There is a comment on Two Children Abducted by EMS Helicopter for One Laceration that demonstrates the ways we keep our standards low in EMS. We refuse to discuss problems and we discourage others from discussing our problems. Then we wonder why we aren’t getting paid what we are worth.
We are getting paid more than what the lowest common denominators we protect are worth.
In the comments, rick loughrey writes –
Ive been a medic before some or lol many of you were born so I do have a little experience in this matter…
My partner last night and my partner for my next shift were both born after I became a medic, so I also have a little experience in this matter.
I also have a little bit of experience reading the research that is worth much more than the experience of a bunch of us old guys sitting around swapping anecdotes.
This article leaves soooo many questions and quite honestly im confused as to why it was even written in the first place…
I already covered the lack of detail in the article.
This was written about the general problem of poor assessment and taking a helicopter out of service to keep a local ambulance in service, but you would have to read it to know that.
We DO NOT know the actual mechinism of injury nor do we know transport time….
What amount of transport time justifies flying two patients in two helicopters for one laceration?
[youtube]YzYxz_uvtSI[/youtube]
MOI (Mechanism Of Injury) is an excuse for a bad assessment.
CONCLUSIONS:
The majority of trauma patients transported from the scene by helicopter have nonlife-threatening injuries. Efforts to more accurately identify those patients who would benefit most from helicopter transport from the accident scene to the trauma center are needed to reduce helicopter overutilization.[2]
Which of these MOI criteria apply?
Significant MOI predictors of trauma center need include death in the same passenger compartment, ejection from the vehicle, extrication time of more than 20 minutes, fall from more than 20 feet, and pedestrian thrown/runover.[1]
We don’t even know if they tried the poke the spine test. In this case, it would be the the poke the laceration test.
So everything is speculation…
No.
That statement is a logical fallacy.
Not knowing everything is not the same as knowing nothing.
We need to stop basing EMS treatment on logical fallacies.
Logical fallacies are things that seem like they make sense, but only if we don’t think them through.
I used this example to highlight something that is not rare and is a real problem.
The problem of inappropriate flights is definitely not speculation.
If your gonna write an article about a particular incident then do your due diligence and interview the medic and goto original sourcing……We have enough speculation coming from the media and lawyers..
You mean interview the medical director, the quality control director, the medic, the rest of the EMS personnel, the family, the bystanders, the flight crew, and the doctors and nurses at the hospital?
Of course, if I do that, then I would be writing about this one specific incident and not the general problem of basing treatment and transport on mechanism and the general problem of inappropriate flights.
We dont need this from our own…
We do need this.
We need to stop imitating the Mafia code of Omerta and start correcting our mistakes.
I clearly indicated the lack of detail in the article, but you chose to repeat that as if you had identified some new information. You did not.
You chose to stress mechanism as if that is important.
We do not know how to assess, we base decisions on mechanism, and we fly patients who will not benefit from the flight.
Treatment without the possibility of benefit is what alternative medicine does.
We need to be better than that.
We can celebrate our ignorance or we can learn from our mistakes and improve.
We can have .
We can learn from our experience and have 10, 20, or 30 years of experience, rather than one year of experience over and over and over and over and refuse to learn, because we think we know better.
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Footnotes:
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[1] Not all mechanisms are created equal: A single-center experience with the national guidelines for field triage of injured patients.
Stuke LE, Duchesne JC, Greiffenstein P, Mooney JL, Marr AB, Meade PC, McSwain NE, Hunt JP.
J Trauma Acute Care Surg. 2013 Jul;75(1):140-5.
PMID: 23940858 [PubMed – indexed for MEDLINE]
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[2] Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis.
Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MF.
J Trauma. 2006 Jun;60(6):1257-65; discussion 1265-6. Review.
PMID: 16766969 [PubMed – indexed for MEDLINE]
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lol get a blog just on my response? pretty cool… Ok good, you did a point counter point response.. so I shall respond likewise.
