helicopters in ems
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HEMS: Luxury or necessity, the cost
NAEMSP Annual Meetingand Scientific AssemblyJanuary 2009 Phoenix, AZ
an consequence o sys em es gn
Thomas Judge / LifeFlight of Maine
Stephen Thomas, MD, FACEP, MPH
University of Oklahoma
Dan Hankins, MD, FACEP
Mayo Clinic
Ira Blumen, MD, FACEP
The University of Chicago
Fixed Wing
Ground CCT
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What is clear
Final Report Expert Panel Review of Helicopter
Utilization and Protocols in Maryland Feb. 2009
HEMS is an essential component of a contemporary EMS system.Its use improves outcomes in a high risk population of traumapatients.
Both aviation and critical care medicine are high consequence
endeavors a (high risk, high cost, high benefit). HEMS programsmust operate at the highest levels of safety practically possible.The safety of patients and of crew members must incorporate acomprehensive systems approach to risk management.
The configuration of the HEMS system, including overall missionprofile and the number and location of aircraft should bedetermined primarily on the distribution of the population, injurypatterns, and the geography of the state.
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46.7 million Americans
have no access to Level
1 or 2 trauma centers
within 1 hour
Helico ters rovide
access for 81.4 million
Americans who
otherwise would not
have been able to reach
a trauma center within
an hour.
Input 3;
One way drive
Decision
Support Time
Modeling
Constant
average speed
per road
classificationR oa d C la ss Spe ed
R ur al L oc al 2 5
R ural H ig hw ay 5 0
R ural F re ew ay 6 5
U rb an L oc al 2 5
U rb an A rt er ia l 4 0
U rb an F re ew ay 5 5
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Input 4;
One way flight
Decision
Support Time
Modeling
CMMC
140 MPH Flight Speed
Improv ingImprov ing
t r iaget r iage
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Santa Rosa, FL October 2004
3 Fatal
Federal AviationAdministration 16
International Helicopter Safety Symposium
September 26-29, 2005
16
600
700
800
900
HEMS Crew Fatalities /100,000 PersonnelHEMS Crew Fatalities /100,000 Personnel
Range: 0-806/100,000
29-yr average: 212/100,000
HEMS
0
100
200
300
400
500
8 0 8 1 8 2 8 3 8 4 8 5 8 6 8 7 8 8 8 9 9 0 9 1 9 2 9 3 9 4 9 5 9 6 9 7 9 8 9 9 ' 0 0 ' 01 ' 0 2 ' 03 ' 0 4 ' 05 ' 06 ' 0 7 ' 08
-yr average: ,
164
What is not clear
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Emergency Medical Services Intervals and Survival in
Trauma: Assessment of the "Golden Hour" in a NAProspective Cohort. Newgard CD, Schmicker RH, Hedges JR, et. al.
STUDY OBJECTIVE: The first hour after the onset of
out-of-hospital traumatic injury is referred to as the
"golden hour," yet the relationship between time and
ou come rema ns unc ear. e eva ua e e assoc a on
between emergency medical services (EMS) intervals
and mortality among trauma patients with field-based
physiologic abnormality.
CONCLUSION: In this North American sample, there
was no association between EMS intervals and
mortality among injured patients with physiologic
abnormality in the field. Ann Emerg Med Sept. 2009
Scene Tr iage Cr i t er iaScene Tr iage Cr i t er ia
London HEMSFall >2m Ent rap LOC Apne a Burns GSW/Stab Limb threat
Helicopter evacuation of trauma victims in Los Angeles:
does it improve survival? Talying P Teixeira PG, et. al.
BACKGROUND: The purpose of this study was toinvestigate the relationship between the method oftransport after injury and survival among traumapatients admitted to a Level 1 trauma facility in Los
, .
CONCLUSIONS: In a metropolitan Los Angelestrauma system, EMS helicopter transportation ofinjured patients does not appear to improve overalladjusted survival after injury. There is however apotential benefit for severely injured subgroups of
patients due to the shorter prehospital times.
