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

- Rogue Medic

Trauma Criteria – preventative medicine – Part I


On this episode of the First Few Moments podcast Kyle David Bates, Steve Murphy, Patrick Lickiss, and I discuss Patrick’s article about trauma triage criteria – Are Prehospital Trauma Triage Criteria Effective?

There are a lot of interesting things about this study, but Table 3 shows that there is some ability to improve the accuracy of triage criteria by combining criteria. This should be a no brainer, but here are some data to support this. 2.8% + 4.7% + 8.0% = 50%. That is a tremendous improvement over the 15.5% that they add up to individually.

This only reinforces the uselessness of just MOI (Mechanism Of Injury) to identify critical trauma patients.

Click on images to make them larger.

48.5% (N = 50) of these patients had inadequate pre-hospital data. – This refers to the patients missed by the triage criteria. However, it is difficult to make any claim about how the criteria would apply to these patients. Without the information, we do not know.

Is missing data a good predictor of failure to follow criteria, failure to assess patients, or a global failure on the part of EMS.

Table 4 shows that a lot of criteria are difficult to assess, because there are more missing data than there are positive data for any of the individual criteria. The pulse oximetry data are missing almost everything, so it is impossible to draw any valid conclusions from that. 54.5% would seem like a great predictive criterion, but we only have data for 3.9% of the patients. This is not a representative sample. The law of small numbers applies.

In small sample sizes, strong, but purely coincidental associations are expected.

The number of oxygen saturation observations was limited due to the fact that currently only MICA paramedics have the equipment required to perform this recording. Out of 17,645 patients, only 1109 (6.3%) patients had a recording for oxygen saturation. In time this equipment will become available to more of the ambulance service’s fleet.[1]

To be continued in Part II.

Go listen to the podcast.

Also see these other sources of information.

2011 Guidelines for Field Triage of Injured Patients Poster from CDC

It’s the damage stupid


[1] Differentiation of confirmed major trauma patients and potential major trauma patients using pre-hospital trauma triage criteria.
Cox S, Smith K, Currell A, Harriss L, Barger B, Cameron P.
Injury. 2011 Sep;42(9):889-95. Epub 2010 Apr 28.
PMID: 20430387 [PubMed – indexed for MEDLINE]

Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage.
Sasser SM, Hunt RC, Sullivent EE, Wald MM, Mitchko J, Jurkovich GJ, Henry MC, Salomone JP, Wang SC, Galli RL, Cooper A, Brown LH, Sattin RW; National Expert Panel on Field Triage, Centers for Disease Control and Prevention (CDC).
MMWR Recomm Rep. 2009 Jan 23;58(RR-1):1-35. Erratum in: MMWR Recomm Rep. 2009 Feb 27;58(7):172.
PMID: 19165138 [PubMed – indexed for MEDLINE]

Free Full Text from MMWR with link to PDF Download

Sasser SM, Hunt RC, Sullivent EE, Wald MM, Mitchko J, Jurkovich GJ, Henry MC, Salomone JP, Wang SC, Galli RL, Cooper A, Brown LH, Sattin RW, & National Expert Panel on Field Triage, Centers for Disease Control and Prevention (CDC) (2009). Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control, 58 (RR-1), 1-35 PMID: 19165138

Cox, S., Smith, K., Currell, A., Harriss, L., Barger, B., & Cameron, P. (2011). Differentiation of confirmed major trauma patients and potential major trauma patients using pre-hospital trauma triage criteria Injury, 42 (9), 889-895 DOI: 10.1016/j.injury.2010.03.035


Violent Patient Tries to Jump From S.C. Chopper

This is wrong on so many levels. I hope that the biggest problem is the accuracy of the reporting.

A patient who leapt from a moving car on an interstate later tried the same thing from a helicopter.[1]

Simple EMS history taking is the best way to prevent bad outcomes. My favorite question is, Has this ever happened before? A positive response to that question results in my second favorite question – What helped make things better, last time?

Reports indicated the man suffered a head injury in a fall from a vehicle traveling about 70 mph.[1]

This isn’t rocket surgery. If someone jumped from a moving vehicle before he had a head injury, why should we assume that this will improve his thinking? This is what is known as a clue. Maybe he didn’t jump. Maybe he was pushed, but the tie goes to assuming the worst, protecting the patient, and protecting the crew.

About five minutes into the flight, he started struggling with medics, the newspaper reported.[1]


I’m shocked, shocked to find that predictable behavior is going on in here!

I thought we would just put the patient in the helicopter and have an uneventful flight, but No, the patient actually needs medical attention.

Deputies said Altoro Alveriz attempted to jump out of the helicopter, which promptly landed at Lowcountry Regional Airport.