But first let me start off, if you dont mind with your opening”There is a comment on Two Children Abducted by EMS Helicopter for One Laceration that demonstrates the ways we keep our standards low in EMS.” ok good, judgmental and agressive.. so now I wont mind not being as nice as I was in the first post 🙂
.so lets begin with the experience thing. Good to see that weve both been around for a while however your comment”.I also have a little bit of experience reading the research that is worth much more than the experience of a bunch of us old guys sitting around swapping anecdotes.” What do you know about me? Three degrees in my field of practice maybe? and to say that you read research articles..um..ok.. I am sure that you have at least a four year degree in this field as I do right? After all,, you did imply that ‘being in the field’ was not good enough..
next is the ” I already covered the lack of detail in the article.This was written about the general problem of poor assessment and taking a helicopter out of service to keep a local ambulance in service, but you would have to read it to know that.”…. Here’s the problem rougue,,,btw, a REAL NAME would be nice,,,You based YOUR ENTIRE ARTICLE off of hearsay did’nt you…Your actually condemning this medic and his actions in this article. It begs credulity . HOW DARE YOU disparage this medic from simply reading an article!!
your next response was” What amount of transport time justifies flying two patients in two helicopters for one laceration?” You then follow up with a conclusion from a meta analysis paper… Ok, now thats reasonable question to ask… You gave the medics,,whoops,, the articles statement that the medic states MOI( mechanism of injury).. You then go off about YOUR protocol.. I dont give a poo about your protocol.. What does HIS PROTOCOL state? Mine states that if the airbags are deployed then its a trauma alert.. Overkill? maybe.. But what happens when you dont follow you protocol?? Do you see where I going? You also bring up the comment about a simple laceration.. tell me Rogue,,, How big was it? where was it at? You interviewed EVERYONE right? Had one of these “simple” lacerations last week. Pt had no loss of conscious, no neck/back pain, gcs of 15. The hospital called for a trauma team.. WHY? PT had fallen more than 12 feet. Their call…Did you state what the medics protocol says about requesting a trauma team? uhhh nope.. Just yours..
next we come to my statement about you basing your blog on speculation. and your response was” That statement is a logical fallacy.Not knowing everything is not the same as knowing nothing.” …. Actually this is the WORST response one could give ESPECIALLY a medic!!! So your willing to cast dispersion’s on another medic when you dont know everything relevant… You wouldnt last a day at my company….How fast were the cars going? What parts of the cars were damaged? Were the kids wearing seat belts? was there interior damage to the car? Well???? ALL OF THESE QUESTIONS are relevent to wether or not a “Quickest way possible” transport is considered…oh ya,, btw,, WHAT was the difference in time for chopper vs ambulance??? you bitched about using the chopper and never addressed that..
now I know I jumped the gun a little by already covering the lack of due dilligence in researching this out properly instead of relying on an article.. and you state” .Of course, if I do that, then I would be writing about this one specific incident and not the general problem of basing treatment and transport on mechanism and the general problem of inappropriate flights.”.. um.. But you did write about this one incident… In fact you MADE it your centerpiece…Right???? If you wanted to write a general educational blog about this subject then you COULD HAVE MADE ONE UP!!! but nope.. instead you lambasted a medic OFF OF A NEWSPAPER ARTICLE!!!! un freaking believable…..
.FINALLY we get to the end where I say that we dont need this from our own… And you say” .We need to stop imitating the Mafia code of Omerta and start correcting our mistakes.” This I TOTALLY agree with…how about that.. A brief moment to agree but the WAY you have done this is unforgivable.. you state that MOI are not important…Now this is arguable but not the point of my complaint, my complaint is that you KNOW NOTHING about this call other than what you read in some paper.. As I said, you could of made up a call, given all the neccessary details for your readers to absorb and then give your thoughts.. but you didnt.. You also have fallen into the trap of “looking backwards” in that your referenced articles that are looking at % of trauma teams called that didnt need it.. What you HAVENT thought about is the time required to assemble a trauma team.. Lets say that the children there had not been flown out and died during the 45 minute transport.. From YOUR article, can you tell me this was not possible??? Can you tell me how long it takes the hospital to assemble a trauma team? so if that child arrives at the hospital and they then call a team, how much time was lost?
