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

- Rogue Medic

First Few Moments – Mechanism Of Injury or Idiocy


On the First Few Moments podcast we had an interesting discussion about the usefulness of mechanism in making treatment and transport decisions.

Mechanism of Injury or Idiocy?

Dr. Jeff Myers, Kyle David Bates, Rick Russotti, and Scott Kier.

Should anyone view mechanism as anything more than an indication of where to pay closer attention during assessment of trauma patients? In this case, a trauma patient does not mean a patient going to a trauma center, but a patient who has had any kind of injury.

One of the points mentioned is that the main controversies that have been discussed recently by several of us on other podcasts (such as Dr. Bill Toon mentioned on Doctor Doctor Doctor: EMS Garage Episode 101) is that too often we use treatments in the absence of a specific indication.

Oxygen – not to treat any signs of hypoxia, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess the patient.

Spinal immobilization – not to treat any signs of spinal cord injury, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently transport the patient.

Naloxone – not to treat any signs of opioid overdose, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess the patient and manage the airway.

50% Dextrose – not to treat any signs of hypoglycemia, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS appropriately assess and treat decreased levels of consciousness with the appropriate treatment – for symptomatic hypoglycemia, titrate 10% dextrose to an appropriate response.

Epinephrine – not to improve survival from cardiac arrest, but because of the short term buzz of getting a pulse back and we figure it can’t hurt and What if . . . ?

The alternative is to limit EMS to effective treatments.

Mechanism Of Injury (MOI) – to replace assessment – not to improve assessment, and because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess the patient.

It is important to train/educate EMS well enough to be able to provide this competent assessment.

It is idiocy to have EMS use an irrelevant damage report on the motor vehicle, which we will not be treating.

Endotracheal intubation – not because it provides a better airway, but because somebody called it a Gold Standard and we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess and manage the patient’s airway.

Helicopters – not to improve treatment or make a significant difference in transport time, but because we figure it can’t hurt and What if . . . ?

The alternative is to have competent EMS.

The answer seems to be that we need to improve EMS and EMS education – a lot.

Maybe we need to create a No Fly Zone around each trauma center. For example, if the patient is closer than an hour drive time from the trauma center any flight should be treated as a sentinel event and investigated thoroughly.

Maybe we need to have the fire companies and ambulance companies pay for any flights that are determined to have been unnecessary. If we really want to limit unnecessary flights, what will work better than forcing those of us who call for the helicopter to have to have the ability to justify the flight medically.

If a helicopter is called, just because it is easier to send a patient by helicopter than by ambulance, a $10,000 to $20,000 convenience charge may be a great way to fund helicopters and to discourage abuse of helicopters.

If we do not understand what is going on medically with the patient, we should not be making patient care decisions.

Calling for a helicopter because I am too stupid to assess my patient is bad medicine.

If we are calling for helicopters, we are making medical decisions, so we need to be able to justify those medical decisions.

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A Conversation on Mechanism of Injury


I was talking with one of the long time, weekend, night shift nurses. The people I count on to do what is right for the patient, because the administrators are not around.

Well, I mentioned in passing – I thought it was going to be just in passing – about the recent comment kerfuffle about MOI (Mechanism Of Injury criteria for trauma triage, or just mechanism). This is the assessment skill substitute for assessment that people use as a justification for flying uninjured patients in helicopters.

As if that is safe.

All of a sudden, the nurse started a little tirade about a medic who brought in a patient to this non-trauma center ED (Emergency Department) because he did not bother to report on the MOI when calling for medical command destination decision.

I do not remember what the mechanism was, but it was something vehicular and must have sounded bad, because that’s what MOI means –

The 911 call sounds bad!

or

That dent looks like it is going to cost a lot to repair!.

That has nothing to do with the patient, except that the mechanism suggests things to be more careful in assessing for.

This is all that mechanism means.

You might want to pay extra attention to these things suggested by mechanism.

