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

- Rogue Medic

Is the Difference in Penetrating Trauma Mortality Truly Significant? Part I

ResearchBlogging.org
 

MV observed the following lack of distinction in scene time for penetrating trauma mortality, which I did not give the proper attention in EMS Time and Survival from Blunt and Penetrating Trauma. I will try to correct my mistake here.
 

I find it interesting (good) that they actually published those graphs. I’m not sure what you can really say based on the graphs, as the error bars are way too wide to make good conclusions. For instance, there is no real difference in death rate due to scene time on penetrating injuries that can be determined by this study based on Figure 5.

 

Here is Figure 5.
 

 

On multivariate regression of patients with penetrating trauma, we observed that a scene time greater than or equal to 20 minutes was associated with higher odds of mortality than scene time less than 10 minutes, with an odds ratio (OR) of 2.90 (95% confidence interval [CI] 1.09 to 7.74). Scene time of 10 to 19 minutes was not significantly associated with mortality (OR 1.19; 95% CI 0.66 to 2.16).[1]

 

I should have paid more attention to this, rather than just looking at the brief description of the 0-9 minute vs. the 10-19 minute scene time intervals, which are not graphed vs. mortality.

Clearly, this graph is not a graph of 0-9 minute, 10-19 minute, and 20-29 minute time periods, but there is no explanation of the numbers represented by the graph.

If we eliminate the blunt trauma part of the graph, the wide error bars on the penetrating trauma percent dying show a lot of overlap. The error bars cover as much as a 50% difference in survival in one time period, while the narrowest error bars cover over at least a 15% difference in survival.

Overlap on error bars is usually an indication that the results are not statistically significant, but it depends on the type of error bar. The text describes CIs (Confidence Intervals) when comparing the 0-9 minute vs. 10-19 minute scene time intervals. However, the graphs do not specify which type of error bar is used, so we do not know how the error bars should be interpreted.
 

Error bars are a graphical representation of the variability of data and are used on graphs to indicate the error, or uncertainty in a reported measurement. They give a general idea of how accurate a measurement is, or conversely, how far from the reported value the true (error free) value might be. Error bars often represent one standard deviation of uncertainty, one standard error, or a certain confidence interval (e.g., a 95% interval). These quantities are not the same and so the measure selected should be stated explicitly in the graph or supporting text.[2]

 

There should not be so much overlap if there is any significant difference. It appears that the only way there is a statistically significant difference is by covering a ten minute time period.
 

 
Click on images to make them larger.

The last time period (≈ 26 minute scene time) has error bars that overlap with all of the other time periods, including the ≈2 minute scene time. The ≈2 minute scene time is the only time period where the median is not within the error bars for the ≈ 26 minute scene time.

 

 

Even the shortest scene time (≈2 minute scene time) has wide enough error bars to include the medians from two other time periods (≈6 minute scene time and ≈10 minute scene time). These would all fall within the 0-9 minute scene time group and the larger group can have enough patients to narrow the error bars. Wide error bars are often an indication of small numbers. For an example of this, look at the graph that contains the blunt trauma patients – those error bars are much narrower than the error bars for the penetrating trauma patients. The study had 16,170 blunt trauma patients and only 2,997 penetrating trauma patients. That means 5.4 times as many blunt trauma patients.

Paradoxically, the much larger group of blunt trauma patients did not produce any statistically significant difference in outcomes based on scene times or transport times. with more penetrating trauma patients, would the statistical significance disappear?

We do not know.

The authors state that the choice of time periods was made before analysis of the data, so this does not appear to be an example of trying to find the right groups to make the data fit the hypothesis.
 

We categorized out-of-hospital times into 10-minute intervals a priori with the intent of choosing an interval that is operationally practical, clinically feasible, and politically acceptable.[1]

 

I would like to see what the graph of 0-9 minute, 10-19 minute, and 20-29 minutes would look like.

None of this suggests that the concept of the Golden Hour should survive.
 

It is crucial for medical researchers to critically examine concepts such as the golden hour that are widely accepted but are in fact not scientifically supported. We frequently strive to push ever higher the ceiling of medical knowledge, but we must also ensure that the knowledge base upon which we stand is solid.[3]

 

Ignorance may be bliss for some people, but we will not improve outcomes for our patients by promoting ignorance.

Footnotes:

[1] Emergency Medical Services Out-of-Hospital Scene and Transport Times and Their Association With Mortality in Trauma Patients Presenting to an Urban Level I Trauma Center.
McCoy CE, Menchine M, Sampson S, Anderson C, Kahn C.
Ann Emerg Med. 2013 Feb;61(2):167-74. doi: 10.1016/j.annemergmed.2012.08.026. Epub 2012 Nov 9.
PMID: 23142007 [PubMed – in process]

[2] Error bar
Wikipedia
Article

[3] 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

Lerner EB, & Moscati RM (2001). The golden hour: scientific fact or medical “urban legend”? Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 8 (7), 758-60 PMID: 11435197

McCoy CE, Menchine M, Sampson S, Anderson C, & Kahn C (2013). Emergency Medical Services Out-of-Hospital Scene and Transport Times and Their Association With Mortality in Trauma Patients Presenting to an Urban Level I Trauma Center. Annals of emergency medicine, 61 (2), 167-74 PMID: 23142007

.

