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

- Rogue Medic

Medevac Helicopter Improvement Act of 2009 – Maryland SB 650 – comment

In the comments to Medevac Helicopter Improvement Act of 2009 – Maryland SB 650, Tim wrote:

Without trying to be a snarky jerk, here’s my questions and comments:

They are valid questions and comments. I will try to answer them.

1. You consistently demand research to justify medical treatments, but offer none to backup your repeated assertion that crosstrained personnel are a bad idea. If this assertion cannot be backed up with empirical data, would you reconsider your point of view?

I do not know of any research that justifies using cross-trained EMS personnel. If there is to be a place where cross-training is a good idea, the rural setting is it. Everybody needs to be somewhat cross-trained to live in a rural environment. Help may not be just a few minutes away, but a few hours or days away. You’d better be capable of doing something until help arrives. That does not mean that everyone should be cross-trained to the paramedic level, but basic EMT might not be a bad idea.

Research should support an intervention before the intervention is implemented. The intervention here is cross-training. This has not been studied in EMS, as far as I know. So there does not appear to be support for adding extra, but unrelated duties, education, and training requirements for paramedics.

If we can put paramedics through more training, let’s make it quality EMS training. Unless you have a problem with too many medics, who are just too good to need any training/retraining. The paramedic scope of practice is likely to keep expanding. This does not suggest that unrelated training will be helpful.

We have too many bad medics. Cross-training makes it just that much harder to train people to be good at both. Having another skill that one performs well, although not related to EMS, can make it harder for a boss to make the right decision to get rid of a dangerous person. Or, since many fire departments see fire fighting as the primary role, even though it is just a small part of what fire fighter/medics do, they do not value the continual education that is important to providing excellent care. Is there any reason to be satisfied with less than excellent care?

If you want to have a high quality EMS system, you need to focus on EMS, not EMS and a selection from column B.

We have a problem with standards that are too low in EMS. I think that cross-training is a major part of the problem. I think this is done to satisfy fire chiefs in some of the big cities. Philadelphia has some excellent medics, but it isn’t because the standards are high. Some people just take a lot of pride in their work. They also have some people who should have a bunch of jail house tear tattoos for killing people. The low standards (and the union) make it difficult for anyone to get rid of these dangerous medics. The medical director is the one who should get rid of them, but he caters to the whims of the fire chief. In a pure EMS system, you should not have a non-medical person deciding who works and who turns in their uniform.

Fire fighting, or police, ability should have nothing to do with the evaluation of a paramedic. What does it have to do with patient care? We should not have to explain to the family of someone, who should have lived, He really is pathetic as a medic, but you should see him put out fires, or He couldn’t manage an airway with an anesthesiologist assisting him, but his conviction rate is the highest in the squad.

We have tests that are just mindless repetition of skill performance and others that are just multiple choice written tests. These are not good at weeding out the dangerous shouldn’t-be-medics.

The places that seem to be most fond of cross-training do not seem to be places that advocate cross-train nurses or doctors. Why not?

Why shouldn’t we cross-train doctors and nurses? They work in a hospital, so they have plenty of back up. If there is a fire near the hospital, we should be able to take advantage of that resource. If there is a crime near the hospital, we really need to take advantage of that resource.

What about the pilots? Why don’t they have to get cross-trained?

Each section is staffed by a crew consisting of a pilot and a Trooper/flight paramedic. Currently, we are recruiting civilian pilots.[1]

It is almost as if there is somebody thinking that being a helicopter pilot is an important skill. A skill that should not be detracted from by requiring a year or more away from that work to attend the police academy, then work on the street. How long it takes depends on openings on the helicopter for medics. Once you are accepted to the flight program you get 14 weeks to learn to become a medic again. Then you are on your own. Not completely on your own. There is a pilot up front. The pilot is not a trooper. The pilot is not a medic. That is your job. Both jobs.

Each helicopter has a two-person crew that consists of a pilot and a paramedic. As a paramedic in this Command, you will be solely responsible for the care of every patient you transport. You will not have a partner. As a result you must have strong pre-hospital Advanced Life Support skills as well as the self-confidence to use those skills. As a Trooper / Medic you will perform skills such as Rapid Sequence Intubation, surgical cricothyrotomy and needle chest decompression. Your skills must be sharp in order to handle this job.[2]

The single most difficult part of becoming a Trooper/flight paramedic is becoming a Maryland State Trooper. As you will learn by visiting the MSP Recruitment Unit Website , you will be required to undergo the same training as every other Trooper. This includes the twenty-six week residential Academy. Once you graduate from the Academy and complete Field Training, you will be assigned to a Barrack. You may then submit a request to transfer into the Aviation Command. The Command maintains an eligibility list that is based on your experience and qualifications, as well as the results of a skills assessment and interview.

