In the comments to Why is air medical transport still killing us? the following comment appears from Samuel Kordik –

Without a doubt, something needs done to reduce the high risks for HEMS crews. But I’m not sure how enforcing the 1 hr drive radius would help.

A one hour no fly zone is one way of measuring distance. I did not state that there should be an absolute ban on flights within a one hour drive time of a trauma center. I stated, We should then require justification for any flight within that radius.

I think that we should require justification for all flights, but that it is essential to carefully review flights within what is a reasonable drive time for unstable trauma.

Where is the evidence that there is a benefit to unstable trauma patients from HEMS transport within an hour drive of a trauma center?

We definitely need to have ground EMS justify calling for helicopters.

Where I work, anything that could remotely justify transport to a trauma center is flown by some agencies only 10 minutes drive time from a trauma center.

Why?

Well, I am not sufficiently familiar with the DSM-IV to give an accurate explanation.

Why endanger flight crews and patients for no possible benefit to the patient?

As I stated, I don’t know how many of the diagnoses in the DSM-IV apply, but the DSM-IV does seem to be the place to look for answers.

I work on a rural MICU unit about 30 minutes from a Level 1 trauma center. My service also flys 3 helicopters, and holds us to account to justify every air transport in our documentation—which makes basic sense.

It makes basic sense to have to justify flights so close to a trauma center. Why do you need 3 helicopters when the trauma center is so close? Why even one helicopter?

If the patient needs it, and the helicopter would get them there faster than we could, then I’ll fly my patient in a heartbeat.

If the patient needs it,

Define needs it. Do you follow up with the trauma center to find out how many of these patients had immediate surgery, or had an emergent intervention in the trauma room, that saved the patient’s life, or made some other significant difference in outcome?

How many of these patients meet that criteria? HIPAA does not prevent the hospital from providing that information. This is a necessary part of any flight justification.

and the helicopter would get them there faster than we could,

How much faster?

The major benefit from HEMS is to make a significant difference in transport time.

A difference of only 5 minutes in transport time, or a difference of only 10 minutes in transport time, or a difference of only 15 minutes in transport time is unlikely to make a difference in outcome.

Yes, there will be the extremely rare patient, where a decrease in travel time of 15 minutes is important, but it is extremely rare.

That is the purpose of justification. There should be an explanation of the particular threat to the patient’s life, supported by EMS assessment findings, information from the trauma center supporting or refuting the initial assessment, and whether it was reasonable based on the limited information available to EMS at the time, to conclude that there would be a dramatically worse outcome if this patient were not flown.

A worse outcome is so rare, that the research on prehospital time periods does not show any effect of these differences in prehospital time on the survival of the most seriously injured patients.

This decision is not based on my desire to go watch TV or sleep, nor is it based on some kind of fear. It comes right out of my position of being a patient advocate and wanting the best possible outcome for said patient.

I did not mean that everyone will fly patients for the same reason. However, there are plenty of people who do fly patients for purely personal reasons.

Restricting unnecessary flights is entirely about wanting the best outcome for patients.

Although I’ll watch for weather and overhead hazards, I still rely on the HEMS crew to watch out for their own safety—weather, terrain, etc.

Perhaps the best way we can protect HEMS personnel would be to require ground EMS providers to justify the flight, and then provide education followup for those providers on patient outcome and whether or not the flight was justified.

Absolutely.

Help ground paramedics learn what is and isn’t a justified use of air transport, so that it will still be around when a patient legitimately needs it.

Agreed.

Let me emphasize what I believe is the most important part.

The risk to the patient is usually significantly greater when transported by helicopter.

The risk to the flight crew is definitely much greater when transporting by helicopter.

We need to decide when the benefit to a patient of a particular and significant difference in travel time is worth those risks.

There should be an explanation of the particular threat to the patient’s life, supported by EMS assessment findings, information from the trauma center supporting or refuting the initial assessment, and whether it was reasonable based on the limited information available to EMS at the time, to conclude that there would be a dramatically worse outcome if this patient were not flown.

We have at least that obligation to our patients and to the flight crews.

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Not much has been done to improve HEMS (Helicopter EMS) safety, in spite of all of the hearings about the alarming fatality rate. That may change. The 2011 US Budget may provide some long overdue oversight.

