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

- Rogue Medic

EMS Needs to Be a Separate Medical Specialty – Now – Part I

Ckemtp documents one of the major problems in EMS in Every Day EMS Ethics – Self Medical Direction?

How are we supposed to deal with bad protocols, when some medical directors would rather endanger patients, than improve patient care?

Which is more ethical?

A. Follow the protocol, even though it endangers patients. I am only following orders. As long as I am following the protocol orders I am not responsible for anything that I do.

B. Violate the protocol, but document it accurately, knowing that my medical director is interested in what is best for the patient, not what is best for the protocol. My medical director makes it clear that he will support me, as long as I am acting in the best interest of the patient.

C. Violate the protocol, but document it accurately. Unlike in scenario B., knowing that my medical director thinks that a medic’s place is under the bus. Knowing that my authorization to treat patients is likely to be revoked, unless I apologize for having the arrogance to question what the medical director put in the protocol. Also, I must promise to never again protect the patient from the medical director. I may end up going to court over this, but the jury is chosen because they are unfamiliar with medicine, not because they have a clue. The medical director will be presented as the expert, while I am just the arrogant know it all.

D. I can titrate the dose of medication to the response of the patient. Stop when the desired effect appears to have been produced, realizing that things change and more may need to be given, if indicated. If my protocol does not include a rate of administration, can it really be said that I have violated protocol, by giving the medication too slowly?

E. Transport without giving the dangerous dose. Transfer care to the physician explaining that, I am incredibly clumsy and can’t imagine why I could not manage to complete a simple task, such as poisoning my patient. Mea culpa. Mea maxima culpa. Meh.

Since Ckemtp is writing about naloxone (Narcan), it is fortunate that I have written just a little bit about this – from my very first post, to one where I describe what may be the most effective way to educate a physician incompetent in the use of naloxone, to a bunch of other naloxone posts – here, here, here, here, here, here, here, here, and here. That probably is most of them, not that I have much to say on naloxone.

In answer to the inevitable comments that the medical director, even an absentee medical director, has spent years in medical school and residency. How dare I question the judgment of a physician?

First. I would hope that anyone that well educated would put the welfare of the patient above the welfare of the protocol.

Yes, protocols are important. However, if protocols are to be respected, they need to keep up with the evidence. Anything less than that just demonstrates that the physician is not acting in the best interest of the patients. The purpose of the protocol is to protect the patient. Making the protocol the weapon to hurt the patient, because the protocol is there to protect the patient, is insanely bureaucratic.

If the physician is willing to harm patients, just to make a point, or just to have his own style of control, that is not an example of patient care to be respected.

Second. Ignorance, in spite of all of that education, is nothing to brag about.

Third. This physician is advocating abusing patients. And people are defending the physician. Why are people defending the abuse of patients?

Fourth. Joseph Mengele was a physician. There is nothing about being a physician that makes one perfect, or ethical, or right. We need for good physicians to strongly oppose the bad physicians. First, both medics and other physicians should try to reason with the dangerous medical director. As I pointed out EMS is not well understood by many emergency physicians.

Fifth. The 8th Law – Half of what is taught in medical school is wrong, but nobody knows which half. Declarations of a Dinosaur – 10 Laws I’ve Learned as a Family Doctor, by Lucy E. Hornstein, MD, who writes Musings of a Dinosaur. There are links to purchase the book in her sidebar. This could explain why some medical directors do not live up to expectations.

Titration of medication is not avant-garde. Paracelsus (he lived from 1493 – 1541, so this is not exactly new) wrote –

All things are poison and nothing is without poison, only the dose permits something not to be poisonous.

To give something in a quantity that is inappropriate is to poison the patient.

If I document good patient care that conflicts with a given protocol, I need to have a medical director, who understands good patient care. I need a medical director, who understands Emergency Medical Services. This is one of the reasons that there needs to be board certification for physicians in the medical specialty of EMS.

Separate from emergency medicine. Emergency medicine is as different from EMS as internal medicine is different from emergency medicine. One may do a good job working in the other specialty, but do you really want to be cared for by someone moonlighting in a specialty in which they are not trained?