So I shall leave you with your own statement ” We can celebrate our ignorance or we can learn from our mistakes and improve.” Next time Rogue, take a step back and think before you respond to criticism, And leave your arrogance behind.
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rick loughrey,
I was responding in kind to your judgmental and aggressive comment.
I will respond appropriately to this more judgmental and more aggressive comment.
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I didn’t state that know anything about you. I was responding to what you wrote.
The two of us sitting around a table swapping stories making decisions based on anecedotes would not be a good basis for treatment decisions.
The same would be true of a bunch of doctors sitting around a table swapping stories making decisions based on anecedotes.
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Three degrees and you still do not understand that this was not about the medic, but about the way EMS approaches these kinds of calls.
If you want to comment on my ability to interpret research, I have a lot of examples on this blog for you to criticize.
Click on research or research blogging.
I can claim that I understand research, but I prefer to demonstrate what I know about research.
Feel free to add your comments to what I have written about research.
I did not state that degrees make up for anything. I regularly criticize people with medical degrees.
What I was stating is that evidence is much more important than anecdotes.
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If I had been writing this as criticism of the medic, I would not have written this –
You are still missing the forest for the trees.
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The reason I did not comment on his protocol is that I am not interested in his protocol, but in general EMS protocols that discourage assessment. MOI is only one part of assessment that may hint at what to look for.
I am writing this to criticize the all too frequent lack of assessment and the overuse of helicopters in EMS.
I do not have to follow my protocol if I can get medical command to give me orders to do what is best for the patient. Sometimes, I explain my deviation from protocol when I arrive at the hospital.
Fortunately, my protocols are more evidence-based than your protocols seem to be. I am trying to change that, but you seem to be happy using MOI to make your decisions for you.
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According to the article –
Why do you think that they were travelling in a car?
They probably were not wearing seat belts, but seat belts would not be appropriate at that age.
I love the way you blame me for your misunderstanding.
I do not care what the details are.
The only reason the medic’s name was mentioned in what I wrote was that I felt that the quote was useful for setting the scene and his name was in the quote. Since you seem to obsess on that, maybe I should have deleted the name. Of course, I cannot delete the name from the original story and maybe you would be just as inappropriately focused if I had written it with the name deleted.
We need to teach medics to focus on what is important – not to be distracted by the first thing that grabs our attention.
Your comments will be useful in pointing out how this error can be a problem in other areas of life.
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Lambasted?
I was more critical of the reporter than of the medic.
I was more critical of Dr. Scalea than of the medic.
You seem to have missed that.
Are your degrees from alternative medicine schools? Alternative medicine schools seem to produce graduates who lack the ability to think in anything other than the most concrete way.
We need to make EMS much less like alternative medicine and start doing what is best for our patients.
You appear to be trying to provide an excellent example of what I am criticizing.
We assess.
We diagnose.
We treat.
We do not assess just mechanism.
We do not diagnose just mechanism.
We do not treat just mechanism.
We assess patients.
We diagnose patients.
We treat patients.
Mechanism of injury should only be a part of our assessments, but our low standards mean that many paramedics are not capable of a better assessment than Look at that mechanism!
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I used the article because it was handy and it was being discussed.
That upsets you. Oh well.
You can provide some entertainment while serving as an example for others.
You have made this about the medic, while I have not.
This call is not what is important.
The concepts are important.
Forest vs. trees.
The research I cited makes it clear that mechanism is just one small part of our assessment.
If there were some assessment finding that would indicate that a flight to a trauma center is a good idea, what might it be?
A 4 stitch laceration to the forehead is something I would expect to be amusing to medical command if I called to request permission to fly a patient, because I do not have a stitches for a laceration flight protocol.
What if there had been a loss of consciousness?
That is not a good reason to fly patients.
What if the patient is not fully oriented, but is still following commands?
That is also not a good reason to fly patients.
What if we base our assessments on evidence that shows us what works?
What if we base our diagnoses on evidence that shows us what works?
