Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Helicopters and Bad Science

There is an article in the Baltimore Sun about the recent MSP (Maryland State Police) helicopter crash. Advantages of medevac transport challenged.[1] The crash killed one pilot, one trooper, one EMT from one of the ground ambulances, and one patient who only appeared to have minor to moderate injuries. The other patient, with similar injuries survived.

If the patients are seriously injured, why is a patient surviving, when a physically fit trooper is killed by the same crash? There are differences in the way they are restrained in the helicopter.

Yet, the whole idea behind HEMS (Helicopter EMS) for evacuation of critically injured trauma patients is they are not expected to be able to survive for very long without treatment at a trauma center.

Patients, who are appropriate for HEMS certainly should not be capable of surviving a helicopter crash on the way to the trauma center, then continue to the trauma center, and still survive. This method of transport is for people who are already trying to die. If they are that stable, that a helicopter crash won’t kill them, then transport by ambulance – without a crash – shouldn’t kill them either.

The article mentions the lack of supporting research for flying patients.

This response comes from the doctors –

“Whenever someone says they want to ratchet it back,” says Dr. Thomas M. Scalea, physician in chief at Shock Trauma, “I tell them ‘OK, how many people can die next year to make that worthwhile?'”[1]

Apparently, Dr. Scalea does not include HEMS crew members in his concern.

Where is there any evidence to support this childish scare tactic. There is good reason to believe that HEMS does help, but only in very limited circumstances. Dr. Scalea is encouraging the indiscriminate use of helicopters. Dr. Scalea’s unscientific promotion of HEMS on trauma scenes is part of the problem. Many people have seen what Maryland has done and they are trying to emulate Maryland’s system.

Maryland does do some things well.

But these do not include –

1. Risk management.

2. Interpretation of research.

Where is the research that shows a benefit from transporting patients with minor injuries by HEMS?

Where is the research that shows a benefit from transporting patients with moderate injuries by HEMS?

Where is the research that shows a benefit from transporting patients by HEMS, when ground EMS will get them to the trauma center sooner?

Where is the research that shows the fatality rate of HEMS transport is outweighed by improved survival of patients transported by HEMS?

Why are we putting flight crews at risk flying patients who will not benefit from the HEMS transport?

Dr. Scalea’s point appears to be – the flight crews are expendable.

Similar to ancient Sparta. If you don’t come back with a patient on your stretcher, you’d better be on a stretcher, yourself.

The flight crew only exists for the glorification of HEMS.

The flight crews are expendable.

The patients are expendable.

The HEMS system is what matters.

The fear must take precedence over all else.

What if . . . ?

how many people can die next year to make that worthwhile?[1]

Anyone, who suggests that HEMS is not the answer – and the question is one that is constantly expanding – is then asked, “What if it were your mother/daughter/sister/father/son/brother? You would want them flown by HEMS.”

This is especially powerful to try to convince parents. What if it were your child?

I have always responded the same way. I would want Rogue Medic Junior transported in the most appropriate way for RM Junior’s condition, and to the most appropriate facility. RM Junior doesn’t bounce any better than anyone else.

Why do we feel the need to increase the risk to our children by playing on fear?

Another question that gets put to EMS crews that are not gung ho for HEMS, is –

You can’t be sure that there isn’t a Zebra Syndrome waiting to pounce on this child, drag him/her off into the underbrush, and leave horrible hoofprints all over the poor pathetic little innocent corpse.

The answer to that is clear. Doctors miss stuff, too. Even trauma centers miss stuff. If the problem is that there might be something missed, we need to fly everyone to only the very best hospital in the world. Nothing else is acceptable. We can’t trust those local ED physicians, who hear hoofbeats and think horses. No. We must react to anecdotal information, ignore science, and return to the dark ages.

Of course, we need the science of medicine to help the injured patients and the science of aerodynamics to get the helicopters to fly.

Quite the conundrum. Do we pay attention to science?

Should we encourage panic attacks when making important decisions?

No. Science has dramatically increased the life expectancy in this country. Life expectancy has approximately doubled over the last 200 years. This is due to good science. This is not due to scaring people about Zebra Syndrome.

Maryland officials are unswayed by the research, which they say is evolving and unclear.[1]

Evolving?

Science is always evolving. That is not a reason to ignore science.

Unclear?

Where is the science to demonstrate that this overuse of HEMS is good?

There isn’t any.

There is science to show that this abuse is bad.

This is like listening to homeopaths babbling about the memory of the diluted water they use. This is not science.

“If it’s my family or my patients, and there’s no definitive research, then I want to have a paramedic and a helicopter available,” said Dr. Robert R. Bass, director of the Maryland Institute for Emergency Medical Services Systems.[1]

What does the research say?

It is true that the research is not clear that HEMS is harmful, but when abused anything is harmful.

If it is my family or my patients, then I want to protect them from the extra risks.

Where is the benefit?

Consider, I am not opposed to all use of HEMS, just the abuses of HEMS. There is no reason to believe that a drive of even 40 minutes puts a trauma patient at greater risk. MIEMSS (Maryland Institute for Emergency Medical Services Systems) uses a 30 minute cut off. Why?

Yes, it is a dramatic show. The fire department shows up and sets up a landing zone. The helicopter can be heard approaching, you can see the flashing lights, you step back from the rotor wash. Everybody has to talk at the top of their voices, because of the noise. Yelling makes everything more dramatic – just look at reality TV. Then you give report to the flight crew.