EMS needs to be its own board certified medical specialty, because there are too many emergency physicians who just do not understand prehospital care. Too many emergency physicians who just do not understand medical direction/medical oversight.

Even those, who have worked in EMS may find that things have significantly changed since they were working the streets, or they may find that the tried and true principle of Mother may I? calls for medical command permission to provide emergency treatment are counterproductive to good patient care. Mother may I? medical command only encourages medical directors to feel comfortable allowing dangerous paramedics to work.

These medical directors claim that, I know that Medic X is dangerous, but as long as he has to call for everything, how much harm can he do? Who is more dangerous, Medic X or the medical director who sets loose a service full of Medic Xs on a defenseless population – a population in need of competent emergency care?

The medical director is there to defend the population, but the Mother may I? calls for medical command endanger the population.

Of course, I would never advocate documenting care inaccurately, because that would allow the state to pull my medic card. I must follow the protocol. I must document accurate compliance with the protocol. We must respect that when the state insists that I do something unethical, it is their position that it is unethical not to perform the unethical behavior.

Paramedic Yossarian reporting for duty.


Changing Standards in Education – from other things amanzi

I am often critical of the way EMS keeps trying to make it easier to keep up a steady flow of brand spanking new paramedics. Not because we produce a high quality product (new medics), but because the public is too ignorant to notice.

The main tool is the National Registry of EMTs exam, but other exams aren’t noticeably better. Dr. Bongi, from other things amanzi, has a post up at Better Health by the name of When Incompetence Kills.

Basically the powers that be are not-so-gradually degrading the degree. To them somehow it seems like a good idea.

It becomes difficult to have half a dozen, or more, medics show up for every emergency call, when we have standards. Do we decide that one competent medic is enough, or do we hit them with a double dose of barber shop quartets – in the hope that all the patient really needs is a lot of company, and maybe a song?

Of course, we choose the high quantity, low quality route.

The image is from the Wikipedia Project Triangle article.

Now not all that long ago, to miss free air on an X-ray even as a student was a mistake that would fail you. These days you can easily get through medical school without worrying about trivialities like free air on X-rays. Also, to have perforated bowel causes intense almost unbearable pain. Even a street sweeper would be able to pick this up in the patient.

Seems as if EMS is not alone in the just push them out the door with a card kind of standards.

Yet the doctor at the referring hospital did not miss this easy clinical diagnosis only on one day or two days or three days, but on four days.

About 9 years ago, I stopped teaching paramedic school, because I could not continue to contribute to this farce. I was forbidden from doing anything outside of the limited classroom time. There were 2 people in the class holding everyone else back, but nothing was to be done about them, because they have not failed the ridiculously low criteria to remain in the course. It’s up to their preceptors to pass, or fail, them. According to the program director. I was forbidden from getting rid of the dangerous students future paramedics.

So not only did his treating doctors totally miss a very obvious diagnosis that any 4th year medical student should be able to make and thereby neglect to treat him appropriately, but the one necessary thing they tried to do, because they didn’t know how to do it properly, caused further damage to the poor man.

One student was considered a troublemaker. One reason was that he would ask questions about things that would not be on the test. It was OK to have to essentailly repeat a lecture, because 2 people want to have paramedic cards, but don’t let on that they haven’t grasped the most basic points, the points from the first 5 minutes of the class. Everyone knows that the real evil is to ask a question about something that will not be on the test.

I cast my mind back to when I was still in academic circles. I remember the professors complaining about pressure from the powers that be to pass students even when they felt the students were not suitably prepared.

I guess I was just imagining things, because that would never happen in paramedic school. Dr. Bongi’s description is of medical school.

I myself was asked to examine a student in a practical exam. I failed her because she was simply a danger to any person unlucky enough to become her patient. And yet the powers that be had so changed the system from when I was a pregrad that she could not be failed and was released into the community.

When you cannot change the system from within, the only choice left is to leave or to force them to throw you out. I have taken advantage of both exit strategies.