Mechanism is not assessment.

Mechanism is the equivalent of stereotype, or prejudice, or bias, or racism.

Mechanism is not about understanding.

Mechanism is a shortcut that encourages ignorance.

Mechanism is just a superficial substitute for a patient assessment.

Mechanism is for those who cannot assess real patients.

Anyway, being the blunt person that I am, I interrupted the nurse’s rant, because my shift is only 12 hours long and her rant was looking like a filibuster. I didn’t even have to ask the obvious question about what a simple assessment showed, because the nurse mentioned over a dozen rib fractures and a flail chest.

Clearly, this is not a patient who should have been transported to the local ED with several trauma centers less than 20 minutes away by ground. This is a case, if reported accurately, of an incompetent medic. And not just a little bit incompetent.

Back to mechanism.

What does mechanism add to the assessment of a patient with a flail chest?

A flail chest is a portion of the ribs acting like a trap door. The ribs are broken in so many places that there is no resistance to pressure, except when the patient exhales.

Breathing is not very complicated. The diaphragm creates negative pressure. On inhalation, the diaphragm pulls away from the chest and the accessory muscles also cause the chest to expand. This sucks air in.

On exhalation, the diaphragm and accessory muscles relax and create pressure. This forces air out.

With a flail chest segment, breathing mechanics are mostly normal for everything except the flail segment. The rest of the chest is creating a pressure difference that moves the air. As long as the ribs are intact, they will all move together. When there is a flail segment (2, or more, ribs broken in 2, or more, places is the textbook definition) that broken part of the ribs will move the opposite direction from the rest of the ribs. The flail segment will move in the opposite direction from the intact part of the ribs.

When the ribs are expanding out to create negative pressure, the negative pressure is pulling air into the chest, but the negative pressure is also pulling the broken ribs inward.

When the ribs are relaxing and creating positive pressure, the positive pressure is  forcing the air out of the chest, but the positive pressure is also forcing the broken ribs outward.

This is one of those assessment findings that is hard to miss. The patient may be trying to keep you from assessing that part of the chest, because . . . well . . . it hurts. It doesn’t hurt a little bit. This isn’t just a hairline fracture that hurts a lot. This is a bunch of broken bones that are moving around – a lot – with every bit of breathing.

Not – It only hurts when I laugh.

Not – It only hurts when I move.

But – It only hurts when I breathe.

The normal response to the first two is pretty easy. If it hurts, when you do that, don’t do that.

That doesn’t work very well for breathing. Go ahead. See how long you can hold your breath. Now take a hammer and break a bunch of your ribs. Now, how long can you hold your breath? Not the same thing, at all.

The only time that a flail chest should be missed is when the ribs are not completely broken, in which case, it is not really a flail chest, except for the textbook definition of 2, or more, ribs broken in 2, or more, places. That is the textbook definition. The textbook definition should include the paradoxical movement. Paradoxical movement is what everyone is supposed to be looking for.

Paradoxical means the opposite of what we would ordinarily expect. We would ordinarily expect the ribs to all move together. With a flail chest, the flail segment is moving in the opposite direction from the rest of the ribs.

If the patient is conscious and not disoriented, the pain should be a clear clue to examine the part of the chest being protected. The patient’s arm may act as an excellent splint. Expect to use a lot of morphine/fentanyl/Dialudid. Pain will interfere with breathing more than the opioids will. Fentanyl is less likely to affect cardiac output (blood pressure), so that is my preference.

If people are missing flail chest, we need to ask Why?

We don’t need to complain that the person is ignoring mechanism.

Focusing on mechanism just ignores everything we understand about assessment.

Or do we just not understand assessment?

Mechanism Of Injury criteria for trauma triage encourage incompetence.

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That’s not Klingon It’s One Word Dyspnea: EMS Garage Episode 98

We were supposed to be talking about the potential harm from the way we use oxygen in EMS, but we ended up with That’s not Klingon It’s One Word Dyspnea.