Fights Waste and Abuse in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). Reducing fraud, waste, and abuse is an important part of restraining spending growth and providing quality service delivery to beneficiaries. In November 2009, the President signed an Executive Order to reduce improper payments by boosting transparency, holding agencies accountable, and creating incentives for compliance. This Budget puts forward a robust set of proposals to strengthen Medicare, Medicaid and CHIP program integrity actions, including proposals aimed at preventing fraud and abuse before they occur, detecting it as early as possible when it does occur, and vigorously enforcing all penalties and recourses available when fraud is identified. It proposes $250 million in additional resources that, among other things, will help expand the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, a joint effort by HHS and DOJ. As a result, the Administration will be better able to minimize inappropriate payments, close loopholes, and provide greater value for program expenditures to beneficiaries and taxpayers. Also, to improve quality and safety, the Administration will strengthen its Medicare requirements to assure that air ambulance operators comply with aviation safety standards.^[1]

The last line is the one that matters – Also, to improve quality and safety, the Administration will strengthen its Medicare requirements to assure that air ambulance operators comply with aviation safety standards.

I would prefer that the regulations not be coming from Medicare requirements, but they are unlikely to be worse than the current safety standards that some HEMS operators use. It may be that this method helps to target some of the most abusive HEMS operators.

One that may be exempt is MSPA (Maryland State Police Aviation), since they take their money directly from motor vehicle fees. This appears to have been a shrewd tactic to avoid oversight. Few may have the ability to investigate the excessive use of HEMS in Maryland, since MSPA and Shock Trauma (their customary destination hospital) have set the system up to by-pass those who might protect the citizens. When someone does attempt to improve the system, the ability of MSPA and Shock Trauma to produce political protests by their mindless true believers scares off most people.

If reimbursement were through insurance companies, someone might question why arrival at the hospital is delayed, just to put the patient in a much more expensive transport vehicle. Surely, if the important contribution of the helicopter is speed, this delay makes no sense. Fortunately, this has decreased since the crash of Trooper 2. Similarly, the concept that EMS must not attempt to assess patients, but must assess the vehicles the patients were in, would eventually be brought to the attention of insurance risk management people. The saddest part is that those most responsible for oversight of the safety of the patients have been most irresponsible in defending the treat the vehicle, not the patient flight criteria.

They promised us that there would be death, destruction, maybe even an apocalypse.

“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]

Dr. Scalea is the top trauma surgeon in the state of Maryland. This statement was several days after the crash of Trooper 2. This was before the flight criteria in Maryland were significantly restricted. That is, the flight criteria were ratcheted back, to use the words of Dr. Scalea.

He predicted that this would lead to more deaths.

Where are the bodies? Where are the news conferences? Flights in Maryland have been at about half the rate that they were before the Trooper 2 crash. The fatality rate does not appear to have changed.

What if we cut the flights by another half?

Dr. Scalea would again be promising death. If you doubt me, ask him.

Should we believe the doctor who cries Wolf and Golden Hour and What if the injured patient was your child or your loved one?

These are not the words of someone trying to persuade you with logic, but the words of someone trying to scare you. This tactic often works because we tend to let emotion suppress our ability to reason. This is why you are prohibited from yelling Fire! in a crowded theater.

This appeal to emotion should be a warning. A warning that the speaker does not have a rational argument. The speaker is only trying to intimidate and scare you to get something from you. We should not listen to that speaker.

I provide more detail about misleading comments by Dr. Scalea in –

Helicopters and Bad Science

A Response to Dr. Scalea’s Letter to EMS

Secrecy and EMS Policy are a Bad Combination

The Maryland Panel Meets

Maryland Helicopter EMS Panel Supports Fewer Medevac Flights

NTSB HEMS Hearings – Helicopter Association International

Footnotes:

^ ¹ United States Federal Budget for Fiscal Year 2011
Free PDF

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

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I will be writing a bit about the use of mechanism of injury as a way to assess patients. An oddity is that mechanism of injury presumes that there is an injury based on possible forces applied to the body. These forces may not have been applied to the body. Even if the forces were applied to the body, they might not have resulted in any injury, or any detectable injury. Because of this, mechanism of injury should only be used to guide assessment, not as a substitute for assessment.