We are killing them with kindness.

Killing the patients with kindness to the students. But the NR validates everything they do, and they are the experts. And you can’t go wrong buying a house when everyone else is, too. We’ll give you one mortgage on the house and another on the downpayment.

Don’t worry about the interest rate.

Debts like these never come due . . .

except in the real world.

The mortgage sellers and the NR don’t have to deal with their mistakes. They are making money selling their sub-prime product. The patients pay.

Dr. Bongi, you have my sympathies. It is too bad that more people do not understand.


Trauma Premier Live Commentary on EMS Garage and MedicCast

From JEMS News

Podcasters, Bloggers Set for Online Premiere Party of Trauma

From online discussion during the show to a post-show call-in chat for tonight’s premiere of Trauma. Join leading EMS Podcasters Jamie Davis, Chris Montera, Greg Friese and others in watching and discussing the premiere of the new NBC show Trauma. Browse to EMSGarage.com/live or http://mediccastlive.com at 9 p.m. EDT/ 8p.m. CST on Monday September 28, 2009 for live conversation and commentary.

Full story.


What Do You Think? Are You Going to Watch Trauma? Discuss Before, During and After …

I will be on the road, so I will not be watching this pean to the incompetent, but bipolar, narcissistic, schizophrenic, psychopath in all of us realistic, thoughtful, and respectful treatment of EMS. however, based on the trailer released earlier in the year, I wrote Trauma – New NBC Drama To Ridicule EMS.

Did it turn out to be everything I feared hoped it would be? Or do I owe somebody an apology?

I would rather apologize, than be right, but something tells me I will not be eating crow tonight, or for the duration of the series (at least as far as my comments on the quality of the series are concerned).


Too Many Medics?

Also posted over at Paramedicine 101. Go check out the rest of what is there.

In some of the posts on the recent intubation study,[1] this question keeps coming up: What is the right number of paramedics to provide the best care to patients?

There was an article that covered this.[2] Here is the chart from the article.


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The study examined cardiac-arrest survival in five
unnamed cities. The findings include:

City with best outcome City with worst outcome
Cases of sudden cardiac arrest per paramedic each year 4.7 1.6
Length of time paramedics arrive after first responders 4 minutes 1 minute
Survival rate 27% 4%

Source: Researchers at Ohio State University in Columbus


This does not mean that medics should not be sent at all. Rather, it strongly suggests, that in our desire for a quick ALS response for cardiac arrest, we may be making things, not just a little bit worse, but a lot worse.

These numbers agree with what I have been stating about ALS getting in the way of BLS during cardiac arrest treatments (CPR). The numbers do not prove what I have been stating, but they seem to be giving a very strong hint.

The places with fast ALS responses are able to respond quickly because they have a lot more medics. In other words, they have dramatically reduced the amount of experience per medic.


To make everybody feel good, even though it appears to be killing people.

Almost a 7 times higher survival rate in the cities with fewer medics.

Feel good?

More medics means that more people are medics, and can feel good about being medics.

More medics means that more people are having medics respond to treat them, and can feel good about receiving care from medics.

This is just to make people feel good. Then, why not make everyone a medic? The response time would be immediate, unless maybe you fall in the woods, and there is nobody else there to hear you fall. In which case the philosophical question is, If a patient falls in the woods and there is nobody there to call 911, is there a response time? Not, Does the patient make a sound? And, since the patient is a medic, there is already a medic on scene, so there is no worry about response time.

Do the response time rules state that the responding medic has to be alive?

Probably not.

We could have all of the patients in nursing homes become paramedics. Talk about cross-training leading to improved response times!

Too many medics = too many failed resuscitations.

Too much of a good thing can be a bad thing.


^ 1 Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed – indexed for MEDLINE]

PubMed states that the full text article is free at the journal site, but it is not

^ 2 Fewer paramedics means more lives saved
Updated 5/21/2006 8:58 PM ET
USA Today
By Robert Davis

The chart is from this article.


Fla. EMS director pulls certification of 25 paramedics

It seems that there is a bit of a squabble going on down in Florida.