Maybe you could have been at Shock Trauma already, but you called for HEMS, because the magic wand on top sends out healing rays as it spins. And it would be bad form to leave after calling for HEMS.

Why do doctors think that delaying arrival at the trauma center is better for the patient?

Why should we take the patient out of the helicopter to the obviously inferior care of Dr. Scalea and the others at Shock Trauma? If HEMS is the cure to everything, then we should take the patients from the hospital to the helicopter, fly around the parking lot for a bit, and come back for the next patient.

If the patient’s arrival at Shock Trauma was delayed only for the purpose of getting the patient in the helicopter, maybe the helicopter is the magic bullet. On the other hand, we are probably only playing Russian Roulette. Even with magic bullets, Russian Roulette isn’t safe.

“The accident victim who’s staggering and slurring his words: Is he drunk or does he have a brain injury? If the pre-hospital guys had X-ray vision, then they could diagnose every injury at the scene. But as a medical community, and as a country, we’ve made the decision that over-triage is preferable to the alternative,” he (Dr. Scalea) said.[1]

Overtriage can be acceptable.

The question is how much overtriage will result in better outcomes?

How much overtriage will result in more crashes and more fatalities?

These two questions need to be looked at together.

Anyone looking at only one of these questions should be ignored.

Does the patient appear to have a life threatening injury?

Will HEMS make a significant difference in transport time, that is likely to make a difference in survival?

Should anyone using mechanism alone, to determine if a patient should be flown, have their medic card shredded in a public ceremony?

Yes.

Should the doctor (medical director), who is responsible for teaching the medic this inappropriate use of mechanism, have his medical license disposed of in the same way, at the same public ceremony?

Absolutely.

It isn’t the individual medic, who sets dangerous policy. It is the medical director who sets dangerous policy.

We need research that looks carefully at enough patients, with enough control of variables, that we actually can conclude something definitive from the research. Where is the research from Shock Trauma that supports transporting these patients by helicopter?

In Maryland, apparently they do not have paramedics on many of the ground ambulances, so they fly the paramedic to the scene. This is insane. They are telling the local community – Don’t worry about paramedics, we will fly one in. There is a significant problem with too many medics in some places. So, why is it that a half hour from the White House, you don’t get a medic unless you call for a helicopter?

MIEMSS must be doing something to discourage medics. I did consider working in Maryland for a while, but not for what medics get paid there. A significant increase in the cost of living and a significant decrease in pay. Maybe they use the savings to buy helicopters. They sure don’t spend it on continuing education, because the medics can’t do much of anything on standing orders – except call for a helicopter.

Today, October 7, 2008, MIEMSS sent out a letter to everyone involved in HEMS – dispatch, ground providers, emergency departments, . . . . The letter states –

Please be advised that effective at 8:00 a.m. Thursday, October 9, 2008, all scene medevac requests for trauma patients that have only Category “C” or Category “D” trauma triage indicators will require medical consultation with the receiving trauma center for helicopter dispatch.[2]

So, what is this mysterious lettering system of trauma patients? If you refer to the state protocol,[3] you will see the explanation on page 142 of the pdf. The counter at the top of the page is easy to use. Type in 142 in the rectangle before /348. Yes, that does mean 348 fun filled pages to skim through otherwise. I realize that I am not the best person to make this comment, but they are writing too much. They are also trying to eliminate provider discretion.

Of course, that is a big part of the problem. We cannot write protocols that eliminate provider discretion. We can try, but all we do is demonstrate our ignorance. We need to train our people to think independently. Independent thinking appears to be heavily regulated in Maryland. Heavily regulated independent thinking is independent thinking in name only.

In the letter, Robert R. Bass, MD, Executive Director, MIEMSS, writes –

Please be assured that the requirement for medical consultation is not intended to imply or indicate concerns or criticisms of the treatment or triage practices by field providers. Instead, the requirement for medical consultation prior to helicopter dispatch for Category “C” and Category “D” patients is being implemented to provide an additional resource to EMS personnel responding to an incident.[2]

As the character of Col. Sherman T. Potter, on M*A*S*H, used to say – Bull Pucky!

This just gives you a taste of the way that the state of Maryland handles EMS. Take a look at the protocols. There was an update[4] sent out just last month. Aspirin for cardiac chest pain no longer requires a medical command order. Woo Hoo! You can clearly see why they want a paramedic to fly in to the scene. Obviously, they have the greatest faith in paramedics – to give aspirin, when clearly indicated, but only for the past month. Sorry, not even for a whole month, yet. Elsewhere in EMS, the bigger problem has been getting medics to get used to giving aspirin to chest pain patients, not in creating obstacles to appropriate care.

What kind of research has been done by Dr. Bass and Dr. Scalea to evaluate their opinion of the need for HEMS? Nothing.[5], [6] OK, there was a comment on a study of HEMS use that was signed by a bunch of trauma doctors. Dr. Scalea was one of them. So was Dr. Norman McSwain. Dr. McSwain is one of the doctors quoted criticizing the abuse of HEMS.

In Air Medical Journal, Ed McDonald writes about the current dramatic increase in HEMS crashes. This was before the September 27 MSP crash –

This can be a hazardous business if we do not exercise good judgment, do not have the proper tools, or push. I was once “10 feet tall and bulletproof” myself. After spending some very uncomfortable and painful moments over the past 39 years pulling what was left of my friends out of a smoking hole, I learned to be vulnerable and teachable. I became teachable enough to understand the value of conservative decision making before every launch and at every moment of every flight. Lose a few close friends who made poor decisions and one sees the value of conservative decision making. The value of “Just Say NO!” became priceless.[7]

Ed MacDonald is lead pilot for PHI Air Medical in Santa Fe, New Mexico, co-chairman of the AAMS/CORE Safety Committee, secretary of the Air Medical Safety Advisory Council, and safety representative for the National EMS Pilots Association. He is not someone who is opposed to helicopter use, just opposed to abuse.

