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

- Rogue Medic

Double Edged Swords

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

A post at Paramedicine 101, by Medic999, raises some important questions. Chronicles of EMS – A double edged sword? This is what I think addresses the most important part of the way we do things and why we do them differently in different places.

Before all of this crazy show started, I lived and practiced in my own little bubble. I used to naively think that we were the best at what we can do.

That is the human thing to do, to assume that our leaders are making the right choices.

I take the opposite approach. I want our leaders to prove that what they are doing is good for patients. Not that their way is the best way, but that their way can be demonstrated to be good for patients.

Most of what we do in EMS fails that test.

Why should we continue to use these experimental treatments?

Why should we continue to we continue to be guided by ignorance?

Medic999 points out that he was unaware of some possible improvements to patient care. Now he wonders why his protocols do not include treatments like therapeutic hypothermia.

We often will dismiss something because it is a foreign idea. If you want to have a political idea ridiculed, one of the quickest ways is to suggest that it came from France, except if you are in France. As if the origin of an idea has anything to do with the quality of the idea.

There is nobody so perfect that he/she never produces a bad idea. Conversely, we should not assume that there is such a perfect fool, that he/she never produces a good idea. To assume that the origin of an idea is more important than the idea, is itself a bad idea.

Unfortunately, Not originated here means not used here is EMS dogma in many places.

We come up with excuses to avoid changing things.

We act as if our patients will be better served by avoiding improvements in EMS care.

If we are not here to provide the best care to our patients, shouldn’t our patients be protected from us?

One objection that I repeatedly hear from EMS traditionalists is that, We have to be able to say that we did everything we could for the patient.

The parts they leave out are –

As long as the idea originated here!

As long as we don’t have to change the way we do things!

As long as we don’t have to sit in a classroom, or read, or do anything else that would be considered learning!

As long as the patient does not expect us to provide excellent patient care!

As long as we get to spend more time stroking our egos than we spend on improving patient care!

Chronicles of EMS is a double edged sword. Through Chronicles of EMS, Medic999 has more knowledge about what EMS does in other places. Now he is less satisfied with the way things are done where he works. His satisfaction level has decreased because his knowledge level has increased. This is where the term ignorance is bliss comes from. The more we know, the less satisfied we are with traditional solutions.

But this is not about satisfaction. The decrease in satisfaction is only due to looking at things the wrong way. With more knowledge we have the ability to make improvements that make things better for patients.

When we learn that most patients flown to trauma centers did not benefit from being flown, we realize that we are contributing to the excessive death rate among flight crews when we call for more flights, which leads to more helicopters, which also leads to a greater dilution of experience for flight crews. Tradition tells us to fly patients based on mechanism of injury. This allows the blissfully ignorant EMS personnel to think that they snatched the patient from the jaws of death.

When we learn that by rushing to perform ALS procedures during CPR, we have been neglecting the quality of chest compressions. When we improve the quality of chest compressions, we triple the survival rate – the real survival rate, not the misleading and short term return of a drug induced pulse. This is the first improvement in survival to discharge. This only came by discarding the traditional way of doing things.

When we learn that intubation is performed horribly in many places, some of us work to improve our intubation skill, some move to alternative airways much more quickly, some do both, while traditionalists just claim that it is more important for them to intubate, than to provide competent airway management.

Ignorance can be bliss. Tradition can be bliss. Both can also be deadly for our patients.

Knowledge is a double edged sword, but it is much better to provide excellent patient care than to hide behind That’s the way we’ve always done things!

Medic999 is not suggesting that blissful ignorance is better. He is pointing out that the more he knows, the more problems he becomes aware of. This is not a bad thing.

If we are not aware of the problems, we will not correct the problems.

If we do not correct the problems, our patients suffer.

The more we know, the less satisfied we are with traditional solutions.

Our goal should be the protection of our patients by the destruction of our traditions.

Over at Medic999, there is a vigorous discussion in the comments to CoEMS – A Double Edged Sword.