EMS Time and Survival from Blunt and Penetrating Trauma

ResearchBlogging.org
 

People will tell you that they just know that we need to load and go. Some even claim that the mythological Golden Hour is real. Maybe there will be an episode of Ancient Aliens about R Adams Cowley identifying the meaning of trauma and writing it on a cocktail napkin in a bar.
 

Debate continues over the “load and go” versus “stay and stabilize” approach to patient care in the out-of-hospital setting because there is a paucity of supportive data for either argument.[1]

 

All trauma alerts and patients who were not trauma alerts, but were later admitted to the trauma service of a level 1 trauma center from 1996 to 2009 were included.
 

Exclusion criteria were extrication, missing or erroneous out-of-hospital times, intervals exceeding 5 hours, missing data, and nonblunt or penetrating injury (ie, burns, drowning, hangings).[1]

 

One odd aspect of the data is that they do not record the response times, so the out-of-hospital times do not include response times.
 

we contacted the county EMS agency to obtain general descriptive information on county response times. For basic life support response, the median 90th percentile for system standard response times is 6 minutes 15 seconds (range 4 to 8 minutes). For advanced life support response, the median 90th percentile for system standard response times is 6 minutes 5 seconds (range 4 minutes 28 seconds to 7 minutes 45 seconds).[1]

 

The response times seem to have pretty good consistency, so maybe that does not affect outcomes. Still, the out of hospital time period does need to have response time added.
 

We categorized out-of-hospital times into 10-minute intervals a priori with the intent of choosing an interval that is operationally practical, clinically feasible, and politically acceptable.[1]

 

 

It is interesting that the mortality rate increases until about 22 minutes of scene time, then mortality improves. This could just be a factor of the small numbers with scene times that long.

For blunt trauma, almost the opposite pattern exists. Fans of immobilization might see this as some kind of evidence that back boards save lives. Maybe immobilization kills any benefit to short scene times, but shorter scene times do seem to increase mortality.

There may be a Diamond Scene Time of 5 minutes for penetrating trauma. Between the ≈2 minute scene time and the ≈7 minute scene time the mortality rate jumps dramatically, but this may also just be a function of small numbers.

How much time is appropriate/necessary for penetrating trauma?

Even PHTLS (PreHospital Trauma Life Support) guidelines tell us that there is no reason to worry about “spinal immobilization” for penetrating trauma, unless there is some noticeable neurological deficit.[2] No worries about distracting injuries with penetrating trauma. There probably still is not any benefit to immobilizing these patients.

Therefore, for trauma patients with serious injuries, the most important parts of scene time are the time taking the stretcher (without the spinal implements of destruction) to the patient, a rapid assessment, plugging the holes and managing airway while moving the patient to the stretcher, then moving the stretcher to the ambulance.

Not much time needed.
 

 

There is a very clear connection between severity of injury and survival.
 

The odds of mortality with patients having an Injury Severity Score greater than 15 was 91.06 compared with those with less than 15 (95% CI 70.07 to 118.34) (Figure 6).[1]

 

An OR (Odds Ratio) of 90 is huge.
 

The association between increased out-of-hospital times and decreased mortality may be in part explained by EMS providers moving with haste for patients thought to have serious injury and taking more time for patients recognized as having minor injuries.[1]

 

With penetrating trauma, there may be less of an effect, but it should not produce opposite outcomes.
 

Our study did not find an association between transport times and mortality.[1]

 

Even further suggestion that we fly far too many patients for no apparent benefit.

The authors suggest that this might reflect the benefit of driving past a non-trauma hospital to arrive at a trauma center.

Almost all of the patients had scene times in the 0-9 minute and 10-19 minute groups and transport times in the same groups. The scene times produced statistically significant differences with distributions similar to the distributions of the transport times.

Is the transport time less important?

Does more time on scene really improve survival for blunt trauma patients?

 

Also see –

Is the Golden Hour Full of Crap?