World J Surgery Nov. 2009
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Air versus ground transport of the major traumapatient: a natural experiment.McVey J, Petrie DA, Tallon JM.
OBJECTIVES: 1) To compare the outcomes of
adult trauma patients transported to a level Itrauma center by helicopter vs. groundambulance. 2) To determine whether using aunique "natural experiment" design to obtaint e groun compar son group w re ucepotential confounders.
CONCLUSIONS: This unique natural experimentled to better matched air vs. ground cohorts forcomparison. As per TRISS analysis, airtransport of the adult major trauma patient isassociated with significantly improved survivalas compared with ground transport. PrehospEmerg Care Jan 2010
CostCost--BenefitBenefitcost per life year savedcost per life year saved
NICU (birth wt. 500-999g)$18,000
Median, 310 medical interventions$19,000
3-vessel CABG for severe angina$23,000
Thrombolysis for acute MI$32,678
Prophylactic AZT post-needlestic$41,000
Level I TC cost per life saved$84,000
Accepted threshold, NEJM 2005$40,000-50,000
HEMS scene trauma, W= 5 $2500
HEMS scene trauma, W= 1 $9700
HEMS use: Massachusetts $2454
HEMS system: U.K. & Norway $10-30,000
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How did we get here?
1970s
Translation miltitary to civilian world: MSP /Flight for Life Denver
trauma medevac and the golden hour
Hospital based / cast wide net for emergingtrauma centers
Geography = destiny
Medical distinct from aviation (contract)
Air vs. Ground (no ALS Baxt)
Costs buried (Part A) (Economics = Driver)
1978 Airline Deregulation Act (ADA)
Medical Centerfold
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1980s
Rapid growth 70s redux (medical centerfold)
Trauma warsextend the cachement
Care vs. speed ????
Scope of practice / team composition ???
ommun ty ase prov ers (medical + aviation)
1986 Hiawatha Aviation of Rochester v.Minnesota Department of Health
1986 DOT to Arizona: is a helicopter an airtaxi?
Safety problems NTSB 1988
1990s
1990 only year without a death in HEMS
Continued Safety Problems (summit 1992)
Emergence of community based providers
(aviation + medical)
1996 Rocky Mountain Helicopters vs.
Missouri Dept. of Health (CON)
Vermont DON Retro Study DHART (1997)
BBA 1997 National Fee Schedule for
ambulance transport Evidence base? +/-
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1990s
1990 AAMS Appropriate Use Guidelines 1991 CAMTS created
1992 NAEMSP Guidelines for Scene
1994 NAEMSP Guidelines for Scene and
Interfacility
1999 ACEP Appropriate Utilization
1999 AAP Pediatric and NICU
1999 ACS Resources for Optimum Care
2000s
2002 NAEMSP Dispatch
2002 ACS Interfacility for rural
2002 ACEP Appropriate Interhospital
2002 AAP Pediatric and Neonatal
Evidence Base (Thomas) compilations) ? +/-
Safety and Risk (Blumen) big problem
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2000s
2002 Ambulance fee schedule emplaced. RVUfor transport. Supposed to be cost based
2002 Section 415 (Medicare Drug)
2002 NAEMSP, AMPA, AAMS DispatchGuidelines
Continued safety (FAA, NTSB 2006/09, IHST)
2006 IOM
2007 GAO
2008 Worst safety record
2000s2000s
1997 BBA negotiated rulemaking with final1997 BBA negotiated rulemaking with final
implementation in 2002implementation in 2002
Medicare Fee ScheduleMedicare Fee Schedule Gas PedalGas Pedal
==
helicopterhelicopter
No requirements other than helicopterNo requirements other than helicopter
The primary driver behind the growth fromThe primary driver behind the growth from
350 to >850 helicopters in 9 years350 to >850 helicopters in 9 years
434% increase in Medicare spending in 7 years434% increase in Medicare spending in 7 years
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Growth / Demand / Need:Growth / Demand / Need:
60 0
70 0
80 090 0
1000
0
10 0
20 0
30 0
40 0
50 0
80 85 90 95 '00 '03 '04 '05 '06 '07 '08 '09
Total HEMS Aircraft
2000s
Problems with oversight demand vs. need
Problems with integration-- competition
Problems with safety
Problems with appropriate utilization
Problems with quality / variation
Problems with costs
Who is in charge?