First, I mentioned that I am blogging at a new location – here. Also at EMS Blogs will be Black Hearts Incorporated, EMS Bloggers, EMS Office Hours, Medical Author Chat, Ready Fodder, The Social Medic, and Too Old To Work, Too Young To Retire. So far, EMS Office Hours, Too Old To Work, Too Young To Retire, and I are posting while things are being worked out. The blog transfer has not been fun, but it has been educational. I expect to learn a lot more. And I have to thank David Konig, who has been putting his blog, The Social Medic, on hold and guiding us through this. He has also come up with a nice simple design for my blog that I like a lot.

Then the topic turned to the recent medical helicopter crashes and Ambulance Driver’s post Is that helicopter really necessary? in response to the M.D.O.D. post Do You REALLY Need the Helicopter? Before the podcast, I wrote a post mostly about the comments on Ambulance Driver’s post. Fly Everyone, Let the NTSB Accident Investigators Sort ‘Em Out.

It should come as no surprise to people who are familiar with any of the participants, that we were very critical of the abuse of helicopter EMS by medical directors, by ED physicians, and by ground EMS personnel.

Why should we try to justify abuse?

The comments in support of helicopter abuse (on Ambulance Driver’s post) are depressing for those of us trying to improve the quality of EMS. These comments do point out the problems I wrote about in Confirmation Bias and EMS. Many of us do not appear to make any attempt to be objective in evaluating what we do in EMS. We only seem to look at things through the filter of our biases. The people writing these comments seem to have decided that helicopters always save lives and they deny that helicopter crashes are a problem.

The purpose of the helicopter is to make a significant difference in transport time for the patient who really is unstable. These patients are not as common as many suggest. They seem to be most commonly encountered by the least experienced people. In other words, as people become more skilled, they panic less and fly fewer patients. The people denying the problems with helicopters seem to be trying to demonstrate that they cannot assess patients well enough to recognize which patients are unstable, which are stable, and which were never even injured.

The people denying the problems with helicopters also seem to demonstrate that they do not understand that they are not saving significant amounts of time. They often are delaying a patient’s arrival at a trauma center just so they can put the patient in a helicopter.

Finally, we did briefly mention harm from oxygen, but that should be covered in an upcoming podcast. Preferably a show with at least one physician on it. There is a lot to discuss, when considering the over-use of oxygen, and it does appear that we use too much oxygen. We have too many patients receiving oxygen without any evidence of hypoxia.

In the absence of hypoxia, there is not evidence of benefit from oxygen, but there is evidence of harm. This goes back to at least 1950, so the idea that oxygen is harmful is not at all new. This is another example of what I write about in Confirmation Bias and EMS.

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Fly Everyone, Let the NTSB Accident Investigators Sort ‘Em Out

Many people think that my posts on science and logical fallacies are not related to EMS. For a Fantastic Feast of Fallacies, head on over to A Day in the Life of an Ambulance Driver. Read his post Is that helicopter really necessary? More important is to read the comments.

Ambulance Driver is referring to a post at M.D.O.D. by the title of Do You REALLY Need the Helicopter?

First, Ambulance Driver writes this:

Over at M.D.O.D., ERdoc85 wonders if some of his patients are being transported inappropriately via helicopter.

And the answer to that question is, “Hell yes, most of them.”

Ambulance Driver does not write a lot of words in his post, but he does provide a lot of evidence.

The Cult of Mechanism
ems1.com
The Ambulance Driver’s Perspective
by Kelly Grayson

Mechanism of Injury in Prehospital Trauma Triage
ems1.com
The EMS Contrarian
by Bryan E. Bledsoe

Alright, I’ll Say It
ems1.com
The EMS Contrarian
by Bryan E. Bledsoe

Two Dead in Oklahoma Medevac Crash
EagleMed chopper crashed enroute to pickup a patient

JEMS.com
by Ken Miller, Associated Press Writer
Friday, July 23, 2010

Ambulance Driver finishes up with this:

And if your primary justification for the flight is mechanism of injury, or the helicopter is the quickest way to clear an ER bed, or to allow your ground EMS crew to go back into service sooner, you’re part of the problem.