Alveriz was then placed in a sleeve that prevented him from moving his arms and legs.[1]

When using RSI (Rapid Sequence Induction/Intubation) for head injured patients, many doctors recommend using lidocaine to protect against increased intracranial pressure from the intubation. With head injuries, increased intracranial pressure and hypoxia are the worst things we can cause.

The best way to increase intracranial pressure may be to restrain the patient without any sedation.

According to the article, what did they do for this patient?

Physical restraint without chemical restraint.


Maybe they were trying to punish the patient for being combative.[2]

Maybe they do not have standing orders for chemical restraint for these patients.[3]

Maybe they mistakenly assumed that nobody can get out of a Reeve’s sleeve.

Image credit.

Who knows? Maybe they did also chemically restrained him, but it was just not reported.

Violent patients should be chemically restrained for the safety of everyone. The patient, the crew, the people on the ground.

The same is true with ground transport. Violent patients should be chemically restrained for the safety of everyone. The patient, the crew, the other people on the road.

Generally, flight crews are appropriately aggressive about chemically restraining potentially combative patients before placing them anywhere near a helicopter. Why was this time different?

Droperidol, ketamine, midazolam, lorazepam, diazepam, et cetera. There are plenty of drugs that can be used to sedate patients to protect the patient from his own potential violence and from possible worsening intracranial pressure.


[1] Violent Patient Tries to Jump From S.C. Chopper
EMSWorld.com News

[2] They can’t help it
Captain Chair Confessions
January 5, 2012

[3] There are doctors who think that protecting a patient with sedation is somehow more dangerous than allowing their unstable medical condition to progress without treatment directly causing the condition to get worse by only using physical restraints. The only appropriate word for these doctors is defendants, but too often, the bad outcomes are assumed to be inevitable. There is no good reason to believe that these bad outcomes are inevitable.

[4] [youtube]mUbytEgTXZQ[/youtube]
No, it isn’t a Reeve’s, but does anyone really believe that Houdini would not have been able to escape from a Reeve’s sleeve.


Elderly patient dies after man blocked air ambulance landing space for half an hour

Some nut blocked a helicopter from landing for an emergency transport of a patient from one hospital to another. The patient died. this raises some questions.

First, was the flight necessary?

Maybe there are not any ground critical care transport ambulances available, but the drive is only 44 – 45 minutes according to Google maps.

How much time would be saved by flying vs. driving?

Would there be any reason to expect this amount of time to make any difference in the outcome for the patient?

If not much time is saved and there is no expected benefit to the patient, why fly the patient?

The air ambulance is called when speed is of the essence. It offers no greater care for patients, but gives them time – an essential factor in emergency cases.[1]

Mr Taylor added: ‘What we give people is time. And that’s something that was taken from this patient.[1]

Second, what is wrong with some people that they will not take a little time out of their lives for someone else?

‘He just shook his head at us. We couldn’t land because we weren’t sure what he’d do – if he had thrown a shoe at the rotors, the ambulance would have become a £5m death trap.

Perhaps more than a little bit of an exaggeration.

If a helicopter will crash due to a shoe hitting a rotor, what would happen if a bird flew into a rotor?

Does anyone other than a bean counter really care about the difference between a £3m death trap, or a £4m death trap, and a £5m death trap?

‘We know the delay wasn’t the cause of his death, but it is so important that we can get through when we need to.[1]

It would be interesting if someone had claimed that the delay was the cause of death. We could expect some lawyers to salivate over a case like this.

Suppose the helicopter cannot land and the patient ends up being transported by ground ambulance. I don’t know what the cost of a flight is in the UK, but in the US $10,000 to $15,000 seems common. Would the guy who prevented the flight be liable for the cost of the cancelled flight?

A spokeswoman for Lancashire Police confirmed officers were contacted by the ambulance service in order to move the man on.

He was issued with a fixed penalty notice for disorder and it is understood his car was impounded.[1]

This is going far too easy on this guy for creating a hazardous situation.

The main reason for limiting inappropriate flights is to make helicopter EMS as safe as practical without endangering patients.

Unfortunately, criticism of inappropriate flights is often portrayed as being about something else.


[1] Elderly patient dies after man blocked air ambulance landing space for half an hour
By Daily Mail Reporter
Last updated at 4:51 PM on 25th June 2011


Hemostatic Resuscitation by Richard Dutton, MD

There is a longer than usual video at EMCrit, but it is worth watching more than once. Dr. Dutton explains about the use of fluids in resuscitation.

Hemostatic Resuscitation by Richard Dutton, MD

We all have our biases. Dr. Dutton does a good job of pointing out those of others, but one that seems to affect Dr. Dutton is the Maryland helicopter system. He does not see that the fly everyone and let ShockTrauma sort them out approach, that was so vigorously defended by Dr. Thomas Scalea, is not supported by any evidence.

After the protocols were changed to cut the flights by about half, there does not appear to have been any change in the outcomes of trauma patients in Maryland.