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Growth
n caefficacy and
appropriateness
Safety
Medical Helicopters TodayMedical Helicopters Today
of helicopters = hospital based of helicopters = hospital based Typically range from 1Typically range from 1--5 helicopters per5 helicopters per
programprogram Vast majority contract with Part 135 operatorsVast majority contract with Part 135 operators
for aviation com onentfor aviation com onent
of helicopters = community based of helicopters = community based Concentration operators, large number ofConcentration operators, large number of
helicopters (e.g. 50helicopters (e.g. 50--300)300)
Some operators only community based, someSome operators only community based, someonly Part 135 vendor contracts for hospital basedonly Part 135 vendor contracts for hospital based
programs, some do bothprograms, some do both Not for Profit, ForNot for Profit, For--profit, Publicprofit, Public
Atlas & Database of Air Medi cal Services
Base Location + 10 min fly circle.Size of 10-min fly circle varies with
cruise speed of specific Rotor Wing model.
95%Complete476 RWBases503 RWAircraft
CenTIR, AAMS, NHTSA, FHWA
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Do the number of helicopters matter?OK ME MA * NAT
# HEMS 18 2 5 17
Pop. Sq. Mi. 49.36 36.03 601.52 74
HEMS / pop. 191,703 637,462 1,587,274 335,425
7 sq. m .
% pop 60 min. TC 36.8 78.9 96.8 84.1
% pop 60 min TC +
HEMS effect
11.6 38.7 31.1 27.7
% pop 60 min TCtotal
48.4 117.6 127.9 111.8
Do the number of helicopters matter?
2008 OK ME MA * NAT
Scene transports 2026 770 1993
Scene trans / pop 5.87 6.03 3.13
Discharge < 24 hrs. 18.2 3.6 5.4
MVC Fatalities per
1000/injuries
14.9 11.7 8.1 12.2
MVC fatalities per 100K
population
21.4 14.2 6.7 14.2
MVC fatalities per 1 million
miles traveled
1.57 1.25 .78 1.41
% reduction in MVC
fatalities 2007 as comparedwith 2002-2006 avg.
+ .06 - 6.1 -8.0 -4.3
What Happens?What Happens?
Increase pressure to flyIncrease pressure to fly
NTSB Testimony: pilots, paramedics, RNs, MDsNTSB Testimony: pilots, paramedics, RNs, MDs
Increased exposure to marginal environmentIncreased exposure to marginal environment
Reduce acuity for flight / medical necessity ?Reduce acuity for flight / medical necessity ?
