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

- Rogue Medic

Maryland Helicopter EMS Panel Supports Fewer Medevac Flights

Apparently I misjudged the independence of the panel that met briefly to review the way the Maryland flight program is operated. I apologize. Perhaps I misjudged those in charge of things in Maryland (Dr. Bass and Dr. Scalea), as well. I hope to be writing more apologies as the panel’s recommendations are implemented.

Maryland’s emergency medical helicopters could fly fewer accident victims to hospitals without reducing survival or affecting quality of care for patients, a panel of experts told state officials yesterday.[1]

This is certainly not news to anyone with a broader experience of EMS than just MIEMSS (Maryland Institute for Emergency Medical Services Systems) and/or Shock Trauma (R Adams Cowley Shock Trauma Center – University of Maryland Medical). Dr. Bass is the CEO of MIEMSS and Dr. Scalea is the trauma surgeon in charge of Shock Trauma.

Shock Trauma brought us the concept of the trauma center. It is named after Dr. R Adams Cowley. Dr. Cowley is the marketing mind behind the Golden Hour. I refer to it as the Bogus Hour, because it is not based on anything other than a desire to sell.[2]

Sell the trauma center concept.

Sell the HEMS (Helicopter EMS) concept.

Sell the R Adams Cowley concept.

If there had been some research behind the Golden Hour, I would not be referring to it as the Bogus Hour. If there were some response to the evolving research, by those running the trauma franchise, many others would not be so critical of the Maryland way of Fly everyone and let Shock Trauma sort them out.

Late addition (11/27/08) – ParaCynic has a great post on the Golden Hour from a different perspective. Go read City Slickers 2: The Legend of Cowley’s Gold.

“We felt there are too many helicopters – not just in Maryland but in the Washington-Baltimore-Philadelphia corridor,” said Dr. Bryan Bledsoe, a professor at the University of Nevada School of Medicine. “That said, there’s no clear definition of what is a correct number.”[3]

“A level of overtriage is occurring that exceeds that of comparable systems,” said panel chair Dr. Robert C. MacKersie, director of trauma services at San Francisco General Hospital. “There is a high likelihood that opportunities exist for reduction in Maryland’s (helicopter) transport of trauma patients without compromising patient outcomes or the quality of care.”

But what were the actual recommendations?

•Reconsider whether Maryland needs 12 helicopters and eight bases. Several members called the fleet excessive.[4]

That would seem to be obvious. If the flights are down by more than half, the state should not need anywhere near as many helicopters. It is a small state.

•Adopt national accreditation guidelines mandating two health care providers on each flight, instead of the single paramedic used now.[4]

Absolutely. How has MSP (Maryland State Police) been able to convince people otherwise? Take a medic off the job of paramedic for a year, so that the medic can work just as a trooper. Then return this trooper to patient care and retrain the trooper as a trooper/medic. And the punch line is that this extra training as a trooper means that the trooper/medic is supposed to be better than the nurse and paramedic crews on all of the other helicopters in the region. Apparently the trauma specialists did not get the joke.

•Monitor recent changes in triage to see if they continue to reduce the number of patients flown. Fewer patients can probably fly without affecting outcome.[4]

If you believed the scare stories that have been coming from a lot of people supporting the status quo, you should have bought up all of the body bags that you could. Shockingly, there has not been a sudden increase in the need for body bags, although flights are down by almost two thirds. Are injuries down, too?

It is beginning to look as if the only need for body bags was for the crew members and patient in the recent crash. If the patients had been driven to the hospital, the pilot, trooper/medic, local EMT, and the patient who died, all would probably be alive and well.

The surviving patient would not have had a lower leg amputation, a couple of months in the ICU, and prolonged rehab. How is it that this patient is too badly injured to be transported by ambulance, yet survives a helicopter crash, is lying on the ground, in the rain, in the woods, and without care for almost 2 hours until rescue crews find the wreckage and her, and she survives an ambulance ride to the hospital?

Those are not signs of a seriously injured patient. At least she does not appear to have been seriously injured before entering the helicopter.

•Comply with the same FAA standards as commercial helicopters.[4]

MSP has been claiming that they need to protect the patients in Maryland from the big bad commercial helicopter services. After all, they will charge you money for the flight, while MSP will tell you there is a free lunch. Free. Free. Free.

Why is it that they are not operating at even close to the standards of the private helicopters in the area?

Only one person to provide patient care. Yes, they can take somebody from the scene. Of course, the personnel they take from the scene are the lowly ground providers, that they have been telling us patients need to be rescued from. I suspect that plenty of ambulances in the area have better staffing in the patient compartment than the helicopters do.

How have they been able to get away with such shortcuts?

How have they been able to convince people that they were setting the standards for the rest of the country to copy?

And the panel called for something of a cultural shift, saying Maryland’s trauma and helicopter system is overly focused on speed and not enough with quality and appropriateness of care before patients reach a hospital.[4]

Gosh. If only we were to focus on providing high quality EMS, things might be a lot better. As The Erstwhile Medic has stated, instead of worrying about spending the hundreds of millions of dollars on the flight program, maybe we should spend some money on better educating the ground providers.

Dr. Robert R. Bass, executive director of the Maryland Institute for Emergency Medical Services Systems, said he expects the system’s board members, who will formally receive the report in several weeks, to give the findings strong consideration.

Only strong consideration?

Maybe I am naive, but I don’t think the people of Maryland are going to continue to buy what he’s selling. Low standards. High cost in money. High cost in lives.

The MSP troopers deserve better.

The people of Maryland deserve better.

“We do think we’re a model for other systems, and we want to continue to be a model,” Bass said.

Perhaps he means a model of how not to operate a flight program.


[1] Panel supports fewer medevac flights

November 26, 2008
Baltimore Sun

[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

[3] Panel: Md. flies too many medevac helicopters
Nov 25, 2008 5:42 PM (1 day ago)

[4] Panel supports fewer medevac flights This is the same as footnote [1]

Baltimore Sun