Once you are accepted into the Command, you will undergo a rigorous fourteen week training program. This training includes:

Didactic Phase (7 weeks)

* A Complete review of all modules of the DOT Paramedic Curriculum
* ACLS Recertification
* Practical demonstration and review of basic and advanced life support procedures
* Clinical rotations in areas such as the Operating Room, Neonatal Transport Team, Shock Trauma and Burn Unit
* Maryland Protocol Review (and certification as a Maryland Paramedic)
* Airborne Law Enforcement training
* Search & Rescue and hoisting techniques

Flight Paramedic Field Training Phase (7 weeks)

* You will work as a flight paramedic under the supervision of a field trainer
* Familiarization with the Eurocopter Dauphin helicopter
* Review and practice with all equipment carried on the aircraft
* Review of the history of the Command, mission profiles, chain of command, etc.
* Use of all communications equipment
* Practical exposure to all aspects of flight operations
* Helicopter Safety

Once you complete the fourteen weeks of training, you will be assigned to one of the eight helicopter sections located throughout the State. You will then be a fully-functioning crew member and will be released to practice on your own.[3]

The single most difficult part of becoming a Trooper/flight paramedic is becoming a Maryland State Trooper. Doesn’t that explain how little importance they place on paramedic kniowledge?

Here is a link to a flight web discussion of the MSP Aviation program. These are all flight medics/nurses, or mostly flight medics/nurses. The people in the field, at least in this discussion, do not think highly of MSP Aviation. Why not? a lot of what I have already described. MSP does not even meet CAMTS (The Commission on Accreditation of Medical Transport Systems) standards for HEMS. They are the accrediting body for HEMS that sets standards for the rest of the country. The standards that MSP is far below.

2. How is the current MSP fleet pork? It is funded by a dedicated revenue stream (surcharge on vehicle registrations) that provides a benefit to citizens.

How is the building of highways pork? Somebody benefits from it.

The taxing of everybody to be able give something FREE to somebody else, somebody who votes for you. That is pork.

Where is the need to provide this service at no charge? Why not make all cardiac catheterizations free? Why not make all ambulance rides free? Why draw the line at a helicopter service that can do showy fly-ins at public events just to remind the voters what you are doing for them. Remember, in politics, you never stop campaigning.

Vote for this and when you are campaigning, we will have a helicopter do a fly by, so that you can show the constituents how cool you are. You can say, I did that. Really, you just had the tax payers pay for it, but this is politics.

Maybe they set this up to be funded by the tax payers, so that they would not have to meet the standards for reimbursement that insurance might require to consider MSP to be acceptable medical care.

You state that it is a benefit to the citizens. Where is there evidence of that? Dr. Scalea will claim that there are countless lives saved, but he does not back that up with any numbers. They point to the Golden Hour[4], but that is just a marketing slogan with no scientific basis[5].

On the other hand, I know of four people who would probably all be alive today, if not for some overly aggressive flight criteria.

3. Why replace a public system with a for-profit model that has not shown to be any safer than MSP? For all the faults of the Maryland medivac system, profit motives (and the need to fly more and more patients) are not among them.

If the need to fly more and more patients is not a problem, then why was there so much outrage at the suggestion that MSP was flying too many patients? MSP cut their transports by 2/3 and they do not appear to be having any worse outcomes, than when they were flying everyone based on vehicle damage.

This is a part of the problem with MSP. Where is the outcomes research to show that they are providing safe care with just one medical provider? Why did the NTSB hearings not produce any other service with just one medical staff member? Is there anywhere else where a single ALS provider is expected to RSI patients with no other ALS personnel? Doctors need to have someone else ALS present to RSI.

There is no major financial difference between private for-profit companies and government run non-profit companies. They both work with budgets and are punished and rewarded based on their ability to work within those budgets. The private companies have larger rewards – assuming that the public employee is not embezzling, which may not be a good bet.

We need fully disclosed operations to minimize the chances for corruption. MSP Aviation is reported to have at least one investigation going on.[6] Are any of the private companies being investigated for anything?

Again, not trying to be sarcastic – just articulate.

I’m interested in your response(s).

I hope I made my answers clear. I expect that there will be some things we continue to disagree about, but I hope you can see that MSP Aviation has not been a good example of HEMS for decades. This reform is necessary. MSP can still end up with both contracts.

Footnotes:

[1] Maryland Department of State Police
MSP Civilian Helicopter Pilot recruiting site
http://www.mspaviation.org/recruit_pilot.asp

[2] Maryland Department of State Police
MSP Trooper/Flight Paramedic recruiting site
http://www.mspaviation.org/recruit_medic.asp

[3] Maryland Department of State Police
MSP Trooper/Flight Paramedic recruiting site
http://www.mspaviation.org/recruit_medic.asp

[4] City Slickers 2: The Legend of Cowley’s Gold
…or 60 Minutes of Pyrite.
ParaCynic

[5] The golden hour: scientific fact or medical “urban legend”?
Lerner EB, Moscati RM.
Acad Emerg Med. 2001 Jul;8(7):758-60. Review.
PMID: 11435197 [PubMed – indexed for MEDLINE]

Link to Free Full Text Download in PDF format from Academic Emergency Medicine

[6] Pilot warned feds about copters before accident
By Kathleen Miller
Examiner Staff Writer 9/30/08
DCExaminer.com
Article

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