Increase marketingIncrease marketing golden troutgolden trout
Increase chargesIncrease charges
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Newberry, SC July 2004
4 Fatal
55Federal AviationAdministration 55
International Helicopter Safety Symposium
September 26-29, 2005
U.S. HEMS and Fatal AccidentsU.S. HEMS and Fatal Accidents
12
14
16
18
20
NTSBNTSB
IHSTFAA
0
2
4
6
8
72-
79
8 0 8 1 8 2 8 3 8 4 8 5 8 6 8 7 8 8 8 9 9 0 9 1 9 2 9 3 9 4 9 5 9 6 9 7 9 8 9 9 ' 0 0 '0 1 ' 02 ' 0 3 '0 4 ' 05 ' 0 6 '0 7 ' 08 ' 0 9
Total Accidents Fatal Accidents
through December 31, 2009
Recent Fatal EMS AccidentsRecent Fatal EMS Accidents
Whittier, AK Dec. 3, 2007 - BK117 - 4 fatal
Cherokee, AL Dec 30, 2007 - Bell 206 3 fatal
S. Padre Island, TX Feb. 5, 2008 -AS350 3 fatal
La Crosse, WI May 10, 2008 EC135 3 fatal
Huntsville, TX June 8, 2008 Bell 407 4 fatal
Flagstaff, AZ June 26, 2008 Bell 407s 7 fatal
Greensburg, IN Sept. 1, 2008 Bell 206 3 fatal
Forestville, MD Sept. 28, 2008 AS365N1 4 fatal
Aurora, IL Oct. 15, 2008 Bell 222 4 fatal
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Reports AMS Community and Regulatory NTSB
AAMS Conference Summary
AAMS Conference Summary
Flight Safety Foundation
Root Cause Study (AAMS, HAI, NEMSPA)
NEMSPA Pilot Survey
Blumen IJ. Safety Risk Review and Assessment
Blumen IJ. Safety Risk Review and Assessment Update
FAA HEMS Task Force
HAI
NTSB
1988
19922000
2001200120012003
2005/06Sept 2005Dec 2005
Jan 2006
Annals of Emergency MedicineHelicopter Crashes
Baker S, Dodd R, et. al. Annals
Hustwit J, AlainDery M, et. al. Pilot Survey
Congressional Research Service
FAA Summary of Initiatives 04-07
NTSB Update
GAO
IOM Emergency Medical Services at the Crossroads-Final
AAMS, NAEMSO, NAEMSP, AMPA State Guideline White Paper
AAMS Community Safety Summit
HAI / AAMS / FAA / NTSB
Flight Safety IRP
NTSB
GAO
April 2006April 2006
May/Sept 2006May 2006March 2007March 2007
Feb 2007April 2007
April 2007July 2008Nov. 2008Jan 2009
Feb / Sept. 2009Dec 2009
Federal Most WantedTransportation SafetyFederal Most WantedTransportation Safety
Improve Safety of EmergencyMedical Services Flights
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National Transportation Safety BoardNational Transportation Safety Board
2006 Study w/ recommendations2006 Study w/ recommendations fewfew
implemented 4 outstanding recommendations.implemented 4 outstanding recommendations.
2008 HEMS on Most Wanted List2008 HEMS on Most Wanted List
Public Hearin on HEMS Feb. 3Public Hearin on HEMS Feb. 3--6 20096 2009
Looked at avionicsLooked at avionics
Looked at industry economicsLooked at industry economics
21 Recommendations, Sept. 200921 Recommendations, Sept. 2009
9 Recommendations, Oct. / Dec. 20099 Recommendations, Oct. / Dec. 2009
Chairman HersmanChairman Hersman Follow the moneyFollow the money
separation of drivers:
Clinical Imperative Aeronautical Reality
Finance
Fiscal Incentives
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Correlation of Medical Helicopter
Transports With ConsensusUtilization Guidelines
The Northeast
Evaluation of Transport
Workgroup
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Evidence Based Medevac Dispatch
An Extension of the Sacco Triage Method
Goal:Eliminate unnecessary flights without impacting mortality rates.Objective:Screen from medevac consideration patients with high survivalprobability and little or no expected deterioration within 90 minutes
Confidential Unpublished Property of ThinkSharp, Inc. All Rights Reserved.
Results:Eliminates 62% of flights by screening patients with survivalprobabilities of 95% and aboveEliminates 46% of flights by screening patients with survivalprobabilities of 98%.NOTES:Results do not include flights where patients are not admit ted!Results do not include flight reductions from travel time analysi s.