This post will be sort of a reference for people to find trauma triage criteria I refer to in later posts. One problem with trauma triage criteria is that they are referred to as being promoted by the ACS (American College of Surgeons). If I go to their web site, I cannot find them, at least not using the kind of search terms I would expect to turn them up. Why does an organization work so hard at establishing standards for trauma triage, but then seem to make it difficult to find this authoritative information. Although, if you want their opinion on what laws we should pass, that is a significant portion of the information they make available to the public.

There is one reason to make it difficult to find the specific trauma triage criteria to refer to. A lot of these criteria do not work. The amount of damage to the exterior of a car may be meaningless in estimating whether the occupants are injured. The injuries to truck occupants may much more predictable from the exterior damage, since truck safety tends to follow the Mongo principle. Collision avoidance is ignored, while the vehicle is made as large as possible, assuming that there is no other Mongo out there.

As an introduction, below are the Pennsylvania Trauma Triage Criteria. I use these because I am familiar with them, they are available on line, and because Pennsylvania is one state that has been doing a lot to change its protocols to what can be supported by science.

These criteria appear to be mostly consistent with the rest of the country. The first category is Physiologic Criteria – the patients with mental status or vital signs changes that may indicate a serious injury.

The most notable differences from the rest of the country are the uses of mental status and respirations. Pennsylvania does not use respirations (less than 10 or greater than 29).

Another difference is that Pennsylvania only uses Patient does not follow commands for the mental status criterion. If the patient does not remember events, or does not know where he is, or does not know what day/month/year it is, there is no reason to rush the patient to a trauma center – and certainly no reason to fly the patient to a trauma center. Here are the Pennsylvania trauma protocols.^[1]

Physiologic Criteria:

• Patient does not follow commands (GCS Motor ≤ 5)

• Hypotension, even a single episode (SBP adults or SBP

Physiologic criteria identify the patients generally considered to be the most seriously injured, but they often do not do a good job of predicting outcome or need for a trauma center, so Pennsylvania adds a twist to this. I left that for the end.

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

Anatomic criteria are less serious and less likely to predict outcome.

CATEGORY I TRAUMA

Requires immediate transport to a trauma center (Level 1 or 2), if possible

Otherwise if possible, transport to a Level 3 trauma center if patient can arrive at the Level 3 center before an air ambulance can arrive to the patient’s location.

Notify Trauma Center ASAP (including category and ETA)

Mechanism of Injury:

• Falls

• Adult: > 20 feet (one story = 10 feet)
• Peds: > 10 feet or 2-3 x height of child

• High Risk Auto Crash

• Passenger compartment intrusion: > 12 in. occupant side or > 18 in. into compartment any side
• Ejection (partial or complete) from automobile
• Death in same passenger compartment

• Auto vs. Pedestrian/ Bicyclist: Thrown, run over, or >20 mph impact

• Motorcycle crash > 20 mph

Other factors combined with traumatic injuries:

• Age 55 years

• Combination of trauma with burns

• Crushed/ degloved/ mangled extremity or finger amputation

• Known bleeding disorder or taking coumadin/ heparin

• Pregnancy (>20 weeks)

Mechanism is the topic I will be addressing. These criteria are often useless. Pennsylvania has eliminated, or modified, many of bad ones and has created a Other factors combined with traumatic injuries category.

CATEGORY 2 TRAUMA

EITHER:

Contact medical command (if required in EMS region)

OR

Transport to Trauma Center (Level 1, 2, or 3) (if possible)

Everything that does not fall into the above –

CATEGORY 3 TRAUMA

TRANSPORT TO CLOSEST APPROPRIATE RECEIVING FACILITY:

Frequently reassess for Category 1 or 2 criteria

Contact medical command, if doubt about appropriate destination

Otherwise if possible, transport to a Level 3 trauma center if patient can arrive at the Level 3 center before an air ambulance can arrive to the patient’s location.

Pennsylvania is trying to find the right way to restrict the use of helicopters in EMS, but there are still some taking the Mongo approach. Assuming that EMS cannot assess patients, so we must fly everything that might be bad. They are essentially saying, What if . . .?