The loudest voice in opposition to HEMS abuse has been often mislabeled as someone opposed to HEMS use. He is not. He is opposed to HEMS abuse. But read his article, Alright, I’ll Say It, in EMS1.com –

it hit me that I knew more people who have been killed in a medical helicopter accident than by virtually any other means. At some point in my life I have met or spoken with at least five people who later died in medical helicopter crashes. They were all great people and died doing what they loved. We owe it to their legacy to assure that not a single flight nurse, flight paramedic, pilot or patient dies unnecessarily.[8]

Clearly, Dr. Bledsoe is not someone trying to take advantage of a tragic situation, but someone trying to protect flight crews and patients.

Even on the federal level, there are attempts to make HEMS safer.[9]

Why are Doctors Bass and Scalea opposed to making HEMS safer?

Yes Trooper Medics wear ballistic armor. No, that does not make them “10 feet tall and bulletproof.”

Footnotes:

1 Advantages of medevac transport challenged
Baltimore Sun
October 5, 2008
Article

2 MIEMSS Medevac Requests Letter.
October 7, 2008
Free PDF

3 MIEMSS Maryland Medical Protocols
Effective July 1, 2008
Free PDF

4 Changes/Additions to 2008 Maryland Medical Protocols for EMS Providers
September 9, 2008
Document

5 Articles by Dr. Robert R. Bass
indexed by PubMed

6 Articles by Dr. Thomas M. Scalea
indexed by PubMed

7 Stop pushing.
Macdonald E.
Air Med J. 2008 Sep-Oct;27(5):210. No abstract available.
PMID: 18775382 [PubMed – in process]

8 Alright, I’ll Say It
By Dr. Bryan Bledsoe
ems1.com.
June 12, 2008
Article

9 S. 3229
To increase the safety of the crew and passengers in air ambulances.

Introduced July 8, 2008 by Sen. Maria Cantwell
Link to bill

.

Updated formatting /25/2011

Comments

  1. I live and work in an area where it can take me 30-45 mins to ground-pound someone to a trauma center. My factors to fly:1. Uncontrollable/unstable airway, since I don’t have RSI. With it, I am confident enough in my intubation skills to intubate a stone.2. Extended entrapment w/ moderate or severe injuries. Common sense.3. Combative trauma patients. Refer back to RSI.One Christmas (2003), I had a GSW in my neck of the woods. I was on-scene in 7 minutes, 5 minutes on-scene, and 20 minutes to the Trauma Center. Earlier that year, I actually BEAT a helicopter to the hospital. When I was a rookie, I would fly most things; now, I don’t unless it’s something I can’t handle.

  2. I’m an EMT-B in Maryland, so I thought I’d speak up.You keep saying paramedic. I don’t know about the other counties, but I know that Montgomery County uses a lot of EMT-I instead of EMT-P. Almost to the point that no one understands the difference. (Why they think a 6 month class is the same as a 2 years associates degree, I’ll never understand so I can’t explain it.) But most of our EMT-I need the restrictive protocols; they weren’t taught to think it through just do the skills.Hopefully other stations are doing something similar to ours and discussing appropriate use of helicopters. Our higher ups are discouraging use of helicopters for almost everything. Of course for us it’s faster to drive to our closest trauma center than it is to wait for the helicopter to arrive, let alone transport the patient. (Obvious exception cited was the fatal collision on I-270 when the 911 operator dispatched a helicopter based on the descriptions from the callers.)

  3. As another EMT-B from MD, I'll echo what the previous commenter said. EMT-I's are becoming much more prevalent throughout the state, as more and more FD that run EMS try to get more and more medics without spending the time and money (for the record, having been through the intermediate class in Montgomery County, it is 10 months, 3 nights a week and the occassional weekend, not 6 months). As an intermediate, you get a VERY brief training in A&P, and a full month on inserting airways (you even go to cadaver lab), but the rest of the time is spent on 'see this symptom, give this drug/do this treatment' type of instruction. You are not taught to think through what is causing the symptom, only to treat it as you ahve memorized and as the protocols say. Personally, having gotten my initial EMT license in PA, in a rural area where helos were slim pickings, I learned a difference way to deal with trauma patients. You should only call for a helo when the pt will NOT survive the transport to a ground hospital (and where I ran in PA, you had to go to a non-trauma center first to stabilize the pt…teh nearest trauma center was 1 hour away). You hit on the biggest problem I've seen in MD. The lowest common demonimator factor. Rather than teaching what is appropriate..good assessment skills, and how to paint a good picture for the doc you're on the radio with…they are creating rules so that the most basic of basics doesn't have to think. You just go down the 'trauma decision tree' checklist and VOILA!!! it tells you how to treat your patient. I've seen a guy RECENTLY flown, who was COAx4, from a car accident with moderate front end damage, restrained, who had a cut on his arm. The medic wasn't sure what she should do, so she called the trauma center and the local hospital. The local doc refused him becuase he had EtOH on board, and it 'could be masking more serious injuries.' IN the time it took to consult with the hospital, call the helo, and then wait for them, the guy could have been to local hospital and been triaged. But the state has every single medic looking over their shoulder for the zebra.