Twenty-five North Naples firefighters are no longer allowed to work as paramedics because they haven’t met training requirements set by Collier County Medical Director Dr. Bob Tober.

North Naples Fire Chief Orly Stolts said the move puts good medics out of commission and endangers residents.[1]

A fire chief opposed to training? WTF?

Oh, it’s EMS training that he is opposed to. That explains it. The chief thought that he would be able to force the medical director to sign off on the ex-medics, just because the chief was going to huff and puff and sputter and grimace and cry like a little baby.

“What he’s done is minimized the fire department’s ability to save lives,” Stolts said of Tober. “We’re going to have to stand there and wait to give life-saving medication until an ambulance arrives at the scene. That puts our guys in a pretty hard spot.”[1]

Well, he is the chief. He should know.

He is a fire chief. His highest ranking medical person is telling him just the opposite of what he wants to hear. He just really, really, really doesn’t want to hear this.

“We’re going to have to stand there and wait to give life-saving medication until an ambulance arrives at the scene.”

If he truly believes that, then maybe he should have acted as a Chief and made sure that his people had the required training. This is all the fault of Chief Numbskull.

This is a wonderful example of a blithering idiot.

Stolts said arranging to have his firefighters pulled from an engine once a month causes significant scheduling and overtime difficulties.[1]

In other words, Chief Stolts is completely responsible for this. He chose not to follow the medical training rules. I wonder if he does that with fire training rules.

Maybe he is cross-trained and incompetent at both fire and EMS.

Maybe. We know he has one area of incompetence fully covered.


^ 1 Fla. EMS director pulls certification of 25 paramedics
By Ryan Mills
The Naples Daily News
August 26, 2009


New Service Rules

Here is another Normal Sinus Rhythm post. The topic this week is themeless. Read the rest of the NSR Blog posts at NSR Week 9.

You get a memo from the ALS coordinator (just below the medical director, the person responsible for oversight of the medics) .

We have had a problem with inappropriate triage of ALS patients to BLS care. As of yesterday, all calls dispatched as ALS will have the medic in the back attending to the patient.

Signed ALS Coordinator and medical director.

One of the problems in EMS (Emergency Medical Services), that is present in everything else, is misbehavior. One example of this is in systems that mix ALS (Advanced Life Support – medic, nurse, doctor with needles, tubes, drugs, . . . ) and BLS (Basic Life Support – stuff that really works, except for spinal immobilization) together. Either BLS on the ambulance and ALS responding in a fly car (or whatever terminology you use for a separate ALS response vehicle) or the ambulance crew is made up of a medic and a basic EMT.

One way that misbehavior exhibits itself is when there is a call that appears to be an ALS call, but the medic states it is a BLS call. He refuses to be the person taking care of the patient. We will assume, for the sake of argument, that everybody knows that this patient does have a legitimate ALS complaint. Let’s say chest pain, but the medic claims that the patient just has indigestion.

Never happened.

I’ve seen it happen with doctors, nurses, medics, and basic EMTs. Some people just jump to conclusions without assessing thoroughly, some have such a bias about what a real chest pain patient should look like, that they practically need to be hit over the head with a life threatening arrhythmia to be convinced that the epigastric discomfort is actually cardiac in origin. There is plenty of evidence of health care professionals doing this. Usually it is a doctor, who is documented as being the one to make this mistake, because his gut feeling was that the patient did not have a serious medical condition. One reason nurses and medics do not have so many documented cases is that they do not generally have the final say on treatment.

So the medic decides that the patient with chest pain does not have chest pain, but just indigestion. No ECG, no good history, no real physical exam. They patient just doesn’t look the way the medic expects a chest pain patient to look, at least, if the chest pain were of cardiac origin. Never mind that atypical cardiac presentations may be as common as typical presentations.