Dr. Scalea promised us dead bodies galore, but he has not delivered.

It appears that this extreme approach of Dr. Scalea is unjustified, yet Dr. Dutton seems to have unrestricted praise for the Maryland system of flying everyone.

Back to the video. Dr. Dutton points out problems with resuscitation research that has similarly focused only on the extremes –

Unrestricted fluids to keep the blood pressure high (at least triple digits).


No fluids to allow the body to stabilize on its own.

Dr. Dutton points out that a Goldilocks amount of fluid resuscitation may may exist between these extremes. There are a bunch of studies used to support this. There appear to be big problems with giving too much fluids and with giving the wrong fluids.

We should not be giving fluids that make clotting less effective do not clot or carry oxygen. Updated 08:23 6/12/11.

What do we give in EMS?


What do do crystalloids to to coagulation?

They make it worse.

What volumes do we give in EMS?

Often we give all we can possibly force into any hypotensive patient who is still bleeding. Just to try to make the blood pressure look better. We generally can make the blood pressure look better.

Does this improve survival?


Go watch the video to learn a lot more.


Ambulance Driver Talks About a Close Call

In Talk About a Close Call! there is some commentary from Ambulance Driver about the wisdom of transporting a patient by helicopter the extreme distance of –

I checked the distance: 1.87 miles, according to Mapquest.

Almost 2 miles? We need to fly the patient!


They might be able to body surf the patient to the hospital faster than the helicopter could transport the patient. This does raise some questions –

How long did it take to set up the landing zone?

Where did they set up the landing zone?

How long did it take to transport the patient to the landing zone?

How long did it take to transfer care from ground EMS to the flight crew?

How long did it take to get from the landing zone to the hospital’s helipad?

How long did it take to get from the hospital’s helipad to the emergency department?

How much extra time did it take to transport this patient by helicopter compared with transport by ground EMS?

According to the map, this requires just heading down Broadway and bearing left onto 21st when Broadway bears left and becomes 21st.

501 Broadway, Nashville, Tennessee 37203 (Bridgestone Arena) to 1313 21st Ave. S. Nashville, TN 37232 (Vanderbilt Department of Emergency Medicine). 7 minutes by Google Maps.

Yes. Concert traffic can be heavy

Is Nashville unique in having heavy concert traffic?


I have worked at concerts and sporting events in several cities larger than Nashville. These cities are known for worse traffic than Nashville. I have never considered flying any patient within any of these cities.

Was there a rush to initiate therapeutic hypothermia?

If there is a need to quickly start therapeutic hypothermia why not have EMS provide the treatment, rather than putting these patients in helicopters to turn on the super-cooling fan on top?

Is there any good reason why EMS cannot initiate therapeutic hypothermia?


This does not seem to be any different from the Maryland method of providing paramedics. Encourage calling helicopters early and often, because Dr. Robert Bass – the Maryland State Medical Director and the CEO of MIEMSS (Maryland Institute for Emergency Medical Services Systems) does not trust paramedics that are not Trooper Medics to provide patient care. Dr. Bass states that the helicopters are his way of providing paramedics to rural areas, yet the patients already appear to be in the care of paramedics. What Dr. Bass seems to be saying is that he does not trust his paramedics.

Is the same thing is true in Nashville?

Are flight medics better than ground medics?

They should be, but I know of too many flight medics who are scary. There are plenty of excellent flight medics, but how is this different from what you get with ground medics? Many flight medics also work on ground ambulances. Do they lose skill when their feet touch the ground? The hiring of flight medics is just as dependent on politics as the hiring of ground medics. Flight medics should have more educational opportunities, but that is a symptom of the lack of attention we pay to the continual education of ground medics.

The problem with pretending that the flight medics are better than the ground medics is that this becomes just another excuse to put a patient in a helicopter and decrease the available experience for ground medics.

This becomes just another opportunity to decrease the abilities of ground medics.

Why are medical directors trying to decrease the abilities of ground paramedics?

Are helicopters just another way for absentee medical directors to protect themselves from liability for abandoning their medical oversight responsibilities?

Late addition – 04/26/2011 at 13:04

There are comments on AD’s post that suggest that the patient was transported by ambulance and that the reporters made the mistake because the ambulance is a critical care transport operated by the flight service. Although there is at least one attempt to justify such a ridiculously short flight with this kind of illogical rambling –

Don’t monday morning quarterback. Hindsight is always 20/20. Even if she was airlifted the crew had a reason. Vanderbilt is one of the best facilities in the nation with some of the best staff. Even if they did fly her, they probably had a good reason.

Comment by Robhub89
Talk About a Close Call!
A Day in the Life of an Ambulance Driver
Link to comment


A Very Unusual Fatal Helicopter vs. Plane Collision

New Years Eve 2010 there was a truly unusual HEMS (Helicopter EMS) crash.

