canadian context where I work.

In Ontario, there are a number of EMS protocols regarding pre-hospital triage. The 3 main areas that this applies to are stroke, MI (heart attack) and trauma. If a patient meets certain specific criteria, the paramedics will alert their dispatch and may end up bypassing smaller hospitals to get to the appropriate regional stroke or STEMI or trauma centre.

With respect to trauma, their are prehospital guidelines that use vital signs, mechanism of injury and certain patient characteristic to triage patient. The idea is that the sickest patients who likely need a trauma team (including a trauma surgeon, orthopaedic surgeon, neurosurgeon, anesthetist and coordinated OR and radiology staff) will go directly to a trauma centre.

MIs will only bypass peripheral hospitals if they fit into the category of STEMI. Not all heart attacks are the same. STEMI is an MI that fits certain criteria on the cardiogram (ECG). There must be ST elevation of a certain amount in certain ECG leads and this is automatically determined by the computer in the ECG machine that the medics carry. Patients with acute chest pain get ECGs by EMS and if their computer reads it as a STEMI they will bypass to a STEMI centre. This is done because STEMI is a type of MI for which there is evidence that early thrombolysis (clot busting drugs) or PCI (stenting of coronary arteries) saves lives and reduces morbidity. There are some areas of the province where there is no nearby PCI centre and in this case the patient is taken to the nearest ED where the patient can by thrombolysed.

Stroke triage is a little more complicated and prehospital triage of strokes is a more recent phenomenon. This is because we only started thrombolysing strokes recently. There are studies that show that an acute stroke that meets certain criteria benefit from receiving tPA which is a clot-busting drug. These criteria are very specific - for example they must have certain neurological deficits, have definitely stroked within 3 hours, and have no contraindications to thrombolysis). If a patient does not meet the very stringent criteria, they can be taken to any ED as the other treatments for stroke can be done anywhere. This is not a decision made by the paramedics in Ontario. If the medics think a patient might fit the stroke protocol criteria they patch through to the base hospital where they speak to an ER doctor who makes the final call.

Although this is all protocolized, there are always situations that deviate from the protocols. Patient are dynamic and someone who doesn't meet criteria on scene may do so once they reach a hospital and they may end up getting transferred. Also the vast majority of patients picked up by EMS don't fit any bypass protocol and so go to the nearest department. If the local ED doc decides that the patient requires a higher (or different) level of care they will arrange transfer between hospitals at that point. We also now have special 'modified scene' transfer protocols whereby a land EMS crew will make it to the scene before air can arrive and they scoop and run to the nearest ED where the patient may be intubated, transfused, and be generally stabilized as much as possible until the air crew arrive to transfer the patient to a regional trauma centre.

I am obviously simplifying a lot of things here but what I am trying to say is that all of these prehospital systems are complex and although it can be confusing as a patient why you were taken to one place and not another there is usually a reasonable good reason behind it - at least in Canada and, I trust, the same applies to the States.
posted by madokachan at 8:00 PM on August 25, 2012 [3 favorites]

I'm an ER doctor. madokachan is correct. If you did not fit criteria for getting clot busting drugs for stroke, then it does not matter what hospital you showed up to with stroke symptoms. There is no other effective treatment for stroke, the treatment is just symptomatic. So there would have been no point in transferring you to a hospital that is a designated stroke center at that point in time.

The most common reason why people do not fit criteria for clot busting drugs (tPA) for stroke is that they come in too late. That is the reason for the big public advertising campaign "time is brain". Stroke is not painful and for some people, doesn't even seem to be particularly scary - they don't really realize what's happening to them, and so they don't seek treatment right away. If you told them you had stroke symptoms but that you woke up with them, or that they started 6 hours ago, then you are not a candidate for the treatment - the upper limit for tPA is 4.5 hours (it's been changed since the original trial which showed the 3 hours that madokachan mentioned). There are a number of other criteria used that could prevent someone from getting tPA, this is to avoid the risk of life-threatening bleeding that can be a side effect of the drug.

The simplified answer to your question is that if you arrive at a hospital, it is your ER doctor's decision whether and how to transfer you, and if you are getting picked up by EMS and need services not available at a local hospital (like the example of special kind of heart attack called a STEMI, or serious trauma), you can be taken directly to a more distant hospital for treatment - however, if you are unstable and the EMS folks are worried you won't make it that far, they can take you to the closest hospital to attempt stabilization before transferring you.
posted by treehorn+bunny at 10:00 PM on August 25, 2012 [3 favorites]

p.s. there is one other treatment we give for stroke, and that is aspirin to prevent recurrent stroke, but of course you do not need to be at a stroke center to get aspirin.
posted by treehorn+bunny at 10:03 PM on August 25, 2012

Also re: helicopters - aside from the costs, traveling by helicopter is quite dangerous. The actual danger level I'm sure varies according the terrain and weather but people die in medical helicopter crashes every year.

My sister saw a guy get helicopter-evacuated from a place popular with backcountry skiers a few months ago and was surprised, because we've known other people who were seriously injured there and they were taken down on stretcher sleds and/or carried on litters. Apparently there are lots of situations where it would be preferable to take the patient out via helicopter but it's very rare for the weather in this area to be good enough.

I'm sure the ER doctor doesn't get to make the decision about whether the weather is good enough to allow for safe helicopter travel, but presumably the helicopter medics give feedback.
posted by mskyle at 7:47 AM on August 26, 2012

I am in a rural area in the United States

You probably need to be more specific. While there are broad practices that are common nationwide, hospitals are regulated at the state level, and so would be ambulance services, paramedics, and EMTs. There can be huge local variations in what is available in terms of trauma centers, patient transport, and first-line responders. For example, in my city, all the firefighters have been cross-trained as paramedics, and they are often the first to get to a call before the EMTs arrive in their specially-equipped vehicle. At the other end of the scale, we just went in the last couple of years from ONE hospital and ER (Level II trauma center, but they make a big deal about being "II+" or something like that) to TWO hospitals and THREE ERs, if you can believe that (the first hospital opened an ER-only clinic on the other side of town to compete, even though both are non-profits).

The first week or so that the second hospital opened, some guy wrote an indignant letter to the editor that his wife was having a heart attack so he drove her into hospital #2's ER, only to have them transfer her to hospital #1, where she died. He somehow blamed them for advertising that they had an ER but weren't ready for a patient in his wife's condition. This is yet another data point in why you should call 911 immediately and get first responders to your location, because they can administer immediate care.

Anyway, the other aspect here is that our state does not regulate how many hospitals there can be, or where, but the next state over DOES -- you have to apply for a certificate through a state board. Hospital #1 has a service area that spills over state lines and a few years ago one of their applications got caught up in a scandal because the contractor who expected to get the work bribed some officials. Only slightly relevant to the question here, but it shows how competitive the industry is, even with non-profit status.

Anyway, I'm sure the situation is much simpler and more practical where medical choices are fewer -- so you're lucky that way. But you'd probably not want to hope that a medical flight was an option to be made without your input if you don't have insurance -- such flights can cost well into five figures.
posted by dhartung at 11:03 AM on August 26, 2012

Response by poster: Thanks to everyone who took the time to answer this post. I do plan on getting my local life flights $250 for 5 years or $1000 for life insurance plan (your whole family can be transported for free).

But I don't see that as the panacea for my situation. (Weather is going to be a big factor - we have winter for 6 months here). I am going to be more insistent on prevention and keeping healthy.

I am still working on my overall emergency planning.

Thanks everyone.
posted by cda at 11:43 AM on August 29, 2012

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