The EMT rides in the back. Or, if the medic responds separately, the EMTs agree to recall the medic, who has not notified dispatch that he is on scene, yet. This way the medic does not need to do any paperwork, other than a recall chart, since he never saw the patient. At least, that is what the documentation will show. So no record of patient contact means no liability for an incompetent workup. That is the way the medic will view this. The patient responded that he did eat a heavy meal before this pain began and that burping (eructation) relieves the discomfort, temporarily. That is enough to convince the paragod that this is not something worthy of his time. It isn’t the pale, cool, soaked with sweat (diaphoretic), crushing substernal chest pressure radiating down the left arm, can’t get the electrodes to stick to the patient, because benzoin is something that other people have to use. In other words, this presentation, that the medic thinks is typical, but is uncommon, is the only thing he is likely to do something about and feel that he isn’t wasting his valuable time. Got more important things to do. Hey, Springer is on.

Nothing about history of diabetes, previous MI (Myocardial Infarction or heart attack), angina, cardiac catheterization, any other history, medication, allergies, because Medic Magoo sees all.

When they get to the hospital, either the medic is not there (released/canceled by BLS) or the medic blames the EMT for not telling him what was going on. In other words, the EMT did not do his job for him. Even though the EMT really was doing his job – taking care of a patient with a legitimate cardiac complaint, because the medic did not want to do anything more than drive.

One medic/EMT system, where the ALS coordinator and the medical director claimed to have a problem with this, chose the wrong solution. There are other wrong solutions. Their solution to the problem?

On any call dispatched as ALS, the medic will provide all care. This will guarantee that the medic does not release care to his partner. It does nothing to get the medic to understand what he is missing in his assessment. It does not require that the medic be competent. It does nothing to differentiate between the medics who appropriately release patients to their partner.

The problem is only with some of the medics.

The solution is to force all of the medics to do things in this thoughtless way.

The problem is that some of the medics do not care or do not understand.

The solution is to ignore the opportunity to use this to remediate those who don’t understand. To ignore the opportunity to find out what the problem is in those who do not care.

There is no discrimination between competent and incompetent.

Ask EMS instructors what the most important ALS skill is. Many, maybe most, will tell you it is a good assessment. This ALS coordinator and medical director have decided that the most important ALS skill is following the direction of dispatch.

Dispatch made the call ALS, because hemorrhage is an ALS call. You arrive on scene and find that it is a paper cut. There is currently no bleeding. There are a couple of drops of blood on a paper towel used to control the hemorrhage.

Dispatch made the call ALS, because abdominal pain is an ALS call. You arrive and treat the patient as having abdominal pain – IV and fluids, per protocol – not performing a good assessment and realizing the patient has epigastic pain as a symptom of a heart attack.

The first case is just making more work for the paramedic. Not really a problem, unless all of the calls are ALS and the medic is spending all of his time treating patients and writing charts. There are places where this is typical.

The second case, just adds an IV to the treatment the patient received, and maybe they are on the heart monitor.

No aspirin. The most effective EMS drug for a heart attack.

No NTG (NiTroGlycerin).

No morphine or fentanyl. The medic would have to get permission to treat abdominal pain with opioids, because the protocols are written by a medical director who is afraid of surgeons and is not familiar with the research on pain management. But that is a different topic.

No 12 lead ECG. That would, in a smart system, lead to a cath lab activation if the medic interprets the 12 lead accurately. There is no good reason why the medic should not interpret the 12 lead accurately.

No beta blockers or other treatments that might be beneficial.

After all, this is just a whiny abdominal pain patient. Probably just ate too much. He should be put in one of the out of sight, out of mind beds.

This is dangerous. If there is a problem with some medics, the solution is to address the problem with those medics. Punishing everyone for the mistakes of a few is not good medicine. It may work in boot camp. If that were the ideal, we would transport patients to boot camp, not to the hospital.

The assessment has not been affected, only the documentation and the addition of the IV lifeline.


Helicopters and Airways

I have been presenting things in a very negative light, not because there is nothing positive to write about helicopters, but because too many people are ignoring the dangers. Dangers to patient and to flight crew. My comments apply to urban and suburban EMS – less than an hour transport by ground to a trauma center. So, not much reason to fly these patients – you are almost always too close to the trauma center to justify flying the patient.

