Helicopters

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

- Rogue Medic

One Laceration, Two Helicopters, Third Part

Wed, 25 Sep 2013 08:00:25 -0400 by Rogue Medic

There is also a comment from steve mauch on Two Children Abducted by EMS Helicopter for One Laceration that deserves comment.

Rouge, I see what you’re getting at, but the problem is not so much with the medic, its what/how he was taught. If in his area they are taught if you see skull you fly, then he did everything right.

Exactly.

That is what I am criticizing.

We are supposed to be doing what is best for the patient.

We are not supposed to be blindly following protocol, nor blindly following the local culture of fly everyone and let the trauma center discharge them right away.

We need to hold the medical directors and the EMS agencies accountable for this ridiculous approach to patient care.

Where is your outcry against the flight crew that made the decision to fly the second child?? Why not crucify the flight nurse too?!

It was not my intent to crucify the medic.

It is my intent to crucify the system.

I just need some people with hammers and nails and we can nail the system to a Star of Life. 😉

OK. I will settle for metaphorical crucifixion, but we didn’t have to settle for metaphor in the good old days.

I agree with rick in the fact that we should not be ridiculing each other, we get enough of that.

Sometimes ridicule is an excellent way to expose a problem.

Again, I was not focused on the medic, but on the actions that are commonplace in EMS.

Look at that mechanism!

We can’t be out of service for an hour! What if a call comes in and our dangerous neighboring service has to cover for us? Many of the people in the neighboring service work for both EMS services, because that is the way EMS works. So how dangerous is the neighboring service, if they have the same employees?

This encourages us to take a helicopter out of service for real emergencies, so that we can fly someone for vehicular damage, yet vehicles are designed to deform to protect the occupants of the vehicle – and that kind of design works very well.

My response to the doctors in the trauma center who have questioned me about why I did not fly a patient, why I did not call for a trauma alert, and/or why we took our time driving with traffic, rather than using lights and sirens is this –

Assess the patient and tell me what you find that is unstable, then we will talk.

I also am familiar with the research. There is no valid research that supports flying patients within a 45 minute drive of a trauma center.

There is no valid research supporting the idea that we are not using HEMS enough.

The helicopters are often in the wrong place. Many are close enough to the trauma centers that EMS should be driving patients, but that is not where a helicopter would make a difference in outcomes. Helicopters make a difference in outcomes for unstable patients who are well over an hour drive time from the trauma centers.

We are encouraging the helicopters to flock near the trauma centers, so that they can service the medical directors who write mechanism-only flight protocols that endanger patients.

Maryland changed their protocols so that medical command permission is required for a mechanism-only flight. Helicopter transports were cut by over half. Where are the dead bodies that Dr. Thomas Scalea predicted would be the result of this cut in flights?

But I agree with you that issues DO need to be addressed, but we need to look at the initial educators. As a fairly recent paramedic graduate, I can tell you that medics are being taught to be cookbook medics, we are not taught to think.

I agree.

But, each paramedic program is different.

We need to encourage those medic programs that do a great job. There are many out there.

We need to discourage those medic programs that teach people to be protocol technicians, IV technicians, monitor technicians, alarm technicians – Oh, look! The asystole alarm is going off. I need to start CPR. There are many out there.

[youtube]sao-uEKgJ6Q[/youtube]

How much have we changed from the days of calling for orders and being told to give one amp of the yellow box?

If we do not understand pharmacology, we do not understand the most important part of pharmacology – when not to give a drug.

The same is true for procedures. We need to understand when not to use a procedure. Defibrillation, as in the video, or cricothyrotomy, or intubation, or synchronized cardioversion, . . . .

When needle decompression is used, the use almost always appears to be inappropriate.

Needle decompression does save lives when used appropriately.

Click on the image to make it larger.^[1]

The chart is for all patients stuck in the chest at least once with a needle in an attempt to decompress a suspected tension pneumothorax.

Many patients never had any kind of pneumothorax.