Model excludes 62% from medevac consideration --
Survival Probability over 95%; no deterioration
Survival Probability After Applying Injury andPhysiological Screens from Medevac Model
RPM 0-7 8-14 15-54 55-74 75+ Total
0 7.87% 7.41% 4.24% 5.22% 1.39% 4.67%
1 75.00% 0.00% 16.13% 10.53% 0.00% 18.00%
2 50.00% 0.00% 20.29% 7.69% 37.50% 20.43%
3 37. 50% 11.11% 38. 55% 6. 25% 13.33% 29. 77%
4 53. 33% 56. 25% 53. 18% 58. 62% 13.64% 50. 59%
5 69. 70% 58. 33% 60. 53% 47. 54% 21.05% 55. 78%
6 81. 58% 62. 50% 69. 81% 48. 48% 38.46% 65. 38%
7 92. 96% 89. 74% 81. 80% 63. 83% 41.54% 77. 86%
8 92. 37% 86. 54% 87. 96% 69. 47% 55.95% 83. 09%
9 100. 00% 98. 50% 93. 19% 82. 05% 67.91% 90. 48%
10 99. 76% 99. 65% 97. 48% 95. 81% 87.68% 95. 85%
11 99. 47% 99. 50% 98. 88% 96. 25% 87.56% 97. 21%
12 99.72% 100 .00% 99.56% 98.27% 95.22% 98.69%
Model excludes 46% from medevac considerationSurvival Probability over 98%; no deterioration
Survival Probability After Applying Injury andPhysiological Screens from Medevac Model
RPM 0-7 8-14 15-54 55-74 75+ Total
0 7.87% 7.41% 4.24% 5.22% 1.39% 4.67%
1 75.00% 0.00% 16.13% 10.53% 0.00% 18.00%
2 50.00% 0.00% 20.29% 7.69% 37.50% 20.43%
3 37. 50% 11.11% 38. 55% 6. 25% 13.33% 29. 77%
4 53. 33% 56. 25% 53. 18% 58. 62% 13.64% 50. 59%
5 69. 70% 58. 33% 60. 53% 47. 54% 21.05% 55. 78%
6 81. 58% 62. 50% 69. 81% 48. 48% 38.46% 65. 38%
7 92. 96% 89. 74% 81. 80% 63. 83% 41.54% 77. 86%
8 92. 37% 86. 54% 87. 96% 69. 47% 55.95% 83. 09%
9 100. 00% 98. 50% 93. 19% 82. 05% 67.91% 90. 48%
10 99. 76% 99. 65% 97. 48% 95. 81% 87.68% 95. 85%
11 99. 47% 99. 50% 98. 88% 96. 25% 87.56% 97. 21%
12 99.72% 100 .00% 99.56% 98.27% 95.22% 98.69%
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Medevac clearly shows age bias
RPM is a physiological score that correlates highly to survival probability. Its
values range from 0, indicating no physiological response, to 12, indicating
respiratory, pulse and motor response within normal ranges. The graphshows that patients aged 75+ receive medevac transport at a much lower
percentage than other age groups with similar physiological presentations.
Percentage of Patients Using Helicopters
0%
5%
10%
15%
20%
25%
30%
35%
RPM 10 RPM 11 RPM 12
Age 0-7
Age 8-14
Age 15-54
Age 55-74
Age 75+
Efficacy and costs:Efficacy and costs:
Dana Strittmatter was boiling water in her kitchen in July when itspilled on her leg. After paramedics from Benbrooks EmergencyMedical Services arrived, they called for a medical helicopterfrom PHI Air Medical, a for-profit company that operates inDallas-Fort Worth and elsewhere.
PHI Air Medical flew her to Parkland Memorial Hospital inDallas She was treated and released in an hour accordin to her
Medical helicopter bill is 'a tough pill to
swallow Thursday, Dec. 03, 2009
. ,
husband, Larry. She had second-degree burns. But at the hospital, a doctor and others were angry that she had
been transported by helicopter, Larry Strittmatter said.
One doctor told him that abuse of medical helicopters is agrowing problem. The hospital expected her to arrive byambulance.
"They were shocked when the helicopter pilot radioed inannouncing his arrival," he said.
The final bill was $17,500.