And my correction of my too simple look at the data and graphs from this study –

Is the Difference in Penetrating Trauma Mortality Truly Significant? Part I

Footnotes:

[1] Emergency Medical Services Out-of-Hospital Scene and Transport Times and Their Association With Mortality in Trauma Patients Presenting to an Urban Level I Trauma Center.
McCoy CE, Menchine M, Sampson S, Anderson C, Kahn C.
Ann Emerg Med. 2013 Feb;61(2):167-74. doi: 10.1016/j.annemergmed.2012.08.026. Epub 2012 Nov 9.
PMID: 23142007 [PubMed – in process]

[2] Spine Immobilization Following Penetrating Trauma
PHTLS podcast
PHTLS (Prehospital Trauma Life Support)
http://www.phtls.org
1/18/2010 12:00 PM
Podcast page

McCoy CE, Menchine M, Sampson S, Anderson C, & Kahn C (2013). Emergency Medical Services Out-of-Hospital Scene and Transport Times and Their Association With Mortality in Trauma Patients Presenting to an Urban Level I Trauma Center. Annals of emergency medicine, 61 (2), 167-74 PMID: 23142007

.

Is there any evidence to support the Golden Hour?

 

In the comments to Emergency Medical Services Intervals and Survival in Trauma – Assessment of the “Golden Hour”[1] is the following from someone identifying herself as Mrs Roberta S Cowley,M.Ed.CCC-SLP.
 

Re Dr. R Adams Cowley inventor of the Concept of the Golden Hour. I recommend that you research the results of Army Contract DA-42-193-MD-229. 1959.
The results of the research studies on “The Golden Hour” as well as ALL professional works were requested by and donated to the University of Utah, Marriott Library. I recommend that you study the thousands and thousands of documents donated to the University before you show the world your
ignorance.

 

I would like to see these documents that you claim support the invention of the Golden Hour.

Please provide some link to the actual documents, because searching Army Contract DA-42-193-MD-229 provides nothing.

Researchers have looked for evidence to support the Golden Hour in the thousands of documents do not support the claims of R Adams Cowley.
 

We made an attempt to identify the origin of the ‘‘golden hour’’ and the scientific evidence upon which it is based.[2]

 

What is in the documents that this person claims contain the evidence that supports the Golden Hour?
 

Cowley passed away in 1991 and the University of Utah maintains his personal papers. A request to the University of Utah library for any additional information on the origins of the golden hour yielded two outlines of Cowley speeches.[2]

 

Thousands and thousands of documents, but all that they include is two outlines of speeches related to the Golden Hour.

These speeches appear to continue R Adams Cowley’s pattern of making claims about the Golden Hour without any valid evidence.
 

A search of research articles by Cowley on trauma provided several leads. One was a trauma case series of 760 patients that he co-authored in 1979.11 This case series gives no details of the patients’ times to definitive care and their relation to outcome.[2]

 

Without any details about time, the research cannot be honestly used to support any claim about time.
 

Within this 1975 article, another review of the Maryland emergency medical services system, he states that: ‘‘the first hour after injury will largely determine a critically-injured person’s chances for survival,’’ but no data or reference is provided.16 [2]

 

A claim with no evidence to support it. That is what I have been criticizing about the Golden Hour.
 

While it appears the term most likely did originate with Cowley, it does not appear to have originated from explicit research findings.[2]

 

Unfortunately, the basis for the Golden Hour appears to be as valid as a used car salesman’s claims about a car only being driven to church by a little old lady.

The Golden Hour is a marketing gimmick to sell trauma systems and routine helicopter transport to the uninformed. While trauma centers appear to be good, routinely flying patients, to avoid a drive of 45 minutes to an hour, is not good.
 

Image credit.
 

It is crucial for medical researchers to critically examine concepts such as the golden hour that are widely accepted but are in fact not scientifically supported. We frequently strive to push ever higher the ceiling of medical knowledge, but we must also ensure that the knowledge base upon which we stand is solid.[2]

 

The Golden Hour, Trendelenburg position, “spinal immobilization,” high-volume fluid resuscitation, MAST (Medical Anti-Shock Trousers), and other superstitious treatments are still encouraged by some trauma specialists.

These superstitions are not based on valid evidence.

Footnotes:

[1] Emergency Medical Services Intervals and Survival in Trauma – Assessment of the “Golden Hour”
Fri, 20 Nov 2009
Rogue Medic
Article

[2] 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

.

Corner Posting – Better, Faster, and Cheaper than Stations – Prove It

A recent article in JEMS has reignited discussion about street-side posting.

Why?

One reason is that it is seen as cheap and some employers become tumescent at the thought of cheap.

The debate to define “acceptable” response times is finally coming to a head, with evidence-based research and customer satisfaction and expectations driving this definition;[1]

Evidence-based research?

Would that be something like clock-based time?

We do not have any evidence (that I know of) that response time is important – except for cardiac arrest.

Cardiac arrest is generally estimated to be about 1% of our calls. Whatever the percentage, it is tiny. Should we respond to every call as if it is a cardiac arrest?

If any of you think we should, please explain why.

If any of you know of any evidence that supports 7:59 response times, or 8:59 response times (on 70%, or 80%, or 90% of calls), please provide that, as well.

customer satisfaction and expectations driving this definition;

That is a part of the problem, we have a system that is poorly understood – even by the people who work in it (the medical directors, employers, and the people in the ambulances), but we let the least informed people tell us how to run things. There will always be some need for public accountability, but they probably do not want to be making decisions based on ignorance.