Was needle decompression used appropriately on any of these patients?

Maybe. Maybe not. We do not know.

It seems that many in EMS need a lot of work in learning when not to attempt needle decompression.

One of the biggest things I recall is SVT. I was “taught” greater than 150=SVT. I went on thinking this was fact. I was not taught svt is a class of rhythms, not a rhythm by itself.

SVT – SupraVentricular Tachycardia.

The sinus node is supraventricular.

Sinus rhythms do not benefit from adenosine or synchronized cardioversion.

Do not blame the medic for not knowing what someone else never took the time to pass along.

Yes and No.

We need to take responsibility for our own education.

Education does not stop once we put on a patch or get authorized to work on our own.

I was supposed to be writing about the presentations at EMS Expo this week, but it is looking as if that will be next week. If we attend EMS conferences, we can learn about the things our instructors misinformed us about.

Backboards probably do more harm than good, especially for the patients with unstable spinal injuries.

Helicopters do save lives, but probably only for unstable trauma patients over an hour from the trauma center.

How to interpret 12 lead (and 15 lead and 18 lead, . . .) ECGs and how to identify unusual rhythms.

Now I am off to once again demonstrate that a heart rate faster than my calculated maximum heart rate is possible and can still be sinus tachycardia. When I wake up, my heart rate will be a respiratory arrhythmia sinus bradycardia. All of these are arrhythmias/dysrhythmias, but they are not bad rhythms and they are not the absence of rhythm.^[2]

These arrhythmias/dysrhythmias are better than normal sinus rhythm.

Arrhythmias/dysrhythmias are treatable, but most do not benefit from treatment.

Should anyone ever use the term normal sinus rhythm?

What do we base normal on?

Does that mean that the patient’s heart is healthy?

How much beat-to-beat irregularity is permitted while still calling the rhythm normal?

What is the difference between normal and healthy?

If a patient is having a normal episode of angina, is that a good thing?

If a patient is having a normal seizure, is that a good thing?

If a patient is having a normal case of hypoglycemia, is that a good thing?

Based on what?

We often use terms we do not think about. Does that mean that it is not normal for us to think?

Is normal good?

In all of that I forgot to mention, I agree that they should not have been flown, ESPECIALLY since mom was against it, but I wasn’t there and it wasn’t my call. I do think way too many people are flow, and even more people are backboarded that don’t require it. We need to improve critical thinking and assessments BEFORE applying devices and treatments, but that’s a whole new blog!

Again, this is about highlighting the problem, not the person.

We have a big problem. Making a scapegoat out of one individual does not change the problem.

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Footnotes:

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^[1] Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study.
Blaivas M.
J Ultrasound Med. 2010 Sep;29(9):1285-9.
PMID: 20733183 [PubMed – in process]

Free Full Text from J Ultrasound Med.

When Should EMS Use Needle Decompression
Rogue Medic
Thu, 10 Nov 2011
Article

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – Full paper
Rogue Medic
Mon, 14 Feb 2011
Article

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – abstract
Rogue Medic
Tue, 07 Sep 2010
Article

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^[2] dys-
The Free Dictionary
Definition

dys-
pref.
       1. Abnormal: dysplasia.
       2.
               a. Impaired: dysgraphia.
               b. Difficult: dysphonia.
       3. Bad: dyslogistic.
[Latin dys-, bad, from Greek dus-; see dus- in Indo-European roots.]
The American Heritage® Dictionary of the English Language, Fourth Edition copyright ©2000 by Houghton Mifflin Company. Updated in 2009. Published by Houghton Mifflin Company. All rights reserved.

Filed Under: Critical Judgment, Education, Ethics, Helicopters, Heresy, Spinal Immobilization

We Should Not Question Two Children Being Abducted by Two EMS Helicopters for One Laceration

Sat, 21 Sep 2013 13:30:38 -0400 by Rogue Medic

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.