Nice and concise with a lot of evidence and some recent news about the real dangers of HEMS (Helicopter EMS).

Dr. Bryan Bledsoe, often wrongly accused of hating helicopters, hating flight crews, and just hating EMS, concluded Alright, I’ll Say It with this paragraph:

I had better bring this tirade to an end. While flying home today from Philadelphia, it hit me that I knew more people who have been killed in a medical helicopter accident than by virtually any other means. At some point in my life I have met or spoken with at least five people who later died in medical helicopter crashes. They were all great people and died doing what they loved. We owe it to their legacy to assure that not a single flight nurse, flight paramedic, pilot or patient dies unnecessarily.

The highlighting is mine. The hating is not there, no matter how much people would like to believe that the only way anyone could point out the problems with HEMS, or with EMS, is to hate HEMS, or to hate flight crews, or to hate EMS.

How many people spend as much time trying to improve EMS as Dr. Bledsoe does? Certainly not those who ignorantly criticize him.

You might think that any contrary opinions expressed in the comments would be well thought out, so that those commenting would not completely embarrass themselves. You would be a hopeless optimist. Maybe some quotes from the comments will cure you.

Reading the comments, I wonder how these Fly Everyone, Let the NTSB Accident Investigators Sort ‘Em Out types even mange to put decipherable sentences together. These comments certainly do not demonstrate anything that passes for understanding.

Even in the week since that post, there has been another fatal HEMS crash.

Arizona: Helicopter Crash Kills 3
By The Associated Press
Published: July 29, 2010

Here is a sampling of the commentary in defense of unnecessary helicopter flights and in defense of the unnecessary deaths of flight crews and patients.

I find this article insulting.

. . . and yes I have lost friends in airmedical crashes, but I still continue to fly and support our system.

Because if he were to admit that a lot of them died unnecessarily, that would really mess with his cognitive dissonance.

Did he read any of the linked articles?

Maybe.

Did he understand any of the articles?

Not much chance of that, assuming he did read any of them, with his cognitive dissonance protecting him from the truth.

Support our system, even if it is killing us! Go Team! Rah! Rah! Rah!

Better to be insulted, than to think.

Another writes:

I WOULD RATHER BE SAFE THAN SORRY.

This is safety?

This is not being sorry?

Then this clown accuses Ambulance Driver of being a city slicker.

Someone else criticizes a flight medic for agreeing with Ambulance Driver about the unnecessary flights.

i am sorry to hear that you get silly calls, but that is part of the job and you go when you are requested. if you dont take it then we get called as the ground crew, then you get to get back to your nap or tv show you are watching.

This one appears to think that the danger involved is limited to missing one’s favorite TV show and having to watch it later on TiVo®. He probably only remembers this bit of poetry:

Their’s not to make reply,
Their’s not to reason why,
Their’s but to do and die:

This from a raconteur wanna be:

Or better yet, when we get launched for an MVA and then declined because they end up taking the patient to the local hospital. Then invariably we’re called about 4 hours later to pick up a soup sandwhich and take them to the Level I trauma center. And what was the Rx given at the hospital, other than a cashechtomy?

Invariably?

adverb
in every case or on every occasion; always:

He is describing a problem. It might only be an imagined problem, since he does seem to have wandered, more than a little bit, from the path of the truth. He seems to be very interested in providing an entertaining story about how he could save the day, if only they would call him earlier. He does not seem to have much interest in improving anything for his patients, unless it involves him swooping in from the sky to rescue them.

Are any of these comments not great examples of the failure of logical thinking and the victory of bias?