The people I have talked to are surprised, when I tell them how the system really works. Some don’t want to know. Some want to know more. If they have any expectation of needing an ambulance, they want to know that it is going to be available and competently staffed. They think that response times are very important, but we still have a lot of people in EMS who think that response times are very important. And nothing good seems to happen quickly when we’re having an emergency.

R Adams Cowley did some good, but he also dragged us deep into the superstition of The Golden Hour.[2] Many of us refuse to escape from that golden cocoon of ignorance. It isn’t gold, it’s urine, but as long as we are warm and wet, we are happy.

EMS is not just package delivery. Even if it were, the outcome for the package is more than just the pick-up time. Should out motto be What can Blue do for you? If you think so, UPS has a position that may interest you, although their slogan doesn’t rhyme. 😉

Prehospital medicine across the U.S. is, for the most part, standardized,[1]

No. EMS care can vary dramatically by travelling across a city line, or a county line, or a state line.

If this is supposed to be justification for ignoring that nasty medical stuff, then Mr. Washko has this backwards. The patients who really need EMS, need the medical care, not a savings of two minutes, or four minutes, or six minutes, just to be bundled into an ambulance for a carefree version of Mr. Toad’s Wild Ride to the closest ED (Emergency Department).

We can initiate care on scene and continue care on the way to the most appropriate ED.

Some services are even providing Community Paramedics, who don’t need to transport patients to the ED. That is a concept that might blow Mr. Washko’s mind – in a grow three sizes kind of way.

Grinch:
How could it be so?
It came without sirens! It came without lights!
It came without yelps, wails, or frights!
Narrator:
And he puzzled and puzzed, till his puzzler was sore.
Then the Grinch thought of something he hadn’t before!
“Maybe EMS,” he thought, “isn’t being first to the door.
Maybe EMS… perhaps… means a little bit more.”
[3]

Some have attempted to correlate survival rates with the number of active paramedics used in the system, but I find this absurd. (I know the e-mail inbox will be filled after this one with those who disagree with this statement.)[1]

Not absurd.

More medics = worse outcomes.

Skills are important. Diluting those skills among a bloated paramedic population that is three, four, or five times larger than it needs to be dilutes skills.

If we dilute skills, and assessment is the most important skill, then maybe we do need to drive fast.

We do not need to dilute skills. We need to educate the public, and those who drink the more medics = better medic Kool-Aid.

Sitting in the front of an ambulance and being placed on a street corner is not as comfortable as responding from a warm bed in a station’s bunk room, but it gets the medicine into a critically ill patient’s veins a lot quicker.[1]

Sleep is important for shift workers. Police, fire, EMS, and emergency medicine. We need to be incorporating naps into our schedules. Lack of sleep may result in the wrong medication going into the patient’s veins.

The results revealed that taking a single 20-min nap during the first night shift significantly improved speed of response on a vigilance task measured at the end of the shift compared with the control condition.[4]

There is a lot to criticize in Mr. Washko’s article.
 

Go read what Bob Sullivan wrote about the rest of the article.[5]
 

Bob also provides links to evidence that more medics means more skill dilution, but there is a lot of evidence, so I will be writing more about that.

And will anyone want us sitting in trucks, with out engines running, with increasing awareness of the connection between diesel exhaust and cancer?[6] Because we often hear people yelling –

Please, put the carcinogens in my backyard!

Footnotes:

[1] EMS Moves Toward New Care Delivery Methods
JEMS.com
Jonathan D. Washko, BS-EMSA, NREMT-P, AEMD
From the July 2012 Issue
Tuesday, July 3, 2012
Article

[2] 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 Acad Emerg Med

[3] How the Grinch Stole Christmas! (TV special)
Wikiquote
The original lyrics.

[4] The impact of a nap opportunity during the night shift on the performance and alertness of 12-h shift workers.
Purnell MT, Feyer AM, Herbison GP.
J Sleep Res. 2002 Sep;11(3):219-27.
PMID: 12220318 [PubMed – indexed for MEDLINE]

Free Full Text from J Sleep Res.

[5] Corner Posting: Better, Faster, & Cheaper than Stations? Prove It.
EMS Patient Perspective
July 7, 2012
Bob Sullivan
Article

[6] Diesel exhaust
American Cancer Society
Information page

.

A Comment on Myths and the 2015 ACLS Cardiac Arrest Algorithm

In the comments to 2015 ACLS Cardiac Arrest Algorithm, Mr. M objects to the following statement of mine –

SSM (System Status Management) continues to burn out crews and vehicles, but some administrators continue to believe. Since they administrate in back offices, we do not know where their hands are. Improved response times? The difference in response times is insignificant and response times have never been shown to be important outside of cardiac arrest.