–

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]

Full Text PDF

Filed Under: 'Alternative' Medicine, Critical Judgment, Ethics, Helicopters, Heresy

Two Children Abducted by EMS Helicopter for One Laceration

Fri, 20 Sep 2013 08:00:48 -0400 by Rogue Medic

What happens when a paramedic tells the parents that their children need to be flown to the hospital?

The parents agree, the parents don’t decide right away, or the parents refuse.

What happens when the parents refuse and their children are taken from them in spite of those objections?

Image credit.

According to the emergency call logs, help was on the way at 3:15 and part-time paramedic Troy Cain of the West Lincoln EMS arrived seven minutes later and went to work.

“With what I saw and the mechanism of injury, I elected to fly the first one to the University of Kentucky Medical Center,” stated the six year paramedic. He said in those moments time is important.

“(She) had an open wound that I could see the skull,” he said, “We’re taught to send them to the most appropriate facility.”^[1]

Do trauma protocols include anything about being able to see bone through a laceration?

My protocols do not.

What about the special case of seeing skull bone through a laceration?

My protocols do not.

My trauma protocols exclude patients who are awake, alert, and oriented unless there is some indication of serious injury.

A laceration is usually not a serious injury. A laceration to an artery, or a laceration compromising the airway would be examples of injuries that would be expected to be serious. A laceration that might need stitches is not a reason to fly a patient.

What about What if . . . ?

What if there is a serious brain injury that is not yet presenting symptoms?

We do not know, because there is barely any mention of an assessment anywhere in the article. The article does not provide enough information to be able to tell if any assessment beyond look at the boo-boo! was ever done. The mother mentions that the paramedic did not treat an injury to the back of one child, but that does not mean the paramedic did not identify the injury.

The way the article is written, the paramedic is stating in one place that he flew one girl because he could see her skull, while elsewhere he is saying that he flew her because of mechanism. Bad reporting? Or did the paramedic make both statements? We do not know, but reading the article does not encourage confidence in the reporting.

The article makes it very difficult to tell what happened, but we too often see EMS come in and tell everyone that we are going to fly a patient for minor injuries, or even for no injuries.

There is a question we should be asking.

Why is EMS not being billed for inappropriate flights?

Where is the benefit from this more dangerous and much more expensive method of transport?

None.

A helicopter is taken out of service in order to keep a local ambulance in service.

Why is the local ambulance more important than the helicopter that is no longer available for true emergencies for a much larger territory?

It isn’t, but EMS logic doesn’t work the way real logic works.

Data source.^[2]

These patients are so seriously injured that they must be flown to the hospital.

But . . .

They are so healthy that most of them walk out of the hospital soon after landing.

The helicopter ride is not curing these patients, so most of the patients were not seriously injured to begin with.

We encourage incompetence.

The comments include a lot of the We’re too stupid to assess patients defense of low standards.

Dr. Thomas Scalea of ShockTrauma in Baltimore made similar comments when the Maryland EMS protocols were being changed to require medical command permission to fly patients based on mechanism.

“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?’”^[3]

The ever-subtle Dr. Scalea has not does not appear to have mentioned any deaths due to dramatically cutting the number of EMS helicopter flights.

Does anyone believe that he would not be saying I told you so?

Where are the bodies?

These bodies appear to exist only in the fevered imaginations of those crippling EMS with lowest common denominator people, rather than teaching better assessment skills.

Consent does not appear to have been present in this case, but coercion does.

We scare people to get them to do whatever they would not ordinarily agree to.

The most stringent protection of free speech would not protect a man in falsely shouting fire in a theatre and causing a panic. It does not even protect a man from an injunction against uttering words that may have all the effect of force.^[4]

We are often the ones falsely shouting fire.

We are often the ones using words that may have all of the effect of force when people are vulnerable.

We are often the clear and present danger.

