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

- Rogue Medic

NTSB HEMS Hearings – Helicopter Association International

Yesterday, I wrote Observations on the NTSB HEMS Hearings. After Dr. Blumen gave his presentation, Mr. Matthew Zuccaro[1] gave a presentation. While Dr. Blumen’s had been about the negative outcomes of HEMS (Helicopter EMS), Mr. Zuccaro, President of HAI (Helicopter Association International) presented ideas for improving safety.

Wait. That really isn’t what he said. The link to his presentation makes a startling demand – we need to reduce the international helicopter accident rate by 80% over the next 10 years.

Immoderate.

As I have mentioned in earlier posts, HAI seems to have the right attitude about safety. They do not try to hide, or excuse, the problems in the helicopter industry. They face these problems and try to figure out how to minimize them.

If only EMS had an organization that took such an aggressive approach. Yes, we have several very good organizations, but even the NAEMSP (National Association of EMS Physicians) seems to be too comfortable with things the way they are. EMSunites.com can only address so much. We need somebody with HAI’s kind of foresight to dramatically change our approach to EMS patient safety. At Emergency Physicians Monthly, there is a review of the OPALS Major Trauma Study[2] that completely misses the failure of quality in EMS. This article has not yet received any comments, except from me. Perhaps my obvious displeasure has discouraged others.

Nonetheless, an argument against inferior training as a reason why these findings might not be applicable in the US is countered by the OPALS paramedic procedural success rates: intubation 72% and IV 90%. These skills compare favorably with US paramedics.[3]

A Tourette’s inducing claim.

How can 72% intubation success be viewed as comparing favorably with US paramedics, by this emergency physician? Are we trying to encourage incompetence? That is one of the great things about HAI. They do not look at the rate of helicopters falling out of the sky, and say something like:

“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?'”[4]

Almost as if we have not evolved the capacity to plan for adversity. Flight crews have a job that, averaged over the last 10 years, is the most dangerous job in America. This is not just based on data from the recent most deadly year in HEMS history, but a 10 year average. Dr. Scalea’s response is to start singing, Hakuna Matata. Where is the evidence that the overuse of HEMS saves more than it kills? Where?

This is not acceptable.

Should I be more subtle? I sometimes get a bit, sort of carried away.

Right! And the 72% intubation success rate?

This is not acceptable, either.

Two peas in the same pod. Tolerance of these conditions is tolerance of behavior that kills. Why be subtle? Oh. It’s only a moderate amount of death. All things in moderation, you know.

We have become tolerant of experts telling us what we should put up with. We have no reason to accept these moderately expert approaches to safety.

If you look at an earlier OPALS study,[5] they kicked 3 paramedic services out of the study for failure to maintain a 90% intubation success rate. Most of the paramedic services remained in the study, because most of the paramedic services were able to maintain at least a 90% intubation success rate.

Finally, paramedics trained to provide advanced care had to successfully perform endotracheal intubation for 90% of patients. These criteria were monitored regularly, and data collection for the advanced-life-support phase of the study in each community did not begin until the criteria were met. The three communities that did not meet the standards were excluded from the study.[5]

Clearly, this can be done. But is 90% even the right number for the low end of tolerable? No, but it is a start. First, we need to re-educate the medical directors of the parts of the US that consider Two Out of Three Ain’t Bad to be an acceptable approach to airway. Then, we can push for even higher criteria – everywhere.

Maybe we should have the medics practice intubation on the medical directors. Maybe that would change their moderate approaches to airway management success.

Look at that. I went and hijacked my own post, diverted it from where i started, which was the presentation by Mr. Zuccaro.

HAI SAFETY POLICY
• Safety As a First Priority
• Safety Above All Else
• Fly To a Higher Standard[6]

Then, if you scroll down to page 11 in the pdf page counter, you will see a chart. If you read this blog on a regular basis, it should look a bit familiar.

This is a chart of 43 years of vaccine progress.[7] Now, look at the charts of earlier HEMS crash rates from Dr. Blumen.[8] Déjà vu all over again. In my post, I show the way each drop in polio is similar to the previous time period. The improvement was at an exponential scale, until there was no more polio in the US. I don’t expect that we will completely eliminate HEMS accidents or missed intubations, but we shouldn’t stop trying or admit defeat.