It is not clear if Mr. M intends to defend SSM, but here is his response.

Response times are insignificant outside of cardiac?

Except for cardiac arrest, there is no evidence that quicker response times make any difference in outcomes.

You need to produce some evidence, if you want to claim that response times affect outcomes (except for responses to cardiac arrests).

I am sorry but i very much disagree, if i have a pt who is having a cardiac problem (usually just ‘my chest hurts’, not usually a full blown AMI) it makes not a whole lot of difference if you get there in 10 minutes or 30, they make it to the hospital none the less, there is no field tested proof that a petal to the metal fast response increases chance of survival.

How do you know the difference between just ‘my chest hurts’ and a full blown AMI.

12 lead?

Troponin?

Neither is capable of ruling out a cardiac cause of chest pain.[1]

There may be a reason for that lack of evidence.

However, what about trauma? How could you in good medical reason tell us that there is no difference if response times are fast or slow in trauma? The first thing they hammer into your head in training as EMS and Doctors alike, is the Golden Hour for treatment and the Platinum 10 minutes for EMS transport, it’s there for a reason.

The Bogus Hour Golden Hour is just one of many EMS myths.[2] [3] [4] [5]

The Golden Hour was also the basis for the predictions of death and destruction by Dr. Thomas Scalea when Maryland scaled back their flight criteria so that a doctor would have to be called for permission to fly patients for MOI (Mechanism Of Idiocy Injury).

“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?’”[6]

As I have mentioned before –

We were promised dead bodies.

Where are the dead bodies?

There does not appear to have been any change in the trauma fatality rate, even though flights have been cut by more than half. 😳

The Golden Hour is just a sales pitch created by R Adams Cowley in a bar to sell his trauma system to the tax payers.

There is no evidence to support the Golden Hour.

The Golden Hour is a just a marketing tactic.

If you want to claim that the Golden Hour is legitimate, then you need to provide some evidence – R Adams Cowley never provided anything except double talk.

Footnotes:

[1] Rule Out MI with 12 Lead ECG
Rogue Medic
Article

[2] 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]

[3] Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort.
Newgard CD, Schmicker RH, Hedges JR. at al.
Ann Emerg Med. 2009;(in press, may end up with a 2010 publication date)
PMID: 19783323 [PubMed – as supplied by publisher]

[4] The Golden Hour
StreetWatch: Notes of a Paramedic
Article

[5] Revisiting the Golden Hour in Trauma
CLIC-EM Clinical Insights from Chicago Emergency Medicine
Article

[6] Advantages of medevac transport challenged
Baltimore Sun
October 5, 2008
Article

.

Emergency Medical Services Intervals and Survival in Trauma – Assessment of the “Golden Hour”

ResearchBlogging.orgThere is a very important paper due to be published in the Annals of Emergency Medicine.[1] I expect that there will be a lot of criticism of this paper. There will be many reasons for being cautious in implementing the suggestions of the authors, but bad research is not one of them.

One of the difficult things about this paper is that the authors are very good about identifying potential confounding influences. They explain that there are many factors that may have affected the results. They are thorough in pointing out the many different ways they analyzed the data to try to minimize any potential confounding influences. While many may look at this study, see the amount of doubt the authors express throughout the study, and conclude that there is too much uncertainty to pay any attention to this study, they would be wrong to do so.

Trusting in the certainty of those promoting the Golden Hour is the true error. Anxious exhortations to Panic! and Faster! and Panic faster! are not substitutes for good patient care.

The Golden Hour has been around for decades. This is the idea that seriously injured patients need to receive definitive care within 60 minutes of that serious injury.

The amount of information used by Dr. R Adams Cowley to concoct the Golden Hour could fit onto a cocktail napkin. According to legend, it was dreamed up in a bar, so maybe it did fit onto a cocktail napkin. The Golden Hour is not science. The Golden Hour is marketing, and very successful marketing. There are still plenty of people citing the Golden Hour as their excuse for all sorts of mistreatment of patients – But we have to get them to the trauma center inside the Golden Hour. A more appropriate term is the Bogus Hour.

The commonly used 8 minute response time (or 8 minutes 59 second response time in some places) limit (in at least 90% of responses) is based on the AHA’s (American Heart Association’s) Chain of Survival. The interesting thing is that cardiac arrest survival appears to be the only condition that has good science supporting a short response time.

To date, patients with out-of-hospital cardiac arrest remain the only field-based patient population with a consistent association between time (response interval) and survival.18,19[2]

The authors of this study probably looked at far more data on trauma time intervals than any other study. They evaluated the data in as many different ways as they could think of, to see if there were any ways that there could be a connection between prehospital time and survival. In spite of all of these different ways of evaluating the data, the conclusion based on all of the evidence is – time does not make a significant difference in survival for unstable trauma patients.