–

Footnotes:

–

^[1] Lincoln Co. girls put on AirEvac flight for minor injuries despite parent’s wishes
By: Tim Johnston
Updated: Tue 11:36 PM, Sep 17, 2013
WKYT
Article

–

^[2] 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]

–

^[3] Advantages of medevac transport challenged
Baltimore Sun
October 5, 2008
Article

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^[4] Schenck v. United States – 249 U.S. 47 (1919)
U.S. Supreme Court
Nos. 437, 438
Argued January 9, 10, 1919
Decided March 3, 1919
Justice Oliver Wendell Holmes writing the unanimous opinion

Filed Under: Ethics, Helicopters, Heresy

Not all mechanisms are created equal

Sat, 27 Jul 2013 00:30:34 -0400 by Rogue Medic

How do we determine which patients go to a trauma center?

Too often by MOI (Mechanism Of Injury).

Physiologic criteria are not too bad and involve some assessment of the patient.

Notice that the GCS (Glasgow Coma Score) is not just for a history of a loss of consciousness or for not being fully oriented.

Anatomic criteria are also not too bad and similarly involve some assessment of the patient.

Mechanism Of Injury is where the most disagreement arises and I have had some entertaining conversations with trauma doctors, but far more disagreement with those doctors who have only anecdotal trauma experience.

The MOI that accurately predicts trauma center need remains a controversial debate within the trauma community. One specific example of this controversy is the rollover mechanism. Single-center experience suggests rollover is not predictive of severe injury, while a review of a large government database suggests otherwise.^13,14 ^[1]

This study excluded everyone who met physiologic or anatomic criteria in order to assess the ability of MOI alone to identify need for a trauma center.

Trauma center need was defined as death, Injury Severity Score (ISS) of more than 15, blood transfusion in the emergency department (ED), intensive care unit (ICU) admission, pelvic fracture, need for laparotomy/thoracotomy/vascular surgery within 24 hours of arrival, two or more proximal long bone fractures, or neurosurgical intervention during admission.^[1]

Some of those duplicate anatomic criteria, but they appear to refer to pelvic fractures and pairs of long bone fractures that were not identified by EMS and were not documented by EMS as criteria for trauma activation.

How much risk of death is there for these mechanism-only patients? We do not know, but only 0.3% died in the hospital.

How many of them would have been triaged as trauma alerts by a good assessment?

The biggest problem with this paper is that it is not able to tell us whether these patients would have been triaged as trauma alerts without MOI criteria to point to for documentation.

The goal of every trauma center is to treat as many seriously injured patients as possible, while directing care of the less severely injured to community hospitals. To achieve this goal, the ACSCOT suggests that an overtriage rate of 50% is acceptable to maintain an undertriage rate of 5% or less.¹⁵^[1]

Our overtriage rate of 77% was higher than that which is considered acceptable by the ACSCOT. The overtriage rate in this study is consistent with that noted in other studies, which used the 1999 guidelines for evaluating MOI in prehospital triage, which ranged from 75% to 91%.^21–24 ^[1]

In 2006, our system stopped requiring trauma center transport of patients meeting Step 3 criteria.^[1]

Step 3 is MOI.

Requiring medical command permission to fly patients meeting MOI criteria in Maryland led to an apocalyptic prediction from the top trauma doctor.

“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?’”^[2]

There have not been any reports of increases in the fatality rate with that change.

How did the MOI criteria do?

Wrong question. Since they eliminated the use of MOI criteria in this system, we have a strong hint.

Orthopedic operations were the most common procedures performed on those patients transported from the ED to the operating room (289 patients, 68%). Eighteen patients (4%) did require a laparotomy, thoracotomy, or vascular procedure directly from the ED. Of those requiring laparotomy (11 patients, 3%), 2 were to repair a liver laceration, 2 for splenectomy, and 4 were intestinal repairs/resection. Three nontherapeutic laparotomies were performed.^[1]

Those numbers are better than what I would expect. I used to work in a trauma center that had less than 5% of trauma alert patients go to surgery in any kind of rush. Surgery is not the only criterion for whether the trauma center is an appropriate destination.

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]

Those are the criteria they think have some predictive value.