Better safe than sorry imagines that transport by HEMS is not any more dangerous than transport by ground. Not only that, he claims that transport by HEMS is safer than transport by ground EMS. I do not doubt that this is the case, when he is the one treating patients in the ambulance. He does seem very dangerous.

Then he assumes that Ambulance Driver must not be familiar with rural EMS, even though Ambulance Driver regularly writes about rural EMS. Better safe than sorry seems to think that the only way anyone would not agree with him is to be unfamiliar with what he deals with. I do not know much about what he deals with, but I can tell you that it is not reality. In his mind, he redecorates reality with a Feng Shui that is pleasing to his prejudices.

Then there is the guy who thinks that the most dangerous part of HEMS is repetitive stress injury from overuse of the TV remote.

Picture Credit

A real medic would walk away from that, with the patient in one arm and the pilot over his shoulder. Piece of cake.

Just put down the remote and fly, you sissies! We need to sacrifice you on the altar of the Magic Rotor Cure! Think of the Glory!

EMS flight crew is only the most dangerous job in the US, so why not abuse them to death – the patients, too.

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Why is air medical transport still killing us? Comment from Samuel Kordik

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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Helicopter EMS Abuse Addressed in the 2011 US Budget

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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Reducing Interruptions – How To Send The Wrong Message

The less time off the chest, the better the results for the victim of out-of-hospital cardiac arrest. Educating EMS providers in performing high-quality CPR possible is crucial. (Photo Ryche Guerrero)[1]

JEMS has a good article, and it is on an important topic, but whoever decided to use the picture (above) that accompanies the article needs to cut back on the use of the crack pipe, just a little bit, or maybe just cut back while at work.

The article is about the importance of quality in the performance of chest compressions, but the picture seems to have been staged to demonstrate as many errors as possible. Maybe this is not at all representative of what this crew normally does, but somebody should have looked at it, giggled let out a heavy sigh of despair, and looked for something that does not contradict the message of the article.

Is this a trauma code? The immobilization may be a part of the movement by some in EMS to have us put collars on intubated patients, rather than have us pay attention to the way we move patients. If the goal is to just prevent the tube from being dislodged, we should not tape the head down as, well. The collar does not make a dislodged tube impossible, so if the tube is dislodged, now (depending on the amount and type of tape used) we might wish we hadn’t applied tape.

So I will assume that this is a trauma code, which raises the question – What century are we in? Why are we doing compressions on a trauma code? Why are we transporting a trauma code?

We have four people and a dead body. Each is in his/her own little world, doing his/her own little thing.

Someone behind the door is bagging the patient through the endotracheal tube, because this is about how much more important compressions are than ventilations.

Monitor Guy is doing something monitorish, because otherwise there might not be anything to do – except relieve the guy attempting compressions.

Headset Guy appears to be pushing drugs, because drugs have not been shown to improve outcomes in cardiac arrest.

Headset? Why do we have headsets? Well, it appears that the fashionable attire of Monitor Guy and Headset Guy includes some dandy little flight patches. So, not only does this appear to be an inappropriate transport of a dead guy, but it appears to be an inappropriate flight of a dead guy. On the plus side, the flight is not for mechanism only. Lemonade anyone?

Maybe the flight crew was called for the patient while the patient was still alive and they are only assisting the ambulance crew to the ambulance with the patient. Nobody flies dead people, at least not in this century. Right? Or should this flight service be known as Corpse Flight – nobody is too dead for low altitude at high prices!

One guy left. The guy who is actually doing compressions. Maybe I shouldn’t use the words actually, or doing, since at the angle demonstrated, Arnold Schwarzenegger would have trouble generating effective compressions.

But we don’t have a better way of performing compressions while loading the patient in the ambulance, for the ride to the landing zone, for the flight to the helipad, for the elevator ride(s) (or is it another ambulance ride) to the ED, where someone may feel the need to continue the code for a little while, just to avoid hurting the feelings of everyone who has worked so hard to get him here.

