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

- Rogue Medic

Update on the Maryland Crash and Unnecessary Helicopter Transport

First – transport by helicopter is appropriate in some instances. I do not disagree with that. My point is that there are too many inappropriate transports.

There have been some recent developments in the story of the fatal helicopter crash in Maryland. A panel has been established to examine the criteria for flying these patients.[1] Last month a Maryland State Police helicopter crashed while transporting 2 patients. The patients apparently had only minor injuries.

How minor?

The only survivor of the crash was one of the people so seriously injured that she was not allowed to be transported by ground EMS. What if she didn’t survive the drive?

Well, the triage criteria used by MIEMSS (Maryland Institute for Emergency Medical Services Systems) resulted in one dead trooper/pilot, one dead trooper/medic, one dead local EMT, one dead patient, and one critically injured patient. The critically injured patient and the dead patient probably were not critically injured before the flight. The EMS personnel were healthy enough to be working.

The people encouraging these flights of patients with minor injuries are asking the question that is used to encourage mediocrity.

What if . . . ?

What if that were your child?

What if the ground EMS personnel missed something?

What if they had serious injuries that even a highly skilled person would have missed?

If this were my child, I would want transport to be appropriate for the injuries. Do not increase the danger to my child with an unnecessary helicopter flight.

If the ground personnel missed something, and it does happen, we should be pushing for better training of the ground personnel and more aggressive medical oversight.

If there were serious injuries that even a highly skilled person would have missed –

Where is there any evidence that flying a lot of uninjured patients, or patients with minor injuries, will lead to an overall lower fatality rate?

To put all of these patients at risk, there needs to be some demonstration of the benefit to the targeted patient population. Those with no apparent injuries, who might suddenly deteriorate prior to arrival at the trauma center.

Where is this evidence?

How many apparently uninjured patients are we actually going to help?

One a decade?

Is there any evidence to show that this number is wrong?

Maybe one a decade is too high a number of patients benefiting from HEMS (Helicopter EMS). Maybe it should be one every 30 years. How do we know?

The proponents of aggressive transportation of apparently uninjured patients want us to believe that a whole bunch of things will happen at the same time. They want us to believe that these coincidences will happen often enough to justify the high fatality rate among patients transported by HEMS.

What has to happen?

1. The patient has to have a serious, life threatening injury.

2. The patient has to be compensating for the injury in a way that makes it unrecognizable to well trained EMS personnel on scene.

3. The patient has to arrive at the trauma center more quickly by HEMS than they would by ground EMS.

4. The difference in arrival time has to result in the sudden deterioration happening at the trauma center, because if they deteriorate in the helicopter, the trauma center services are of no use to the patient, since they are not in the trauma center.

5. The trauma center has to react appropriately and have the resources to resuscitate this suddenly unstable patient.

    How many patients will meet all of these criteria?

    Maybe my guess of one a decade is too high a guess, but it is only a guess. If you disagree with this conclusion, provide research to support your aggressive intervention. Without good research to support the aggressive intervention, we need to assume that it is too risky.

    A review by The Baltimore Sun of crash records and other documents on the 26 fatal medevac crashes in the United States since 2003 shows that many did not involve urgent, minutes-from-death missions. At least eight involved patients who waited longer for a helicopter than a ground ambulance might have needed to drive them to a hospital. And at least six were for patients discharged soon after a helicopter dropped them off at a hospital, or who survived a lengthy ambulance ride after the helicopter sent to get them went down.[2]

    Clearly, we are not doing a good job of deciding which patients should fly.

    How does delaying arrival at the trauma center, just to fly the patient, benefit the patient?

    The benefits of helicopter transport are very limited.

    1. Decrease transport time to a trauma center by a significant amount – an amount likely to make a difference in outcome.

    2. Deliver some treatment not available from ground EMS.

    It took, or would have taken, longer to transport the patient by helicopter in almost 1/3 of the fatal crashes.

    How is that defensible?

    Why are the people, responsible for these flights that delayed arrival at the appropriate destination, not condemned by the medical community?

    Why are the people, encouraging the use of clearly dangerous transport, not having to prove the benefit of this aggressive approach to transport?

    It is easy to find the patients and crew members who have died because of HEMS.

    Where are the patients who have survived because their arrival at the trauma center was delayed, just so they could fly?

    Where are the patients who survived because they were flown to a trauma center, when ground transport would have resulted in their death?

    Do any of these patients really exist?

    These are the patients flight crews are dying for.

    These are the patients that other patients are dying for.

    Where is the evidence that they really do exist?

    Shouldn’t we demand evidence before encouraging something that kills patients?

    Shouldn’t we demand evidence before encouraging something that kills EMS personnel?

    Shouldn’t we demand evidence before encouraging something that kills State Troopers?

    Footnotes:

    ^1 7 named to state panel on Medevac guidelines
    By Robert Little
    Baltimore Sun
    October 25, 2008
    Article

    ^2 Unnecessary flight risks?
    Review of 26 fatal medevac crashes shows many didn’t involve life-or-death missions
    By Robert Little
    Baltimore Sun
    October 23, 2008
    Article

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