This was not a study just looking at all trauma patients, the patients meeting only anatomic criteria were not included. The same is true for patients only meeting mechanism criteria. In other words, they excluded most of the patients transported to trauma centers.

Why?

Because these patients do not have serious enough injuries to expect time to make a difference. Even though these patients are rushed to trauma centers, their injuries have not resulted in unstable vital signs/level of consciousness. Therefore, they are not considered to have significant injuries for the purposes of this study.

Here are some representative anatomic criteria and mechanism criteria for trauma triage –

Anatomic Criteria:
• Penetrating injury to head, neck, torso and extremities proximal to elbow or knee (unless obviously superficial)
• Chest injuries with respiratory distress (for example, flail chest)
• Two or more proximal long-bone (humerus or femur) fractures
• Pelvic fractures
• Limb paralysis (spinal cord injury)
• Amputation proximal to wrist or ankle[3]

None of these qualify to get the patient into the study – shooting, stabbing, nibbled at by a lion, – unless the patient has signs of being unstable.

Mechanism of Injury:
• Death of another occupant in same vehicle
• Auto vs. pedestrian (bicycle) injury with significant impact
• Pedestrian thrown or run over
• Extrication time > 20 minutes
• Falls from > 20 feet
• Ejection from vehicle
• Vehicle rollover
• High-energy vehicle crash (e.g. significant intrusion into
passenger compartment)
• Motorcycle crash with separation of rider from motorcycle
Other factors combined with traumatic injuries:
• Age 55 years
• Combination of trauma with burns
• Known heart disease, CHF, or COPD
• Known bleeding disorder or taking coumadin/ heparin
• Pregnancy (>20 weeks)
• Rigid or diffusely tender abdomen
• Amputation of fingers with possibility of reattachment[3]

These are the kind of criteria that Maryland was using to fly patients. When they had their fatal crash last year, these mechanism criteria required permission from medical command to fly patients. Flights dropped by about two thirds and outcomes do not appear to have changed. Few of these criteria are useful for predicting instability. This study was only concerned with patients who really are unstable, not those with significant damage to their cars or trucks.

So, what is unstable in the study?

The criteria from the study –

Injured patients with one or more of the following criteria were included: systolic blood pressure (SBP) less than or equal to 90 mmHg, Glasgow Coma Scale (GCS) score less than or equal to 12, respiratory rate less than 10 or greater than 29 breaths/min, or advanced airway intervention (tracheal intubation, supraglottic airway, or cricothyrotomy). “Injury” was broadly defined as any blunt, penetrating, or burn mechanism for which the EMS provider(s) believed trauma to be the primary clinical insult.[2]

And still they have 10 physiologically unstable patients per day, if averaged over a year – with a few left over. Remember, this is after excluding most of the patients who would automatically be flown to trauma centers, because the authors do not believe that those patients are injured enough for time to make a difference in their outcomes.

Editor’s Capsule Summary

What is already known on this topic

The “golden hour” concept in trauma is pervasive despite little evidence to support it.

What question this study addressed

Is there an association between various emergency medical services (EMS) intervals and in hospital mortality in seriously injured adults?

What this study adds to our knowledge

In 3,656 injured patients with substantial perturbations of vital signs or mental status, transported by 146 EMS agencies to 51 trauma centers across North America, no association was found among any EMS interval and mortality.

How this might change clinical practice

This study suggests that in our current out-of-hospital and emergency care system time may be less crucial than once thought. Routine lights-and-sirens transport for trauma patients, with its inherent risks, may not be warranted.[2]

So, if time is not making a difference in survival, maybe we should stop killing people just to get patients to the hospital a little bit faster.

Some more details from the paper –

. . . total EMS time was not associated with mortality . . . for every minute of total time . . . When the sample was assessed with 10-minute increments for total EMS time, there was no evidence of increased mortality with increasing field times . . . Similar results were obtained when total times were grouped by quartile . . . We were also unable to demonstrate independent associations between mortality and any other EMS interval for the overall sample . . . [2]

No matter how they broke down the time intervals, there was no detectable change in outcome.

For categorized response interval, there was no association with mortality for patients with a 4- to 8-minute interval . . . or greater than 8-minute interval . . . compared with patients with a response less than 4 minutes.[2]

The same for response times.

In multivariable logistic regression models, there was no demonstrable association between time and mortality for any subgroup.[2]

Although some seriously injured individuals may require time-dependent EMS interventions to survive (eg, airway obstruction, respiratory arrest, external hemorrhage at a compressible site), faster application of such interventions may not have a measureable effect on outcomes for most trauma patients.[2]

There may be isolated patients, who benefit from less prehospital time, but there are not enough to make any detectable difference in the outcomes of these unstable patients. No difference in the cumulative outcomes. No difference in any of the subgroup analyses. No difference in any of the time subgroups. How many people are being injured and killed, just to get EMS crews there faster, because in EMS we just know that faster is better. Are we killing more people trying to get to the occasional patient who might benefit from a more rapid response, or a more rapid transport, than we are helping?