Peters said it appeared the helicopter was attempting to land and the 1967 Cessna was taking off when they collided. He described the airplane as a small, general aviation four-seater.[1]

Generally, this kind of collision is not good for either aircraft, but if anyone is expected to have the worst chance of survival, I would expect it to be the people in the helicopter.

Witness Joshua Becker told the Daily News Leader of Staunton that he was driving to visit family near the airport when he saw the plane graze the top of the helicopter. The plane immediately nose-dived into the ground, while the helicopter landed in the field.

There were no patients were on board the medical helicopter and the HEMS crews walked away from the landing.

Photo credit

The 2 people in the plane were killed in the crash.

Photo credit


[1] Two Civilians Killed After Virginia Medical Helicopter Collides With Plane
EMS World
The Associated Press


Flipping the Patient the Bird

There is a nice sarcastic comment to The Bird is the Word – Coma Toast by Can’t say, clowns will eat me

What? You mean oxygen doesn’t cure all ills?

It will be just our little secret, but oxygen is not a panacea . . . and . . . it . . . is . . . sometimes . . . bad.

The way it seems the vast majority of ALL EMS responders must think is that it’s better to give oxygen than to just transport. And god forbid you don’t have a pulse ox.

You have to consider the thought process involved.

Use the gadget with the flashing light.


Use my brain.

Gadget with flashing light wins too often . . . and . . . it . . . is . . . sometimes . . . bad.

But want to call HEMS for the cool pins and a nice hat? You’re a hero.

Use the noisy flying gadget with a lot of flashing lights and the free lapel pins.


Use the gadget with the flashing light.


Use my brain.

Gadget with flashing light wins too often . . . and . . . it . . . is . . . sometimes . . . bad.

So, go ahead and do us a favor and get some docs with you to replace the registry and possibly the joint while you’re at it.

I am just ranting away about these darned naked emperors prancing around with nothing.

These stark naked guys are the pall bearers for a lot of flight nurses, flight medics, EMS pilots, and patients.

These killer buffoons need to be stopped.

Some of the doctors are realizing this, but many emergency physicians are fanatical helicopterists. They will transfer patients from the suburbs by helicopter no matter how much the flight delays transport and even if those on the helicopter work on the ambulance when not scheduled on the helicopter.

This often has nothing to do with quality of care.

This often has nothing to do with speed of transport.

This is nothing new.

This is purely for the emotional satisfaction of the person calling for the helicopter – regardless of whether that person is a first responder with minimal medical training or a board certified emergency physician.

The only thing that changes, from Ricky Rescue to Dr. Rescue, is that Dr. Rescue uses fancier words when making his lame excuses.

This is irresponsible behavior.


The Bird is the Word – Coma Toast

At Coma Toast, there is a thorough thrashing of the EMS addiction to flying uninjured patients just because we can. The Bird is the Word.

Now, there are a lot of arguments out there about the use of medical helicopters. It’s in the dispatch criteria….it’s in the protocols…..patients can get to the hospital faster. However, most of these arguments can be debunked by actually looking at patient statistics of those transported by ground ambulances verses those who were flown.

Another problem with helicopter abuse, perhaps the most deadly abuse of the helicopter, is to excuse the employment of medics and basic EMTs who cannot competently assess patients.

We don’t need to know what is going on – just put them in a helicopter.

We don’t need to be able to treat patients – we only need to be able to immobilize, get 2 large bore IVs, and hook up the ECG before the helicopter arrives. And don’t forget the non-rebreather mask with 25 liters per minute of oxygen flow.

Why think about patient care, when we have already decided what we are going to do to the patient – before we even see the patient?

We say – Look! The patient we flew the day before yesterday is driving a new car today. The helicopter saved him! We are so awesome!


We should hang our heads in shame at flying uninjured people.

If we overloaded the cath lab with patients who do not have STEMIs, we would be the laughing stocks of EMS.

But put a patient with a bruised fender and a mangled bumper in a helicopter and nobody will criticize a thing.

A large percentage of the people we inflict perform needle decompression on, do not have even simple pneumothoraces, yet we treat them for life threatening tension pneumothoraces. We even document the rush of air escaping from the needle that never even reached the lung.

The needle wasn’t in the lung, so where did the air come from? A brain fart?

We immobilize even the witnesses to car crashes, because we are that bad at assessment.

We do a pathetic job of educating people to perform trauma assessment (of patients – not cars) and we do not remediate those who regularly demonstrate incompetence at trauma assessment. Maybe we need a White Paper on the abuse of patients by EMS.

We justify these treatment errors that injure and kill patients with, You can’t be too safe!

Injuring patients with incompetence is safe?

Killing patients with incompetence is safe?

Compared to what?