Page 12 looks the same as page 11, but if you look at the dates, you will see that this projects the decrease in accident rates with the application of better technology and procedures. The charts look the same, but the scale is different. This is an exponential improvement in safety. This is not a fantasy.

OK. If the Defenders Of Tradition oppose it, then the time scale is fantastic, but it will happen eventually. How many people do you want the Defenders Of Tradition to kill?

Do other aircraft have better safety rates? Yes, so we can improve HEMS crash rates by a lot.

Do anesthesiologists have better intubation success rates? Yes, so we can improve intubation success rates a lot.

What? It is unreasonable to expect medics to intubate at that level of proficiency?

No. It is unreasonable to accept 72% intubation success.

72% is blind squirrel territory. If I could get a blind squirrel to manipulate a laryngoscope with any kind of dexterity, I could get that blind squirrel to intubate at better than 72%. I might have to teach him to use a bougie, but it could be done.

H/t to CrzeGrl for another site with a similar approach to HEMS safety is Vision Zero from the Association of Air Medical Services.

Footnotes:

^ 1 Witness #2 Matthew Zuccaro,
President, Helicopter Association International, Alexandria, Virginia
Mr. Zuccaro has been active in the helicopter industry for nearly 40 years. He was president of Zuccaro Industries, LLC, which provided aviation consultation services and specialized in helicopter-related issues. He holds airline transport pilot and instrument flight instructor certificates for both airplanes and helicopters. Mr. Zuccaro has also held several executive and operations management positions, with commercial, corporate, scheduled airlines, and public service helicopter operations in the northeastern United States. Mr. Zuccaro is a past president and chairman of the Eastern Region Helicopter Council. He received his initial helicopter flight training as a U.S. Army aviator and served with the 7/17 Air Cavalry unit in Vietnam. During his tour, Mr. Zuccaro earned several commendations, including 2 Distinguished Flying Crosses, 3 Bronze Stars, and 19 Air Medals.

Matthew Zuccaro’s slide presentation is Helicopter Association International Presentation on Industry Safety Initiatives
National Transportation Safety Board
Washington D.C.
Free PDF from NTSB of what was a PowerPoint presentation by Mr. Zuccaro.

^ 2 The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity.
Stiell IG, Nesbitt LP, Pickett W, Munkley D, Spaite DW, Banek J, Field B, Luinstra-Toohey L, Maloney J, Dreyer J, Lyver M, Campeau T, Wells GA; OPALS Study Group.
CMAJ. 2008 Apr 22;178(9):1141-52.
PMID: 18427089 [PubMed – indexed for MEDLINE]
Free Full Text . . . . Free PDF

^ 3 The Evidence Against “Stay and Play” Pre-Hospital Care
by James E. Brown, MD, is on the faculty of BEEM (Best Evidence in Emergency Medicine) and is the vice-chair & residency director at the Wright State University department of emergency medicine
Free Article

^ 4 Advantages of medevac transport challenged
Baltimore Sun
October 5, 2008
Article

^ 5 Advanced life support for out-of-hospital respiratory distress.
Stiell IG, Spaite DW, Field B, Nesbitt LP, Munkley D, Maloney J, Dreyer J, Toohey LL, Campeau T, Dagnone E, Lyver M, Wells GA; OPALS Study Group.
N Engl J Med. 2007 May 24;356(21):2156-64.
PMID: 17522399 [PubMed – indexed for MEDLINE]
Free Full Text . . . . Free PDF

^ 6 National Transportation Safety Board
Washington D.C.
Free PDF
Page 4 in the pdf page counter. Yes, this is the same pdf from footnote [1].
There is no good reason not to go through this presentation carefully. The safety information applies to all areas of risk management. Only some of it is specific to helicopters.

^ 7 11/10 Anti-Vaccinationists Are Smarter Than Scientists
MMWR Summary of Notifiable Diseases, United States, 1993
October 21, 1994/42(53);1-73
Free Full Text

^ 8 Dr. Blumen’s slide presentation is An Analysis of HEMS Accidents and Accident Rates
Free PDF from NTSB of what was a PowerPoint presentation by Dr. Blumen.

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