  4. Its rare for us to use them down here. In fact I think in my 6 yrs I have only seen them maybe 3 times. Ground transport is faster here. unless the dr. just insist and then it depends on the weather and availability of the helo. They are just to far out. so if available we take a nurse to help the medic in the back.

  5. Herbie,If they turn to stone, they probably don’t need a piece of plastic to keep the airway open. :-)I agree with your criteria. I think you would scare Doctors Scalea and Bass.GSW to the neck – even just in your neck of the woods – is reason to fly in some places. 🙂

  6. Beaker,I am not used to working with EMT-Intermediates. I am less interested in the letter after EMT, whether B, I, P, CC, or something else. What matters to me is that they understand what they are doing. More than once, an EMT-B has needed to remind me that I was forgetting something.Trauma treatment is almost exclusively BLS. I do not believe that blood dilution with saline helps, unless the alternative is CPR. Not that CPR works in trauma.It is good that things are improving.

  7. Ice Gnome,Maybe Beaker meant that as a Monday to Friday 9A – 5P course, it would be 6 months. I don’t know how the hours work out.I am less concerned with the actual amount of time in class. I know some of people who have spent years in medical school and are now attending physicians, but I would not want any human to be treated by them.What is learned is the important part. Sadly, there are some paramedic schools that are only interested in producing people who can memorize their way through the National Registry medic test.The LCD (Lowest Common Denominator) will always be there. We need to insist that they require a much higher LCD – one who is capable of thinking and authorized to use critical judgment.

  8. Life of an EMT,When it might affect destination, in a way that I don’t want it to, I do not believe in contacting medical command until I have to, for notification. If they want to tell me to fly the patient, I explain that I am now closer to their facility than to the scene of the injury (where the landing zone might be set up). Some doctors just take it for granted that a helicopter is somehow better. These tend to be the ones, who will insist that you wait on scene for a medic to show up, even though the hospital is closer than the medic. Helicopters do have paralytics, but if my patient can wait around for a helicopter to bring an airway, maybe the airway is not as bad as I think.

  9. As both a former EMS worker, someone who served in the US Air Force in a job whose primary responsibility in wartime is aeromedical transport (including a stint in Maryland during which I flew on Trooper 2 numerous times during transfer of patients out to Bethesda, Shock Trauma and elsewhere) and somone who currently researches aviation safety, I have to say this is probably the most mature conversation I have seen about this topic in a long time. It is certainly not the lowbrow, troglodytic sort of recourse I have seen from most of the people (mostly flight medics, but a few ground based medics and even a couple of docs) who have e-mailed me or called my home since I began speaking up about this. Thank you (all of you) for keeping the discussion mature and professional.RM, you are certainly right on the money with many of your points and these are the same ones I have have raised time and again along with my concerns about the lack of safety measures in place at most services. Dr. Scalea even told a reporter (and was quoted in an article) that he more or less did not give one iota what the evidence said, he did not see a problem with the current system. Perhaps it’s time both he and Dr. Bass be removed from their posts if they are going to treat prehospital emergency medicine more like a religion and less like a science. I think the only way anything will improve in Maryland with regards to EMS is to install a new leader, preferably one who has his feet on the ground and his head not in the clouds. However, knowing the state like I do, I think the chances of that happening are about as good as my chances of not being burned in effigy (along with Bryan Bledsoe, Ken Mattox, et al) at every conference for the air medical crowd from here on out.

  10. I was an active Maryland EMS provider for 12 years, an EMT-P for 10 of them. There are plenty of paramedics in Maryland–possibly too many, which is another debate in and of itself. I’m not as familiar with the county where this accident occurred, but I’m reasonably certain that there were ground paramedics available, and probably on the scene.My experience with Maryland EMS providers is that, in general, they don’t like to ride in the back of an ambulance for longer than 15 minutes. We joked that crews in the northern part of Montgomery County (Where I was) had no idea how to drive the the trauma center at the southern part of the county (maximum 30 minutes away by ground) since they flew everything out. I am reliably told that in Montgomery, at least, the practice has subsided thanks to a new county medical director. But as you can see, the state medical director does not entirely agree that diesel can be equally therapeutic as jet fuel. Beaker and Ice Gnome seem to have more recent experience in Montgomery County than I do, though. I was gone before the EMT-I phenomenon took over.As for the rest of the Maryland Medical Protocols…348 pages is a LOT of pages to say very little.

  11. In PA, there were some 40+ minute trips to the trauma center. I would be alone in the back, so I don’t know how to get to the trauma center, either. My partner does. I have always felt that these transports are an important part of the development of a medic. If you really can’t handle an unstable patient for 30 or 40 minutes, can you handle them for 10 or 20 minutes? The ones I call to fly are the ones where a helicopter will make a significant difference in travel time, not 5 or 10 minutes, and I think the difference will be important in the patient’s outcome. Mechanism is not a part of that.People would express shock at the suggestion of driving to a trauma center, but as the only medic on scene, I had the final say and we drove.That is one of the reasons I like working with a BLS partner. A large majority of the patients I have flown were because a medic officer on scene, usually my partner, insisted that the patient be flown. Since they outranked me, the patient was flown, but always for mechanism.It is actually just 326 pages, but the way pdfs put in blank pages adds 22 pages. Still not a short document. PA’s upcoming protocols are only 121 pdf pages. My lips do not need that kind of workout. 🙂

  12. The Erstwhile Medic,Thank you.I try to keep my arguments logical, with a healthy dose of sarcasm. We should adopt more of the CRM (Crew Resource Management) approach to EMS. Not to fixate on checklists, but to practice dealing with multiple malfunctions.There are many other examples of poor science in EMS, so I have plenty to write about. In Pennsylvania things do seem to be improving in many ways. Although, I still find plenty to criticize. I used to think that no progress would happen in Pennsylvania without a change in medical director. I have seen much more progress than I ever expected. I keep hearing good things about the state medical director from the local medical directors I talk to. It is still too focused on the Lowest Common Denominator, but it is improving.The root of almost every EMS problem is the lack of education in critical judgment and the attempts by some to try to prevent critical judgment.If we have thinking medics and protocols that encourage medics to think, then the treatment and transport decisions should end up being what is best for the patient. After all, helping the patient is the whole reason for EMS to exist.