That little bit faster is insignificant, except psychologically. Perhaps we should refer those in need of lights, sirens, speed, and helicopters for CISM (Critical Incident Stress Management) in stead. Oops, that is also a treatment that lacks evidence to support it.[4]

The authors conclude with this bit of common sense –

In the setting of a perceived “emergency,” the public may not necessarily value whether faster EMS time and expeditious care have been shown to save lives for the majority of clinical conditions. However, meeting these expectations costs money (eg, establishment of fire houses and positioning of EMS crews to achieve predefined response intervals), can place EMS providers, patients, and the nearby public at risk,20-22 and is a common reason (ie, emergency vehicle crashes) for tort claims against EMS agencies.58[2]

The big questions are –

Will more than a handful of people in EMS pay any attention to this?

Will we wait until lawyers force us to do what is right?

Why do we continue to choose mythology and expert opinion over science?

Dr. Bledsoe provides his own commentary on this trauma paper.[5] Peter Canning also writes about this.[6]

Footnotes –

[1] Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort.
Newgard CD, Schmicker RH, Hedges JR. at al.
Ann Emerg Med. 2009;(in press, may end up with a 2010 publication date)
PMID: 19783323 [PubMed – as supplied by publisher]

[2] This is the same as footnote [1].

[3] Statewide BLS Protocols Effective November 2008
Pennsylvania
Page with link to the full text PDF of the protocols.

[4] Critical Incident Stress Debriefing and Mythology
Rogue Medic
November 10, 2009
Article

[5] Speed and Time in Prehospital Trauma Care
The EMS Contrarian
by Bryan E. Bledsoe
EMS1.com
Article

[6] The Golden Hour
Street Watch
Article

Newgard CD, Schmicker RH, Hedges JR, Trickett JP, Davis DP, Bulger EM, Aufderheide TP, Minei JP, Hata JS, Gubler KD, Brown TB, Yelle JD, Bardarson B, Nichol G, & Resuscitation Outcomes Consortium Investigators (2009). Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort. Annals of emergency medicine PMID: 19783323

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Will Maryland State Police Aviation Continue To Resist Safety Improvements?

The NTSB (National Transportation Safety Board) is still trying to encourage rules that will improve the safety of HEMS (Helicopter EMS) for flight crews and for patients.[1]

Even if the FAA does create rules in these areas, public services do not need to follow them.

These will probably be ignored. One of the poster children for ignoring safety standards continues to be MSP Aviation (Maryland State Police Aviation Unit).

This is a presentation of changes desired to improve safety.[2] MSP Aviation may continue to ignore these, yet they claim to be concerned for the safety of their patients. A lot of talk, but where is the action?

Even attempts to use Medicare reimbursement, to try to get HEMS to improve safety, will not have much effect on MSP Aviation. They charge the drivers in the state extra, when drivers register vehicles. Then MSP Aviation demands more money from the legislature, while they still claim to be free. MSP Aviation has such a powerful political lobby, that they are like the tantrum throwing teenager of immature rich parents. They will get whatever they want with no real accountability or oversight.

MSP Aviation can do whatever MSP Aviation wants, such as having just one medical provider on board, but they brazenly push the lie that they are the safer alternative to ground transport. MSP Aviation is not only not the best, but is far from the best in providing medical care. Eventually the Maryland voters will realize that they are being lied to, but after how many lives?

MSP Aviation continues to place the safety of patients and crew members below balancing their budget, while claiming that other, much higher quality, flight services are corrupted by monetary influences. Pure hypocrisy.

Shock Trauma doctors continue to promote the lie of the Golden Hour, which would be more appropriately named the Bogus Hour.[3], [4], [5]

Why should we expect Shock Trauma to be aware of research? They practice voodoo.[6]

Footnotes:

[1] Four Safety Recommendation Letters Concerning
Helicopter Emergency Medical Services

National Transportation Safety Board
Public Meeting of September 1, 2009
(Information subject to editing)
NTSB Synopsis AB09-HEMS

[2] Opening Statement, Overview of HEMS Safety Issues
Dr. Joseph M. Kolly, Acting Director, Office of Research and Engineering
[PDF, 892 KB – PPT, 7.45 MB]

[3] 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

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

[5] Medevac Helicopter Improvement Act of 2009 – Maryland SB 650 – comment
Rogue Medic
Article

[6] Shock Trauma Infested With Evil Spirits
Rogue Medic
Article

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More Helicopter EMS Politics and Pork in Maryland

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

Is there a for profit 7×24 medivac service that operates in the black? Doubtful. Do they operate very closely with favored hospital service providers? Count on it. Is their objective life saving or profit?

That describes the relationship between MSP (Maryland State Police) Aviation and Shock Trauma.

For more than 65 years Marylanders have depended on MSP for emergency medical transport in rural areas.