This is resuscitation theater, not medicine.

This is not about the patient, but about putting on a show – and in this case it does not even appear to be a good show.

Why are we endangering all of these people, just to put on a show? Ground crews deserve better. Flight crews deserve better.

Compressions are important. Interruptions in compressions lead to worse outcomes.

it’s clear that educating EMS providers in performing the best quality CPR possible and monitoring those efforts to ensure that these skills are not deteriorating over time is also a crucial component that EMS systems need to direct time and resources to in order to increase OOHCA saves.[1]

I think this is a picture of an interruption of compressions.

This is not CPR.

Is this anything other than just going through the motions?

Educating EMS providers in performing high-quality CPR possible is crucial.[1]

And it should be continuous.

Footnotes:

^ 1 Reducing Interruptions – Continuous chest compression CPR and minimally interrupted CPR result in improved survival
By David P. Keseg, MD, FACEP
2010 Jan 1
JEMS.com
Article

Updated Article Link 7-15-10

The article was also selected by JEMS as one of its Best of JEMS series, where they chose what they believe to be their best article of the year. This is their choice for 2010 – as of the Ides of March, 2010. Late addition – 7-15-10 19:48

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Can EPs Fix the Helicopter EMS System?

Over at Emergency Physicians Monthly, Dr. Bryan Bledsoe writes Can EPs Fix the Helicopter EMS System?

Dr. Bledsoe, an EP (Emergency Physician), starts with the following paragraph that puts things in a perspective quite a bit different from what we think of, when we think of helicopter EMS –

Imagine that several times a year (approximately every 50,000 procedures) there was a cardiac catheterization lab accident in which the medical team (cardiologist, nurse and technician) perished along with their patient. There would be an immediate outcry to make the procedure safer (technology, practices, safeguards) and reduce risk for the patient and providers. Second, all cath lab procedures would undergo intense scrutiny to assure appropriate utilization. Although such a scenario may seem outrageous, it is essentially the same risks that helicopter EMS (HEMS) crews face on a daily basis. In fact, HEMS transport is the only medical procedure that holds a much higher morbidity and mortality for the providers than it does for the patient.

The only other category of medical personnel that has had a higher fatality rate than their patients is the military medic. That is because the opposing military views killing/disabling the medic as an important way to demoralize the troops served by that medic.

The difference is that nobody is intentionally trying to kill flight crews, are they?

Unintentionally, there is a lot done that does increase the danger for flight crews. Dr. Bledsoe is trying to decrease the unnecessary risks of being a flight medic, flight nurse, flight physician, or EMS pilot.

So why do so many of those he is trying to help view him as the enemy?

Ignorance is the only answer I can think of.

Dr. Bledsoe speaks all over the world about EMS and the things we need to improve for our patients and for ourselves. While there are some out there who understand what he is doing, most seem to automatically oppose anything that does not fit in with the way they want to do things.

Their motto seems to be, Screw the patients – this is about our egos.

We put the safety of flight crews in the hands of the most ignorant providers in EMS – those who think that it is cool to call for a helicopter, or those who are not comfortable taking care of unstable patients, or those who want a shiny pin to put on their shirt, or just those who do not want to drive 20 minutes to a trauma center. After all, the patient will be the one paying for this, so what do they care?

Why are the most irresponsible people in EMS encouraged to make these mistakes?

We should be treating fight crews as if they are valuable. They are supposed to be specialists, but they are called for every little thing that might be twisted into an excuse to call a helicopter.

We should not be defending this abuse of patients. We should not be justifying this abuse of flight crews.

I did make a bit of a misrepresentation, the article is written by Michael Abernethy, MD, Bryan Bledsoe, DO & Dale Carrison, DO. This is not just Dr. Bledsoe. There are other emergency physicians aware of HEMS abuse and willing to speak out about HEMS abuse.

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