  13. One of the problems with deciding about whether to fly or ground transport a patient is that we don’t really know what the risks are for ground ambulances. There has not been good data regarding ground ambulance crashes, so it makes it hard to calculate the relative risks of the two transport modes. Helicopters provide two things: speed and expertise (a highly trained crew). If it is quicker to go SAFELY by ground, then by all means, the patient should go by ground. If the patient needs a higher level of care than local EMS can provide, then the helicopter may have an advantage. The bottom line is that we need to provide the right patient the right care in the right amount of time.

  14. Actually there was an excellent study by the CDC (if I recall correctly….it may not have been the CDC) about the mortality related to ground ambulances. The truth is that far fewer people die in ground ambulance crashes than do in medical helicopter crashes, despite an overwhelmingly greater number of ground ambulances. The other part of your stance that is not necessarily correct is the claim that a medical helicopter is a higher standard of care. In many areas, this is not the case. The only places where the flight paramedics and nurses have a significantly more advanced capability is in states (such as Maryland) and other jurisdictions where the ground ambulances are handicapped by medical directors who do not put much faith in them. The few skills that might be thrown into the bag of tricks for the average flight crew are by and large not proven to be beneficial. Where the advantage of having a nurse (or RT, as a few services do for critical care transfers) on board really comes into play is in intrahospital transfers where things like IABP, etc are necessary to keep the patient alive. In fact, if there were significant differences that seriously mattered to the average patient picked up off of a scene one would see some survival advantage which is simply not borne out by the evidence. The only setting where the ALS provided by a helicopter crew might be beneficial is in a setting where no Intermediate or Paramedic is otherwise available. However, keep in mind that most ALS interventions have minimal proven benefit in trauma (outside of cases where advanced airway techniques are the only way to establish an adequate airway and a couple of other scenarios), so for the majority of patients (including some very critical patients) the most beneficial thing is going to be excellent BLS and rapid transport. For the cost of the MSP helicopter operations, more or less every EMS operation in the state could be upgraded to a paramedic level service with some of the most advanced training and skill sets on the planet. This however will never come to pass because Dr. Bass and Dr. Scalea would much prefer to have the media attention for their system that helicopters naturally attract.