This bill does nothing to decrease availability of care to rural patients.

With the statewide increase in population density and frequency of serious injury traffic crashes MSP has demonstrated its competency in saving lives during that golden hour.

The Golden Hour[1],[2] is a fraud. The Golden Hour is nothing but a marketing tool made up by Dr. R Adams Cowley. When somebody starts telling this lie, it is a good sign that they are selling something. They are not looking out for patients. Why does MSP Aviation keep telling this lie?

Do we have names and dates of the lives saved? No.

Do you have any evidence that this program saves lives, at least more than it kills? Do you have any evidence that this boondoggle is about anything other than political power? No.

But we know how those whose lives have been saved would vote on this issue.. and how their friends and families would vote.

This is a well oiled political machine at work. Here you go for the Huey Long populist approach. This is nothing but politicians working for political power.

Do we value human life enough to continue saving lives, or should we just write that off as a public service, ignoring the vote of the people to fund the service?

That sentence makes no sense. The purpose of the bill is to provide better care to the residents of Maryland. Better care than MSP Aviation has been providing. The residents of Maryland deserve to have responsible people in charge. MSP Aviation will have the opportunity to reform itself and apply for the contract. It will take a lot of reform. Your comment appears to be an attempt to sway the vote of the people to stick with something that is broken; something that has resisted being fixed. The people of Maryland deserve better.

Do rural residents deserve a lesser availability of emergency transport than urban residents? I don’t think so.

MSP Aviation has spent a lot of time on the flight of urban/suburban patients. Patients who would have arrived at the hospital sooner, if they had been transported by ground EMS. If MSP Aviation were interested in the care of these patients, they should have been educating EMS about when not to fly. Instead MSP Aviation was looking for ways to expand. A government organization out of control. A scam.

These were inappropriate flights. When they were criticized for endangering patients, MSP Aviation has refused to improve.

Maryland taxpayers voted for the MSP program, and know it is invaluable, a source of pride and comfort.

That is a great description of pork. They are voting for pride and comfort, but not anything substantial. Maryland voters need somebody responsible to provide better patient care than MSP Aviation seems capable of. MSP Aviation has only one provider to take care of the patient. Why does every other helicopter EMS service have 2 ALS (Advanced Life Support) providers taking care of the patient? Because that is the standard of care. MSP Aviation is substandard.

If you are treating critical patients, you need 2 ALS providers. 2 providers who specialize in the care of critical patients. Not one Trooper/Medic, who dabbles in both patient care and law enforcement. MSP Aviation is a laughing stock when it comes to patient care. This is not quality.

Citing examples of patients flown to Baltimore and walking out of the hospital the next day is a plus: a life saved. That is the idea.

The research showed that most MSP Aviation patients do not need to be flown and may not even need to go to a trauma center.[3] That is not an example of lives saved. That is an example of waste. A life endangered by an unnecessary flight. Other patients endangered because the helicopter is not available for real emergencies. Other patients endangered, because the ground EMS providers learn bad assessment and bad treatment.

Flying uninjured patients around is just putting on a show for the voters. Flying uninjured patients around is not patient care. Flying uninjured patients around is wasteful. Flying uninjured patients around is dangerous. Flying uninjured patients around needs to stop.

This is pork. Which seems to be the idea – Protect our Pork.

MSP’s aviation team may be second to none, while simultaneously wanting it to be still better.

MSP Aviation provides substandard care by all of the criteria that matter. When people have tried to get MSP Aviation to change, they have resisted improvement.

MSP Aviation is only second to none, when there is nobody being compared to them. When they keep everyone out of Maryland, they are the best in Maryland, but they are also the worst in Maryland. MSP Aviation is not up to the standards of helicopter EMS in America.

MSP Aviation – 1980’s care on a modern bloated budget.

That is MSP’s tradition: excellence, integrity, & respect for human life. Emergency life saving should not be relegated to profiteers.

Excellence would be at least providing 2 ALS providers. Even 2 cross-trained sometimes I’m a medic and sometimes I’m a trooper providers would be better than MSP Aviation’s solo trooper/medic – at least, if patient care is important.

Integrity would be addressing this and other serious problems, rather than spending time covering up the problems.

Respect for human life would be putting the patients first, not selling the patient out for political gain.

Emergency life saving has been in the hands of the MSP Aviation profiteers who seek political profit. MSP Aviation has abused their position. MSP Aviation has taken advantage of their patients for political reasons.

MSP Aviation – We’re just a different kind of profiteer.

All talk and no quality care.

Is anybody surprised that there is a demand for somebody else? Somebody who can provide better care.

Footnotes:

[1] 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

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

[3] Helicopter scene transport of trauma patients: a meta-analysis
Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MO.
Journal of Trauma 2006; 60:1257-1266
PMID: 16766969 [PubMed – indexed for MEDLINE]

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