Here are the ones that are old wives’ tales.

Criteria that did not meet our definition of trauma center need were vehicle intrusion, vehicle rollover, speed of more than 40 mph, autopedestrian/autobicycle of more than 5 mph, and both of the motorcycle crash criteria.^[1]

Separation of the motorcyclist from the motorcycle is not a bad sign, but it shows that the MOI criteria were written by someone who does not understand motorcycles. In a crash, remaining inside a car/truck is protective, but remaining attached to the outside of a motorcycle is almost as bad as being strapped to the outside of a car/truck. This is the reason motorcycles do not have seat belts. Motorcycles do not offer physical protection. The protection is in the increased maneuverability and the ability of the rider to avoid getting in trouble. A motorcycle crash at highway speed is only bad if you are hit, hit something, or if you are not wearing protective gear.

How much better would a good assessment be at correctly identifying patients who have critical injuries?

How much worse would a good assessment be at correctly identifying patients who have critical injuries?

A good assessment would require good education and good oversight.

As with other interventions, this should be studied prospectively.

–

Footnotes:

–

^[2] Advantages of medevac transport challenged
Baltimore Sun
October 5, 2008
Article

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Stuke, Lance E. MD, MPH; Duchesne, Juan C. MD; Greiffenstein, Patrick MD; Mooney, Jennifer L. MD; Marr, Alan B. MD; Meade, Peter C. MD; McSwain, Norman E. MD; Hunt, John P. MD, MPH (2013). Not all mechanisms are created equal: A single-center experience with the national guidelines for field triage of injured patients. Journal of Trauma and Acute Care Surgery, 75 (1), 140-145 DOI: 10.1097/TA.0b013e3182988ae2

Filed Under: Helicopters, Heresy, Research Blogging, Trauma

Was a helicopter necessary to save 5 minutes?

Sun, 30 Sep 2012 08:00:45 -0400 by Rogue Medic

news-press.com file photo

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There is a big kerfuffle in Florida over the dispatch of a helicopter to a scene not far from the destination hospital.

Or were they transported to different hospitals? The articles do not include enough information to tell, but they want us to be upset at the lack of a helicopter for unknown injuries in a vehicle crash not far from the hospital.

Was the patient critically injured?

According to three of the four articles I found, Yes. The only basis for that is the people quoted using the word critical.

Critical because of extrication time? Critical because of mechanism of injury? Critical because of something else?

Nobody even suggests that either patient had a scratch, but they keep using the term critical – whatever that means to them.

It happened early Friday, when 2 teens struck a power pole with their truck. Both were critically injured, requiring extrication. Estero’s paramedics requested Lee County to send a helicopter. This is where problems began.^[1]

That helicopter, Wahlig said, was needed to carry a critically injured 19-year-old from the scene of an auto accident.^[2]

First responders who were working to pry a critically injured 19-year-old from the passenger seat of a truck canceled the helicopter once they learned its estimated time of arrival, according to county documents and Estero Fire Rescue officials.^[3]

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Why wasn’t a helicopter available right away?

The government’s Medstar helicopter service has been suspended. Why was it suspended? That depends on whom you listen to –

Those pilots were terminated last month under the guise of suspending the county’s emergency medical flight program to obtain a voluntary accreditation that no other government in the state possesses.^[2]

A Sarasota-based helicopter has become the second option in medical emergencies here, after Lee County officials last month grounded both taxpayer-funded helicopters, according to a county statement released Monday.^[3]

A billing scandal grounded Lee County’s Medstar program.^[1]

In the meantime, the FAA is in town working with county leaders to determine just how $3-million in flights were billed without the proper certification.^[4]

–

How long did it take to get to the hospital?

It took 22 minutes to carry the truck’s driver to the hospital and 16 minutes to bring the passenger, once he was freed from wreckage.^[2]

The 19-year-old arrived at Lee Memorial hospital 53 minutes after the first ambulance was dispatched, according to documents.