If you disagree, provide some research to support your position.

I have chosen to fly patients, but only about one per year, since it is rare that a patient meets my criteria to fly.

  • The illness/injury has to be serious enough that I think, based on my assessment of the patient, that the patient will deteriorate significantly in the next half hour, or so. Never based just on mechanism.
  • The helicopter will make a significant difference in the amount of transport time to the right hospital.
  • The helicopter is available in the next few minutes (not 20 minutes away) and the landing zone can be quickly set up near by.
If any of these are missing, I see no reason to fly the patient.

What about airway?

A lot of people will call the helicopter for airway management. I do not see the benefit in this. The number of patients I have treated, who actually needed RSI, is small enough to count on one hand. This does not mean that using RSI in EMS is a bad idea, but we need to straighten out medical oversight before anyone should be taking away a patient’s respiratory drive.

So, you are too good for the helicopter?


The helicopter is going to take a while to get to the patient.

If the patient has a difficult airway, then the patient should be managed by other means.

Calling a helicopter, because you do not want to show up at the hospital without a tube, is bad airway management.

Here is a list of important airway equipment:

  • Oxygen, regulator, and delivery tubing.
  • Suction – possibly the most important equipment.
  • NPA (NasoPharyngeal Airway).
  • OPA (OroPharyngeal Airway).
  • KY jelly.Lidocaine-type spray.
  • Waveform Capnography.
  • EDD (Esophageal Detector Device).
  • BVM (Bag Valve Mask).
  • LMA (Laryngeal Mask Airway).
  • CombiTube.King LT Airway.
  • Eschmann Introducer or Gum Elastic Bougie.
  • BAAM (Beck Airflow Airway Monitor).
  • Laryngoscope handles.
  • Laryngoscope blades.
  • Stylettes.
  • Batteries.
  • Bulbs.
  • Syringes (to inflate the cuff).
  • Something to secure the tube.
  • ETTs (EndoTracheal Tubes).
  • Retrograde intubation equipment.
  • Transtracheal Jet Oxygenation (it is not ventilation).
  • Surgical airway equipment.
Did I forget anything?

A helicopter!

There is a reason the helicopter is not on the list – it does not belong there. For the same reason you do not call a helicopter to start your IVs. For the same reason you do not call a helicopter to defibrillate your patients. For the same reason you do not call a helicopter to assess your patients. If you cannot do these things without the helicopter, you are in the wrong business.

If you call a helicopter to manage your patient’s airway and wait for the helicopter to manage your patient’s airway, what is your patient doing for oxygenation and ventilation in the mean time?

If the patient is breathing, maybe you did not need the helicopter?

If the patient is not breathing, maybe you needed to be at the closest hospital (no matter how bad at airway they may be)?

Maybe the patient does not need a really big fan to help with breathing.

Some of my other helicopter misuse posts are:

Interfactility Helicopter EMS

Helicopter EMS – The Starbucks Effect.

Dispatch would have told us if it were something serious.

Safety über alles!


Helicopter EMS – The Starbucks Effect.

Dr. Bryan Bledsoe says, “We are putting patients and flight crews at risk, when there is absolutely no chance for the patient to benefit from the risk.”

Does that sound like a definition of malpractice?

Maybe he was just trying to get some attention after a big accident. Maybe he is just trying to make a name for himself.

He wrote about this recently, before this crash, in Alright, I’ll Say It at ems1.com.

“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.”

Clearly, not someone trying to take advantage of a tragic situation, but someone trying to protect flight crews and patients.

Back to the video clip at the top of the page. Reporting on this, Tom Costello said, “But the medics on the scene often don’t know how serious the injuries are. And it’s not until the patient gets to a trauma center that those injuries can be assessed.”

Why wouldn’t a medical professional get on camera to say this?

What evidence backs this up? Yes, there are low standards for EMS. I have been very critical of the medical oversight that encourages this incompetence. The medical directors need to stop allowing anyone with a card to go out and inflict their incompetence on patients. Patients are not in a position to know who is competent and who is not. It is the job of the medical director to determine this before signing the paper that says this person is safe to treat patients with all of the life threatening drugs and equipment they carry.