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Effect of # Helicopters on Charges
Area A Area BSq. Miles:
58416 (Avg. NIC AK)
Population: (Avg. NIC AK)
5,743,304
R ti A r ri te e# Helicopters 4
# Helicopters 17
Pop per Hel: 331,084
Sq. Mi. per Hel 3436
Avg. Charges Necessary:$22,493
Population per
Appropriate Use: .0005
HMS Transports Per
Population: 2872
Annual Ops Budget:
$3.8m per aircraft
2 Engine IFR, NVG
Pop per Hel 1,407,109
Sq. Mi per Hel 14,604
Avg. Charges Necessary:
$5292
Note: Medicare Spending on HEMS up 434% in 7 years
Is this aviaiton?
Is this medicine ?
Who is in charge?
The Public AssumesThe Public Assumes
All medical helicopters have the same levels ofAll medical helicopters have the same levels ofperformance and aviation safety technologyperformance and aviation safety technology ----they do notthey do not..
All are well staffed by similarly trainedAll are well staffed by similarly trained
technology to provide the critical care neededtechnology to provide the critical care neededto keep them aliveto keep them alive ---- there is no suchthere is no suchguaranteeguarantee..
Helicopters transport those in need quicklyHelicopters transport those in need quicklyand efficiently to the closest appropriateand efficiently to the closest appropriatehospital at the right timehospital at the right time ---- tthat may or mayhat may or maynot be true depending on where they livenot be true depending on where they live..
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State Medical Oversight UnclearState Medical Oversight Unclear
Allowable state laws limited to care on board theAllowable state laws limited to care on board the
aircraftaircraft Medical equipment and supplies (to limited extent)Medical equipment and supplies (to limited extent)
Qualifications of medical personnel aboard theQualifications of medical personnel aboard theaircraftaircraft
Design of medical bay??????Design of medical bay??????
Configuration of aircraft for critical care??????Configuration of aircraft for critical care??????
Climate control??????Climate control??????
BUT, Hawaii letterBUT, Hawaii letter
Quality, availability, accessibility andQuality, availability, accessibility andacceptability prohibited regulationacceptability prohibited regulation
Medical equipment/supplies can go so far as toMedical equipment/supplies can go so far as toconstitute prohibited economic regulationconstitute prohibited economic regulation
Finding
the way forward
High Acuity Transport Medicine
What is your vantage point:
AMS Medical Director
Ground CCT Medical Director
Regional Medical Control
State Medical Director
EM Physician that needs to move patient
EM Physician receiving hospital
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High Acuity Transport Medicine
Medical oversight = risk analysis at
multiple levels: clinical, safety, fiscal,societal
Access / level playing field acrossgeograp y
Alignment, continuity and integrationwith EMS and tertiary care resources
Acceptable risk benefit ratio public andclinical transparency
Issues: Evidence Base Challenges
Limited outcome studies: + Support with accurate patient selection - Population based studies - System wide studies vs. disease specific
Limited cost benefit studies(metrics, additional lives, lifeyears)
Limited system replacement cost studies ground vs. air air vs. air air vs. no air air vs. rural / community hospital
Few policy studies unpublished / State of Vermont
Issues: Patient Selection Challenges
Trauma / Medical
Variation in practice Dispatch / Triage Use / Triage
Medical oversight variability
Mode of Transport Decision / UtilizationReview
Time / Distance accuracy secondary to careneeds
Kinematics / vehicle technology
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Issues in Designing System
Access and Equity
Medical oversight Practice of medicine (non-physicians)
Organization of services
ynam c env ronmen (organization across statelines, multi-state providers)
growth (iatrogenic changes in healthcare)
Evidence base for benefits (clinical / costs)
Use criteria
Risk / Safety
Quality management / practice variation
Medical Oversight: transport medicine
is a medical therapy decision.
Knowing is not enough, we mu st apply,willing is not enough, w e must do.Goethe
Epigraph :EMS at the Crossoads.Institute of Medicine 2007