  15. Rogue Medic, You said “The root of almost every EMS problem is the lack of education in critical judgment and the attempts by some to try to prevent critical judgment.” You hit the nail on the head! There is no substitute for judgment! You can teach a monkey to intubate, what’s important is knowing WHEN to do it! I am lucky to have lived and worked as a paramedic in an area (East Central Indiana) where field protocols for ground medics are fairly progressive (although they can vary dramatically from county to county). That said, the local medical director is almost always having to adjust protocols to the skills and judgment of the worst medic in the service area, and not all areas have ALS service in their county.I have been the ground-medic responding on the scene (ALS intercept) where the BLS service called for HEMS even before their arrival on scene (based on mechanism). My best practice was to assess the patient and then disregard the aircraft if the patient was not in need of HEMS.I will confess, however, to being on at least one scene when I pulled up as the helicopter was landing (single-vehicle motorcycle crash). Because of logistics, I arrived at the patient approximately 1 minute prior to the flight crew (MD/RN). In that one minute, with report from BLS and from a visual assessment, I could tell that this patient was VERY stable. Sadly, I didn’t have the cohones to tell the HEMS crew to “go home”. The patient flew. I still shake my head at that one. Of course, the helicopter could have crashed just as easily on the way back to base without the patient, so maybe I didn’t increase their risk-exposure as much as I fear. Still, I am dumbfounded at the adrenaline-driven “need” for a HEMS transport in some situations.The flip side of that coin is that the trauma center is sometimes an hour or more away by ground (depending on time of day and scene location)and medical direction almost always requires patients to be transported to the NEAREST hospital for “stabilization”. What happens, in reality, is that a sick trauma patient is taken to a non-trauma center and usually, at best, spends 1+ hours there with a staff who might see one serious trauma a month, if that. The local hospital does a “wallet biopsy”, drawing labs, getting plain films and CTs only to say “yup, they’re sick alright”. THEN the hospital calls for an “emergent transfer” (by air or ground). When the patient gets to the trauma center, they repeat all of the diagnostics. The “Golden Hour” has become the Golden FOUR hours. At WORST, the local hospital has an ICU and a neurosurgeon on staff (they even do surgery M, W and F!) and they admit the sick patient, only to let them CTD for another long period until the patient dies or is transferred when they are too sick to be helped.I bring this up only to say that on occasion the helicopter is the only way around the ludicris delay imposed by local hospitals. Thankfully, the best paramedics here know a sick patient when they see one and often call the helicopter, even if they are 1 mile from the “community hospital” citing prolonged extraction or some other “loophole” in the local protocols. The state of Indiana has no state-wide trauma system and thus there is no standardized way to deal with trauma patients. Ironically, my understanding is that Maryland does. I confess, I don’t understand using a helicopter close to the trauma center under the majority of circumstances. No one in a major metropolitan area should have to call for a helicopter to get a paramedic!I also worked a flight paramedic, and I also flew some patients who had NO need for HEMS. Over-triage aside, some were just calls by either panicked or adrenaline-driven scene providers.Ed McDonald is a wise man. I am proud to say that he is trying to change the “balls to the wall” culture of PHI HEMS, and the HEMS corporate culture at large, to one that is self-aware and as safe as possible, using AMRM (CRM for Air Medical providers). I flew for Dove Flight (a PHI Air Medical program) and was taught their “three to go, one to say no” policy. I was the wet-blanket on more than one flight, saying “Y’all go right ahead. I’m not going anywhere.” This policy, however, is only as good as the ability of the entire crew to use their judgment (there is that word again) on the go/no-go decision.The problem, as I see it, comes from both the HEMS “culture” and from the ground EMS systems and policies. In response to Herbie, I commend him for his short scene time and rapid transport of the GSW. Here is where the “devil is in the details”. If the GSW was to the NECK (as Rogue Medic playfully suggested) there could be a case made for HEMS IF the helicopter crew has RSI and the ground ambulance does not. The same goes for some serious burns (facial with suspected airway involvement, circumferential chest burns). Here is where the education piece comes in. Ground providers need to know what their local HEMS crews can do (not just that they have a “cool ride”). There have been times that the patient could have gone by ground in roughly the same amount of time as our flight, but we could do things that ground crews simply could not.I think extreme black and white thinking when it comes to HEMS is dangerous. Err in one direction and flight crews (and sometimes patients) die…err in the other patients die un-necessarily. The use of HEMS and the justification of flying sick patients has to be judged (there is that word again!) in CONTEXT: how sick is the patient, hwo far is the closest APPROPRIATE hospital, what are the capapbilities of the ground EMS crews…A final note, three of my co-workers were seriously injured when “our” helicopter crashed in February 2006 (the shift that relieved mine was the shift that crashed). I have watched them struggle to regain their health with mixed success. Some things will never be the same. They are fortunate. They are alive. They are there for their families to “love on”. The crew of AEL out of Rushville, IN was not so lucky. Their aircraft crashed just moments after lift-off from an LZ class/PR. Initial reports are that the main rotor just flew off. Three families will never see their loved ones again this side of Heaven.Thank you Rogue Medic for hosting a reasonable discussion of this important issue. I miss flying more than I can say (my career as a medic/RN was cut short by ALS/Lou Gehrig’s Disease)and I am proud to have probably acutally made a difference in the outcome for a FEW patients and lived to tell the tale.

  16. “You can teach a monkey to intubate, what’s important is knowing WHEN to do it!”Actually what is more important (and vastly more difficult to teach and convince people of) is when NOT to intubate or do any other procedure that.”Ed McDonald is a wise man. I am proud to say that he is trying to change the “balls to the wall” culture of PHI HEMS, and the HEMS corporate culture at large, to one that is self-aware and as safe as possible, using AMRM (CRM for Air Medical providers).”He is one of the ONLY people in the aeromedical industry whom I have any faith in the words that that come out of his mouth. Everyone else is extremely suspect until proven otherwise by good evidence.”The state of Indiana has no state-wide trauma system and thus there is no standardized way to deal with trauma patients.”In some ways, this is the best way to approach a very diverse area with a wide variety of circumstance and responders. The final decision on protocol development should be left to the local medical director. “The crew of AEL out of Rushville, IN was not so lucky. Their aircraft crashed just moments after lift-off from an LZ class/PR. Initial reports are that the main rotor just flew off. Three families will never see their loved ones again this side of Heaven.”I worked with the flight nurse aboard that flight (I also knew and had flown with the pilot who died on board Trooper 2). She was one of the kindest and most competent nurses I have ever had the pleasure of working with. She simply had the misfortune of working for probably the least safety oriented and most profit-driven aeromedical operation in this country.”my career as a medic/RN was cut short by ALS/Lou Gehrig’s Disease”I hope you are doing well. It is always a shame when health concerns sideline one of our colleagues. Both my fiancee and I wish you the best.

  17. I’m sorry it took me so long to respond, I was unexpectedly without internet.I actually don’t remember the exact length of the class, it was just an approximation of the difference. I was aiming more for what ice gnome said about treating the symptoms. Most paramedic programs that I know of (and it’s very few so maybe they’re odd) take the extra time to to teach more of the why and more of the thinking and not just the how.From the scuttlebutt around our station, the helicopter was called around the same time the ground people were called. So yes there were paramedics on the ground. But the helicopter landed before they were even done with the extrication. Here’s an article about the accident:http://www.wtopnews.com/?sid=1465359&nid=25Actually, we had another incident in Montgomery County recently. And you can already see the difference. A firefighter was badly burned. In the past they would have called a helicopter, but this time they transported him by ground.Washington Post Article

  18. Actually there was no extrication. Per both media reports and an MSP trooper acquaintance of mine, neither of the victims was entrapped. At least one of them was up and walking around after the crash.