That time includes the 16 minute ambulance ride, according to documents. The truck’s driver had a 24 minute ambulance ride, according to documents.^[3]

But now public safety officials claim a helicopter wasn’t even necessary in this case since…”The incident did not meet the Lee County Guidelines for Air Transport….because a chopper is only sent for patients that exceed a ground transport time of 30 minutes.”^[1]

One transport took 16 minutes, but the other took 24 minutes (one and a half times as long)?

Why?

Nobody explained in the articles.

–

Was the helicopter requested according to protocol?

If the protocols do have a mechanism of injury criterion for greater than 20 minutes, or 25 minutes, of extrication time, then it is technically within protocol, but if extrication is the only reason, then there is no good reason to fly the patient. These articles do not provide any information about any injuries that would be so critical that saving 5 minutes would matter.

5 minutes?

A 16 minute drive vs a trip to the landing zone, a transfer of care, a flight, moving from the helipad to the trauma room – how much less than 16 minutes will that be? Not much.

Would saving 5 minutes matter?

Were either of these critical patients even admitted to the hospital for observation, or were they discharged while the ambulance was still at the hospital?

We do not know.

Though no one can prove whether Friday’s accident victims would have benefited from air support, Wahlig says it’s not the first – or last time – it will be needed.^[4]

5 minutes.

“When precious time is consumed untangling occupants of serious crash such as this one, utilizing medical air transport can give that time pack to the patient by dramatically reducing time to the trauma center,” he explained.^[4]

Maybe that explains why there was so much drama described in these articles.

This drama is all about 5 minutes.

Would saving 5 minutes matter?

–

PS – The main complaint appears to be coming from one of the flight medics laid off when the government helicopter service was suspended.

–

Footnotes:

–

^[1] Lee County officials under fire for Medstar mess…again.
Estero Fire Rescue doesn’t want to be blamed for county’s mistake
By Mike Mason
Created Sep. 24, 2012
FOX4 News WFTX-TV
Article

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^[2] Veteran paramedic resigns over ‘continued lies’ in Medstar controversy
2:14 PM, Sep. 25, 2012
Written by Thomas Himes
news-press.com
Article

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^[3] Sarasota chopper becomes fallback in emergencies
12:35 PM, Sep. 25, 2012
Written by Thomas Himes
news-press.com
Article

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^[4] Lee EMS administrators called ‘disgraceful’
Posted: Sep 25, 2012 4:39 PM EDT
Updated: Sep 25, 2012 6:18 PM EDT
By Karla Ray, NBC2 Investigator
nbc2.com
Article

Filed Under: Assessment, Helicopters, Heresy

A loose screw equals 3 dead

Fri, 11 May 2012 08:00:40 -0400 by Rogue Medic

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Very easily preventable.

The crash could have been much worse, since this is in a residential neighbor hood of a city with a population of over half a million people.

Image credit.

Ian Gregor, spokesman for the Federal Aviation Administration, told The Associated Press that the agency wants to lodge a $50,625 fine against Air Methods, which is the parent company of LifeNet Arizona and the helicopter’s operator.^[1]

If this was such an easily preventable crash, why is it only $16,875 per person killed? That is assuming that the fine is applied in full.

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On July 28, 2010, at 1342 mountain standard time, an American Eurocopter AS 350 B3, N509AM, descended rapidly and collided with terrain in an urban area of Tucson, Arizona. The helicopter was operated by Air Methods Corporation, as LifeNet 12, on a repositioning flight, under the provisions of Title 14 Code of Federal Regulations Part 91. The commercial pilot and two medical flight crew members were fatally injured. The helicopter was substantially damaged, and consumed by a post impact fire. Visual meteorological conditions prevailed,^[2]

Flight nurse Parker Summons, 41, and paramedic Brenda French, 28, pilot Alexander Kelley, 61.