Rather than try to improve the ability of EMS to care for patients, they adopt the motto – When In Trouble Or In Doubt Run In Circles Scream And Shout. Calling for a helicopter may be part of the screaming and shouting.

These are the EMS leaders. Many have graduated from medical school. Many have decades of experience in the hospital. They have access to this information, but it is like changing the direction of a large ship with Larry, Moe, and Curly at the helm. Change is slow.

In contrast to trauma, where about 5% of the patients meeting trauma criteria end up in surgery soon after arrival, there is the opposite approach to cardiac care. There is tremendous resistance to having EMS call STEMI (ST segment Elevation Myocardial Infarction) alerts, even though the erroneous STEMI alerts may only be about 5% with competent EMS.

With trauma, there are many other reasons to go to a trauma center, besides immediate need for surgery, but that is the excuse given for flying patients with minor injuries – What if EMS misses a serious injury? These patients can often be transferred later on.

With heart attacks, the opposite approach is taken. What if you wake up a cardiologist and it is not a STEMI?

With one approach, we have specialized trauma centers to keep round-the-clock trauma surgery available, no matter how little it is used. While, with the other approach, we seem to go out of our way to delay care and to come up with idiotic excuses for those delays.

Is the sleep of a trauma surgeon less valuable that the sleep of a cardiologist?

Is the life of someone having a heart attack less valuable than the life of someone with minor injuries?

There is another category for Trauma in Pennsylvania. This is the group of patients too serious for the trauma triage criteria listed above. From page 20/97 on the PDF.

A. Extremely critical patients that are rapidly worsening:

1. Patients with the following conditions should be transported as rapidly as possible to the closest receiving hospital:

a. Patients without an adequate airway, including patients with obstructed or nearly obstructed airways and patients with inhalation injuries and signs of airway burns).

b. Patients that cannot be adequately ventilated.

c. Patients exsanguinating from uncontrollable external bleeding with rapidly worsening vital signs (for example, a patient with severe hypotension and rapid bleeding, from a neck or extremity laceration, that cannot be controlled.).

d. Other patients, as determined by a medical command physician, whose lives would be jeopardized by transportation to any but the closest receiving hospital.

2. The receiving facility should be contacted immediately to allow maximum time to prepare for the arrival of the patient.

Footnotes:

^[1] Pennsylvania Statewide Basic Life Support Protocols
Effective November 1, 2008
Sections 180 and 181
Pages 20/97 to 25/97 on the PDF page counter.
Page with link to the full text PDF of the protocols.

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In this, and other posts, when I refer to paramedics, I am referring to basic EMTs as well, unless I am describing something that is outside of the basic EMT scope of practice. In the comments to Emergency Medical Services Intervals and Survival in Trauma – Assessment of the “Golden Hour”, Anonymous wrote –

Interesting research on an issue I have anecdotally observed for years. We’ve all got to stop treating speed in transport as an end in itself, and start treating it as a means to improve outcomes in patients who can truly benefit from it.

This is just an example of one of the big problems of EMS – we act as if the patient is there to serve the protocol/old wives’ tale/need for excitement, when the reality is that we are there to serve the patient.

This is about the medical care of the patient, not about how cool the rescue squad/fire company/ambulance company is.

On a related note, back in 2000, I was lobbying my regional EMS counsel to stop letting people fly patients based on mechanism alone. Why use an expensive and (potentially) dangerous resource to shave 15 minutes off of what is fundamentally a non-critical transport? Treat the patient, not the vehicle was my mantra.

I will have several post on mechanism.

There is more than one problem, here.

You have the control freaks, who believe that we cannot teach EMS to properly assess patients. These are the ones who will claim that a doctor refusing pain medicine to a patient in severe pain, but without any contraindications/relative contraindications to the use of fentanyl/morphine/dilaudid, must know something the paramedic doesn’t know and that because of this psychic ability that comes with a doctor’s license, the abuse of the patient is not an example of why we should have standing orders for pain management. This is a bright shining example of the glorious doctor protecting the patient from the reckless and irresponsible paramedics.

There are endless examples of this error of logic. There are the rare cases that do support the idea of limiting what a paramedic may do on standing orders. However, these are actually examples of reckless and irresponsible medical directors authorizing dangerous paramedics to treat patients. If the medical director would not permit dangerous medics to work, the medical director would not have to be constantly stopping his minions from harming patients. The competent medical director does not allow dangerous medics to work as paramedics. The patients come first.