  19. A long time ago in a galaxy not very far away, there was a new field of medicine in civilian life: EMS. In the 1960s and 1970s, emergency medicine was emerging as a specialty rather than a sideline for staff physicians. The first residents for this specialty were in 1970. At the same time, field providers, “paramedics,” were being educated and trained to provide some interventions out of the hospital. Trauma care was also evolving through the 70s, leading to the foundation of ATLS in 1978.Fast forwarding 10 years or so, Dr R. Adams Cowley worked to advance the care of trauma patients in Maryland as well as EMS in general. This resulted in the RAC-STC (R. Adams Cowley- Shock Trauma Center) being build and funded in Baltimore in 1989. The implementation of a statewide EMS system (based on trauma but including non-traumatic care as well) with permissive protocols and HEMS for transportation to THE trauma center catapulted Maryland into the forefront of 1980s emergency medicine.Sadly, the heirs of Dr Cowley’s program appear to lack his vision and Maryland has remained on the cutting edge of 1980s emergency medicine to this day.Please don’t get me wrong. Statewide protocols make it significantly easier to maintain licensure and move between different jurisdictions with multiple jobs, or with services not tied to a single jurisdiction. The mismash of protocols in some other areas makes things problematic for the medical direction physicians who are less familiar with their field medics’ capabilities. Especially when different services in the same jurisdiction are using different medication indications, dosing, etc.The problems that I have with Maryland’s system are that the state rests on their laurels while dislocating their shoulders patting themselves on the back about the “great” and “cutting edge” EMS system that they have. It is now 2008–19 years after RAC-STC opened–and the state has not significantly progressed in EMS. Medicine (not “even” emergency medicine) is not a field that can remain unchanging and still be state of the art. As previously pointed out, the science of medicine advances. With that advancement, some therapies may be found to be ineffective or less effective than others. Sometimes the studies are poorly done (but science illiteracy is another rant) or insufficiently subdivide the patient population. But the knowledge advances and the systems must keep up.

  20. If you don’t mind one patient’s perspective on the issue, I’d like to say how grateful I am to ALL emergency medical personnel, from those with only BLS training to the ER docs and nurses. We have an excellent EMS helicopter service in this area. A few months ago, I needed emergency transport to a larger hospital in another community and was later told that the docs at our local hospital considered calling for the helicopter, but decided not to based on weather conditions. I am very glad that a flight crew wasn’t put into danger that night, as I do NOT believe it would have been worth risking their lives simply to save my own! (I just hope the paramedic who ended up bagging me for the 30 mile ground trip will eventually forgive me for the inconvenience….)

  21. Rouge,I too am impressed with the way PA is progressing in EMS. Baby steps, my friend. That’s why I’m job hunting in PA. Either back to Stroudsburg, or to the Lancaster-Hershey area.

  22. The Erstwhile Medic,I am not familiar with what the costs would be to train the providers in Maryland, but I agree with everything else that you write.Trauma is treated best by BLS, except in rare cases.Not delaying transport is another important treatment.HEMS does not necessarily mean quality or expanded scope of practice, or more experience, but it should.

  23. I agree. After all, basic EMTs were derived to address the appalling number of deaths from motor vehicle crashes and paramedics were created to address medical cases that require ALS interventions to have their best chance of survival (cardiac arrest in particular). Thus far, no one has conclusively proven that ALS in the setting of trauma offers any significant increase in survival with a few specific exceptions, mostly involving inability to establish an airway. My estimate that you could train a most, if not all, of the EMS providers in Maryland was simply an extrapolation based on the exorbitant amount of money expended on helicopters in the state annually.

  24. Claudia Burrows,When Rogue Medic, Jr. was 6, coming to ACLS classes to demonstrate intubation was something that was cool, since the doctors and nurses had trouble with this. Unfortunately, instead of demonstrating that the skill is not the important part, the students viewed it as a put down. Not the message I wanted to deliver, so this was not repeated.You are absolutely correct. It isn’t any particular skill, but the common sense to make decisions about when to use the skill, that really matters.Although Dr. McSwain has been advocating transport to the closest facility, I am not a fan of this idea. This continues the dogma that we should keep EMS out of the decision making. There have been a few patients I have transported to the closest facility, because I did not have protocols that allowed otherwise. Maybe they would have died anyway, but their care was far from optimal in the local hospital.I have no problem with the appropriate use of helicopters. I do believe that one of the appropriate uses is to bypass the facility that is likely to miss something that will be more easily spotted at the specialty hospital, whether it is trauma, pediatrics, burns, cardiac, . . . . I think that the scope of practice should not be that different between HEMS and ground EMS for 911 calls. The medical director’s involvement is the most important part of a quality EMS agency and quality providers. Simulation is underused for training, but works very well. CRM is one example of good use of simulation.My wishes for the slowest of progress of your ALS. It is an illness that leads me to think of The Myth of Sisyphus. While Sisyphus was not able to control what he did with his body, he was fully in control of his mind. How you deal with that can make a tremendous difference in your sanity. Maybe there will be some sort of cure, soon. Perhaps from nanotechnology.

  25. The Erstwhile Medic,Calling Rogue Medic, Jr. a monkey. Grrr. :-)As far as a state-wide or nation-wide trauma system is concerned, I think that we should have larger coordinating groups. I used to work in an area, where the closest trauma center was across a state line. The local facilities were generally afraid of trauma and wanted everyone on a backboard to go to a trauma center. I worked in another area, where the local hospitals would put pressure on our bosses to take patients to the closest facility, even with GSWs to the head. The closest trauma center was about 5 minutes farther by ground than the closest local hospital. With no trauma criteria to bypass the local facilities, how many patients died to keep the census up? This also kept the census up in the morgue.There are many local vs, regional issues, but trauma, pediatrics, and burns are best handled by the specialists. We should be looking for ways to remove the obstacles to the patient arriving at the correct facility in a timely fashion.I do not think that a smart local medical director would oppose that.