–

In 2008, the Federal Aviation Administration (FAA) principal maintenance inspector (PMI) for the repair station removed the repair station’s authorization to perform work at locations other than its primary fixed location.^[2]

The duty pilot performed a 7.5-minute abbreviated post maintenance check flight the evening before the accident. A full maintenance check flight conducted in accordance with the manufacturer’s flight manual should, under normal conditions, take 30 to 45 minutes to complete. Had a full check flight been performed, it is likely that the union would have detached from the boss during the check flight. Because the helicopter would not have been operating near its maximum gross weight and the check flight would have been conducted over an open area, the pilot would have had greater opportunities for a successful autorotative landing.^[2]

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

The repair station technician did not properly install the fuel inlet union during reassembly of the engine;

the operator’s maintenance personnel did not adequately inspect the technician’s work; and

the pilot who performed the post maintenance check flight did not follow the helicopter manufacturer’s procedures.

Also causal were

the lack of requirements by the Federal Aviation Administration for an independent inspection of the work performed by the technician.

the lack of requirements by the operator for an independent inspection of the work performed by the technician.

the lack of requirements by the repair station for an independent inspection of the work performed by the technician.

A contributing factor was the inadequate oversight of the repair station by the Federal Aviation Administration, which resulted in the repair station performing recurring maintenance at the operator’s facilities without authorization.^[2]

Even the FAA is at fault.

–

A loose screw = 3 dead.

Image credit.

I wrote about this several days after the crash, in part because of the absurd comments being made by people who were offended by Is that helicopter really necessary? by Kelly Grayson of A Day in the Life of an Ambulance Driver.

Fly Everyone, Let the NTSB Accident Investigators Sort ‘Em Out

The NTSB has finished sorting on this crash.

Read the synopsis of the NTSB findings. Just one page, but a lot of information. Or read the much longer full narrative.^[2]

The NTSB does very thorough work, which not leave much for me to add.

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Footnotes:

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^[1] Sanctions sought in fatal air medical crash in Ariz. – Crash killed the aircraft’s three-member crew
May 09, 2012
EMS1.com
Article

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^[2] NTSB Identification: WPR10FA371
Nonscheduled 14 CFR Part 91: General Aviation
Accident occurred Wednesday, July 28, 2010 in Tucson, AZ
Probable Cause Approval Date: 05/03/2012
Aircraft: AMERICAN EUROCOPTER LLC AS 350 B3, registration: N509AM
Injuries: 3 Fatal.
Synopsis Full Narrative

Filed Under: Helicopters, Heresy, Management

Flawed Helicopter EMS vs Ground EMS Research – Part II

Thu, 19 Apr 2012 12:30:16 -0400 by Rogue Medic

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Continuing from Part I of the latest JAMA headline grab based on exaggerations of what the research almost shows.

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What about the times?

Total elapsed EMS times from dispatch to ED arrival were excluded as a variable be cause of a 57.8% prevalence of missing data (eFigure). A sensitivity analysis was performed for all complete cases to examine the role of total EMS times as an independent variable.^[1]

Most of the data was incomplete? Is this a surprise?

No. The authors used the NTDB® (National Trauma Data Bank®) to number crunch to find associations and then declared that association is proof. The NTDB® is very flawed data.

The scientific method does not state that we should use weak data to data mine for associations and then claim that these weak associations are proof of anything. This is a failure to use the scientific method.

The NTDB® has been used before. I have pointed out the flaws with the NTDB® before.

The NTDB® is just incomplete and misleading data.

–

Click on images to make them larger.^[2] ^[3]

Do any of these numbers come anywhere close to representing the trauma patients you deal with?

More than three patients have MAST applied for every spinal immobilization?

Half of trauma patients have an IV started, but only 8.1% are immobilized?

For every spinal immobilization, there is a needle decompression of the chest?

For every time you did one of these –

Image credit.

You did one of these –

Image credit.

If you immobilized 100 patients this year. If you represent the average, you also needle decompressed about 100 patients. This is what we are supposed to believe if we are going to accept the NTDB® data. Maybe I am wrong. Maybe this association represents reality and I just don’t get it.