In stead, medical directors write liberal protocols for helicopter transport. These liberal protocols are often violated egregiously, yet the medical director ignores this. Why? He probably does not know, because he is probably never going to see the patient and will never know that the patient chart is largely a work of fiction.

Some examples of bad flight decisions:

An adult with a lower leg fracture, about 20 minutes from trauma centers in two directions by ground. The idiots called for a helicopter for this stable patient, because that is what they do. They are too stupid to appropriately assess and treat the patient. But wait, some of the idiots who do this are the same medics who work on the helicopters on their other job. Why would anyone trust them with a patient, just to try to save a little time? Good pulses, sensation, and movement. No other injuries – at least according to the report that was given to the flight crew. Who knows how incompetent the assessment was that led to this report.

A child with his foot caught under the seat of a car that struck the guard rail. No intrusion into the patient compartment, everyone restrained, the driver was sitting in the seat that was on top of the child’s foot. The driver had an ankle injury (possible fracture) and was flown. Once one person is flown, usually everyone goes by air. So the five occupants of this car, of which the ankle injury was the most serious, were all flown. We had our own little air shown because somebody can’t treat an ankle injury. My patient was the child. I called the trauma center to get permission to drive him to the local hospital, since he is uninjured, but his parents want him checked out. Medical command at the Ivy League trauma center insists that this child must go by air to the pediatric trauma center. The parents are no longer on scene – they were not in the car, but were far from attentive to their child. Had the parents been on scene, maybe I would have been able to get them to sign a refusal for the helicopter transport and transport to the appropriate hospital with pediatricians on staff.

A stabbing to the chest 8 minutes by ground to the trauma center. The first in medic doesn’t quickly move the patient to the stretcher and transport. He calls for a helicopter. 40 minutes later the now pulseless child is placed in a helicopter to fly to a different trauma center. The patient was still alive 30 minutes after the arrival of the first medic. The patient would have arrived at the trauma center alive and had a chance to live – if he had not been flown.

Since the patient was a child the helicopter flew this dead patient and the trauma center worked the code for almost an hour. Nothing can bring back the wasted half hour that might have made the difference between a casket and an ICU bed. The child might have died anyway, but why call the helicopter to delay transport?

As for the Starbucks Effect, the number of medical helicopters has expanded similar to the way Starbucks have exploded across the countryside, but Starbucks does not explode the same way helicopters explode across the countryside. If you look at the chart it does look like the price of SBUX (Starbucks stock symbol), over the past 5 years, has taken off and flown pretty high, only to take an plunge reminiscent of Icarus, or a crashing helicopter. Today Starbucks announced that they are closing 600 stores – the customers are not flying in to buy their scuppie coffees. When will the flight programs put patients first and do something similar? We are creating bogus excuses to put patients in helicopters to satisfy the growing need for paying customers (patients).

And for anyone reading, who might be offended by what I wrote – if it does not apply to you then you know who I’m talking about; if it does apply to you stop being part of the problem and don’t complain that I pointed out your incompetence. Have I gone too far with crash and burn metaphors? I doubt it. Idiots will still be flying minor trauma after reading this.

Dr. Bledsoe says, “We are putting patients and flight crews at risk, when there is absolutely no chance for the patient to benefit from the risk.”

Words worth repeating.

Maybe we should start requiring competence from medics, so that we can protect patients and flight crews.

Here is a link to the abstract of the study mentioned in the video:

Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MF.
Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis.
J Trauma. 2006 Jun;60(6):1257-65; discussion 1265-6. Review.
PMID: 16766969 [PubMed – indexed for MEDLINE]

Another blog to read on the same topic, from a different perspective, is Too Old To Work, Too Young to Retire. His post is Helicopters in EMS. Ambulance Driver also writes about this and gives it more of a human touch in Gut Check….

My other helicopter misuse posts are:

Interfactility Helicopter EMS

Helicopters and Airways

Dispatch would have told us if it were something serious.

Safety über alles!