  26. Beaker,you are responding more quickly than I am and this is my blog. I have no excuse.You are correct, the time difference is less important than the understanding of assessment and care.It is the doctor, who should be most familiar with the resources, who has been stating that the purpose of the helicopter is to bring paramedics to the patients. A very disturbing alternative to training EMS appropriately. He appears to want to control things, not delegate control. A sign of a poor manager.Thank you for the links. I will add them to my reading for tomorrow.

  27. Medic 3,Thank you for the history lesson. Shock-Trauma by Jon Franklin and Alan Doelp was a good book about the development of trauma as a specialty. It was a bit rah rah, but made a good case. Alan Doelp also wrote In the Blink of an Eye: Inside a Children’s Trauma Center, a good look at a similar specialty approach to patient care.The drive to stay on the cutting edge and the understanding to be moving that cutting edge scientifically for the benefit of the patients, is sometimes lost when there is a transition in leadership, or what passes for leadership.Perhaps, because they were catapulted?, they ended up plugged in the ground and have not been wise enough to just take the 2 stroke penalty and move the ball back a bit, but into play. Of course, it does feel good to flail at the weeds with a 7 iron (or a 5). :-)I have worked with a variety of protocols. I have statewide protocols now. They vary. When we had to have command in each different region, I had command in 5 different regions. I only needed to know the significant differences among the regions. The insignificant stuff was, well, insignificant. The statewide protocols are supposed to bring the dark ages medical directors kicking and screaming into the 90s, but they still allow them to require medical command permission for everything ALS. This is progress in name only. Some doctors should just not be medical directors.Science illiteracy is a huge problem. I have been working on some posts on that.

  28. Anonymous,I hope you are recovering well.Bagging a patient for half an hour is not really a big deal and nothing you should be apologizing for. A properly working transport ventilator would have been a better choice, since it is able to provide the lower concentrations of oxygen more accurately than adjusting the oxygen flow to the bag. A ventilator is also able to provide more consistent volumes of air than someone squeezing a bag. Many patients have trouble with manual bagging and need to be sedated. Some people are able to focus on the patient and deliver breaths in a way that keeps the patient relaxed.Since you are writing this, it seems as if the decision to transport by ground may have been the right way to go, regardless of the weather. Your life would also be one of those put at risk to fly into bad weather.

  29. Herbie,It isn’t just baby steps. They make big moves forward in one area, but pull back in other areas – and with no good reason for the restrictions.I am very glad they are restricting furosemide. I think that the number of pneumonia patients receiving furosemide should encourage them to improve education and medical oversight in the state, not just make furosemide a medical command only medication. It is a good thing that it is a useless EMS drug.It is good to have fentanyl and some standing orders, but they need to become much more aggressive in pain management. We had better standing orders for pain management in a couple of counties before the state protocols. Those now require medical command permission, especially when the bad medical command doctors are on. If the medics can’t handle aggressive pain management, should they really be treating patients with life threatening conditions?Hershey – mmmmm, chocolate. 🙂

  30. The Erstwhile Medic,I wasn’t really doubting your estimation of the costs. I just do not have any familiarity with the numbers as a practical matter. I try not to mess around with the financials of EMS. The maze of diversions for unrelated essential costs is dizzying.Medics were created to use the defibrillator, now that is something that does not even require an EMT or first responder.We want to think that medics make a big difference, but we restrict them in two of the areas where the difference can be clearly demonstrated – pain management and sedation. In stead, we have them starting large bore IVs to flush out the blood so oxygen doesn’t get to the cells, to dilute the clotting factor, and to force out any clotting that may have begun, or something like that. We are just treating vital signs and claiming that we are helping.It’s all about putting on a good show. Bring the helicopter to public events to impress the kids and make the moms swoon. And what real dad hasn’t played with toy helicopters. Ooh, Ahh!ALS is just emergency theater on a smaller scale. Especially if we can not provide the care that we are good at. And waveform capnography is mandatory for ALS in the new protocols. 🙂 Actually that last comment should have been added to my response to Herbie.

  31. Dave,

    I posted a bunch of charts, the first one should give you an idea about the relative frequency of fatalities when transporting patients by ground EMS.

  32. And now four more are dead because of all of this faux-science from the aeromedical community, including the 13 month old patient. The helicopter crashed in the Chicago suburb of Aurora. May God watch over their souls and their families in this horrific time.

  33. And now, the ground-pound times here in PA have been increased to 30 minutes or less.Baby steps.

  34. The Erstwhile Medic,Maybe they will be the ones who wake up the right people to make some changes.

  35. Herbie,Not that this was going to change what you were doing, but it may help change what others were doing. Fewer flights for no gain means less needless risk.

  36. There was some discussion of the number of EMT-Ps vs EMT-CRT-Is. Odd terminology. Either an EMT-I or a CRT, but if there is only one level of CRT, how is it an intermediate level?

    Here are some numbers from MIEMSS October Newsletter.

    Current Maryland EMS Providers.
    The total number of current Maryland EMS Providersis 28,328 as of October 14, 2008, (current, extended, jeopardy, military and inactive status)and distribution is as follows:EMD 911FR 8,291EMT-B 16,695CRT-I 863EMT-P 2,479

    There are almost 3 times as many EMT-Ps as EMT-CRT-Is. Many/most of those will be in the Baltimore area, but it does not tell us if the EMT-Ps are being replaced at a much quicker rate by EMT-CRT-Is.

Speak Your Mind