I hope you used better needle decompression technique, even though we are dealing with a purely imaginary association and an image from fiction.

This is an example of the quality of the NTDB® data and the fantastic associations we can find in fairy tales.

–

But wait – there’s more.

Should you trust just me?

While it may be impossible to prove conclusively our hypothesis that co-morbidities and complications are underreported in the NTDB, our study certainly raises the strong possibility that this could be the case. Rates of complications within the NTDB are astonishingly low especially when compared to the UM NSQIP General Surgery group which represents a reference cohort of largely elective operative cases.^[4]

There aren’t just problems with the prehospital data. The problems appear to be throughout the NTDB® data.

We do not learn anything about the effect of helicopters on outcomes by mining the NTDB® data.

Next the authors will tell us they have used the NTDB® data to answer the ancient question of How many angels can dance on the head of a pin?

Act now. Order your copy of the NTDB® psychic predictions kit today. If you are among the first 73 callers, you get a free pair of hip waders, which are essential for dealing with data of this quality.

–

Image credit.

You will have to provide your own shovel.

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Flawed Helicopter EMS vs Ground EMS Research – Part I

Wed, 18 Apr 2012 15:30:48 -0400 by Rogue Medic

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Image source.

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The media are posting headlines that there is finally evidence that helicopters save lives.^[1]

This is from JAMA (Journal of the American Medical Association), which generated a bunch of headlines with the misleading claim that a glucose-insulin-potassium cocktail saves lives just a few weeks ago. The press bought it. A lot of people accepted the news reports.

Is this research similarly exaggerated far beyond what the evidence justifies?

Is this research valid?

–

Maryland already provided excellent evidence that MSPA (Maryland State Police Aviation unit – the only scene response EMS helicopters allowed in Maryland) were flying far too many patients. How did they demonstrate this? They cut the number of flights by well over half.

The head of Shock Trauma, Dr. Thomas Scalea seemed to be channeling one of the end of the world prophets when he said –

“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?’”^[2]

We are still waiting for Dr. Scalea to provide some sort of evidence that the fatality rate changed at all.

Where are the dead bodies that Dr. Scalea promised?

People constantly warn of death, destruction, and dogs and cats living together. I want results or an admission that the scare story was just that – a completely fabricated scare story, based entirely on the anxieties of the person speaking.

Has Dr. Scalea produced either?

This was a natural experiment. Where is the increased fatality rate?

–

Why did the authors of this study, from Shock Trauma in Maryland and Johns Hopkins in Maryland, have to find patients from other states to try to show a benefit from flying patients?

Are the authors admitting that flying patients in Maryland doesn’t improve outcomes?

Or are the authors admitting that they just can’t come up with any evidence that Maryland (the Helicopter EMS State) is providing any benefit to patients by putting so many of them in helicopters.

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Few people doubt that there is a benefit from flying critically injured patients who are more than 45 minutes from the closest trauma center.

Did this show that there is any benefit to patient closer than 45 minutes from the closest trauma center?

No.

The authors didn’t draw any conclusions about time saved.

The authors used the NTDB® (National Trauma Data Bank®) to number crunch to find associations and they declared that association is proof. The NTDB® is very flawed data. I will explain in Part II.

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Footnotes:

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Free Full Text from JAMA.

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^[2] Advantages of medevac transport challenged
Baltimore Sun
October 5, 2008
Article

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Filed Under: Assessment, Helicopters, Heresy, Mythology, Research Blogging

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

One Laceration, Two Helicopters, Third Part

We Should Not Question Two Children Being Abducted by Two EMS Helicopters for One Laceration

Two Children Abducted by EMS Helicopter for One Laceration

Not all mechanisms are created equal

Was a helicopter necessary to save 5 minutes?

A loose screw equals 3 dead

Flawed Helicopter EMS vs Ground EMS Research – Part II

Flawed Helicopter EMS vs Ground EMS Research – Part I

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