The other problem is from the You can’t be too safe freaks. They believe that you can avoid mistakes by creating more and more rules. They believe that anything bad that happens must be because some evil person broke the rules and must be punished severely. Or the mistake is because we need more rules. One excellent example of this is a set of protocols that tries to come up with a rule for every possible patient presentation. They think that, if we can just think of everything that can go wrong, we can write rules to prevent the mistakes.^[1]

What they do not realize is that they are making the biggest mistake possible. They are viewing the possibility that the paramedic may make a mistake as the problem to be prevented. Yes, it is a problem, but their solution is to prevent the paramedic from thinking. They think that the paramedic is the weak link in the system. The weak link in the system is the reliance on rules, rather than critical judgment.

We should be taking advantage of the ability of the paramedic to think. We should be providing an environment that encourages critical judgment, an environment that develops the ability to use critical judgment. The decision to prevent paramedics from doing this is dangerous and encourages patient abuse.

Critical judgment is about figuring out what is best for the patient in this case, initiating treatment while constantly reassessing for changes, and changing treatment as indicated by reassessments. This is what is best for the patients.

Critical judgment is not about herding protocol monkeys.

You mention using helicopters to shave 15 minutes off of flight time, but I often see helicopters used where they delay transport. I used to work in a trauma center. The patients from a multipatient scene transported by ground would almost always arrive before those transported by air. There was only rarely a justification, such as entrapment. This was just use of a helicopter to delay treatment, but follow a protocol and/or become tumescent about a helicopter.

The medical command doctors, who want to know about the damage to the vehicle, generally do not have any experience working as auto body repair technicians and are not going to be repairing the car. The damage to the vehicle should only be in the radio report if it is relevant. One of the problems with being on the other end of the radio is that it is difficult to shut up and listen to the people on scene describe what is relevant. A report that estimates the amount of body damage is meaningless. An actual thorough physical assessment is valuable. Mechanism is only useful when it helps to guide us to find things that we might have otherwise missed in our assessments. Mechanism is dangerous when it encourages us to transport the patient in a way that increases the risk to the patient.

The response I got was rooted in a fear of liability. Better to have a few patients flown unnecessarily than to have one critical patient “slip through the cracks.” It was never really clear to me who our medical director was more worried about form a liability standpoint: the EMTs who might forget to call the helicopter, or the rent-a-docs moonlighting in the local ER who might be forced to treat a critical trauma patient (the likes of which many of them haven’t seen since med school).

Over-triage is important. We need to be erring on the side of caution, when there is good evidence to support that approach. Just sending everyone by helicopter to the trauma center is not rational over-triage. We need to use critical judgment. Mechanism is not critical judgment. Mechanism ignores critical judgment.

There is a balance of over-triage and under-triage that minimizes the number of slipped through the cracks patients and minimizes the increased risk that we inflict on patients in order for doctors to feel they are protecting their malpractice insurance. Maybe we need to have some lawyers go after the protocol writers, when patients with minor injuries are killed (or injured) in helicopter crashes and ambulance crashes, just because the protocols state to do everything so quickly that it endangers patients.

I suppose the “err-on-the-side-of-caution” approach is all well and good so long as you’re not the one paying for the unnecessary helicopter ride, and so long as truly critical patients are not being turned away because the bird is wasting time on non-critical transports.

I think that we should have the trauma centers, or insurance companies, deciding if the helicopter ride is appropriate. If it is not appropriate, the ambulance company and medical director should pay the bill. In places like Maryland, that use taxpayer dollars to pay for the helicopter ride, just so that nobody ever feels that they have a reason to avoid calling a helicopter, we should have the ambulance company and the medical director reimburse the state for the waste of taxpayer dollars.

Who knows when or if common sense will ever prevail. The only thing I know for sure is that when you ask me why I decided to fly a patient out, my response will be something other than “you should have seen the car.”

Exactly.

The scary thing is that so many doctors are not smart enough to recognize this.

Footnotes:

^ ¹ MIEMSS Maryland Medical Protocols
Effective July 1, 2008
348 pages of trying to predict everything that can go wrong.
Free PDF

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