What if we base our treatments on evidence that shows us what works?
What if we stop listening to the old guys sitting around a table telling anecdotes?
What if we make EMS about taking care of the patients, rather than continuing the EMS specialty of telling tall tales and making excuses?
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I did think about my response to your arrogant comment.
I think I did a good job of keeping it in line with your criticism.
You were more arrogant this time, so I was more critical.
I will keep trying to improve EMS, because our patients deserve excellent evidence-based care.
You can do the same or you can continue to obsess about what’s his name.
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Ok, now I’ve figured you out… you ask “what if we base our diagnosis on…….” bingo…there’s the problem…the forest through the trees…sadly you have lost site of the purpose of ems….There’s a phrase we use called worst case scenario. ” sir I don’t think your having a heart attack and simply pulled a muscle but to be on the safe side considering yr age and other factors, I’m gonna put you on a heart monitor n start an iv as precaution.” Do we have treatment overkill?? Of course…and why is that?? Maybe it’s because were not a mobile hospital w lab work n xrays and were not doctors…You keep referring to yr look from behind corrolational data to show x % didn’t need this or that…what about the ones that did?? THAT IS THE PURPOSE of protocols…to keep certain medics from making decisions that they NEITHER the education nor equipment to make…You said that you don’t care about what that medics or flight crews protocols said… we don’t diagnosis in the field….
rick loughrey,
It is by using assessment that we do not automatically treat everything as the worst thing it could be.
To treat everything as a worst case scenario is to dumb things down to a lowest common denominator level that does not require any kind of thinking medic – or any kind of medic.
Worst case scenario only requires a landing zone technician.
Call the helicopter for everything, because that is all we can do.
Thinking is dangerous.
What if somebody makes a mistake.
No need for standards.
No need for competence.
Standards and competence are not perfect.
Standards and competence are too dangerous.
You have fallen for the precautionary principle.
The problem is that perfection is an illusion.
We are too stupid to know what we are doing, so we can’t even try to provide competent patient care.
No more intubation.
Needle decompress everyone, just to be safe.
How can we be sure it is not a tension pneumothorax?
I know you are already anxious about having trouble breathing, but I have to stick these big needles in your chest in case you have a tension pneumothorax. We don’t have lab work, and X rays, and we are not doctors, so this is just to protect you from our incompetence. It’s for your own good.
Not treating it as a tension pneumothorax would require assessment, but we are using the worst case scenario, so we cannot assess patients.
What if . . .?
Worst case scenario treatment is dangerous, because everybody gets treated for the worst cases. Having someone competent at assessment treat the patients based on a competent assessment is much safer.
Competence appears to be a terrifying concept for you.
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Having protocols written for the lowest common denominator is a bigger reason for treatment overkill.
Having medical directors (doctors) who do not provide medical oversight, but assume that paramedics are incapable of learning, is another reason.
Having QA/QI/CYA department that do not know how to evaluate for good patient care, but only know how to compare charts with protocols, is yet another reason.
There are many things that paramedics can be taught to do safely, that improve outcomes, but looking only at the possible adverse effects will prevent us from improving outcomes.
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The first paper does look at the patients who did appear to benefit from transport to a trauma center. They were transported according to protocols that required transport for mechanism of injury. The results of the study show that your approach is not good patient care.
The second paper is a meta-analysis of 22 studies. The overuse of helicopters is because too many patients are transported by helicopter. Where do you get the idea that patients are not being flown? The studies show that most people are being flown with no need to go to a trauma center by helicopter.
Are you claiming that the paramedics are flying the uninjured patients to trauma centers and taking the unstable patients to the local hospital?
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As I stated above, you are claiming that we should lower the protocols to accommodate the weakest medics.
No standard appears to be too low for you.
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What is important is the systemic overuse of helicopters, not distraction by the comments of individuals.
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Except that it is not true.
You can also claim that protocols cover everything, but that does not make it true.
De jure, we do not diagnose.
De facto, we do diagnose.
You can try to ignore reality, but reality has a way of catching up with you.
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