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.


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.


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.


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.


The Catch-22 of Homeopathy and Patient Choice

I have written about the fraud that is homeopathy before. Earlier this week, the British Parliament reviewed the evidence supporting on homeopathy and whether the NHS (National Health Service) should fund homeopathy. They have a lot to say. Let’s look at the area of patient choice.

Patient choice

98. Patient choice is an important concept in modern medicine. Medical practice used to be highly paternalistic, whereby the doctors would know what was best for patients and would prescribe whatever treatments they felt best. Today, doctors are trained to communicate with patients about their treatments and, while providing advice and guidance, ultimately enable patients to make informed choices, where possible, over treatment options and more control over the management of their conditions.

99. Indeed, patient choice was repeatedly cited in written submissions as a reason why homeopathy should be provided on the NHS.[120] The Minister stated:

I think there is an illiberality in saying that personal choice in an area of significant medical controversy should be completely denied, and I think the Government should be cautious about constraining that illiberality, or interfering with it. We should not take the view that patients should not be able to have homeopathic medicine when they want it.[121]

100. However, patient choice is not simply about patients being able to pick whatever treatments they like. They must understand the implications of their decisions, which means that patient choice must be informed choice. As Professor Ernst put it: “patient choice that is not guided by evidence is not choice but arbitrariness”.[122] The RPSGB echoed this view:

It is essential […] that the patient is given the appropriate information to make these informed choices and as a consequence it should be clear to the patient that there is no scientific evidence for homeopathy.[123]

101. We agree with Professor Ernst and the RPSGB. For patient choice to be real choice, patients must be adequately informed to understand the implications of treatments. For homeopathy this would certainly require an explanation that homeopathy is a placebo. When this is not done, patient choice is meaningless. When it is done, the effectiveness of the placebo—that is, homeopathy—may be diminished. We argue that the provision of homeopathy on the NHS, in effect, diminishes, not increases, informed patient choice.[1]

The bold highlighting is in the original document. The RPSGB is the Royal Pharmaceutical Society of Great Britain.

If we lie to the patient, we are not behaving ethically.

If we tell patients the truth, the placebo (homeopathy) is not likely to provide any benefit, since patients need to believe in placebos for placebos to work.


^ 1 House of Commons – Science and Technology Committee – Fourth Report – Evidence Check 2: Homeopathy
2 NHS funding and provision
The evidence check
Homeopathy on the NHS
Patient Choice


Whistle-Blowing Nurse Is Acquitted in Texas

Much has been written about the fanatics criminals trying to get Anne Mitchell, RN locked up. I will only give a brief summary.

A quack – Rolando G. Arafiles Jr., who for some odd reason has not yet been stripped of his medical license, had the sheriff investigate anonymous reports to the Texas Medical Board about his abuse of patients. The sheriff arrested Nurse Mitchell and charged her with a felony that could put her in jail for 10 years and could include a $10,000 fine. The fraudulent investigation probably did contribute to her being wrongfully fired. The county prosecutor, who works for the charlatan, decided to prosecute.

All of these frauds belong in jail.

The case was investigated by Sheriff Robert L. Roberts Jr., a friend and admiring patient of Dr. Arafiles, and tried by the county attorney, Scott M. Tidwell, a political ally of the sheriff and, according to testimony, Dr. Arafiles’s personal lawyer.[1]

In case you are thinking that this is a misrepresentation of their criminal abuse of power, the jury did not have to deliberate for long.

The jury foreman said the panel of six men and six women voted unanimously on the first ballot, and questioned why Mrs. Mitchell had ever been arrested.[1]

Where would a good story about fraud be without a bunch of cognitive dissonance?

Sheriff Roberts said he was disappointed in the verdict but did not regret the prosecution.[1]

The next jury should arrange for these frauds to be bunkmates in a prison where they do not have any friends.

We want nurses and others to feel comfortable reporting potential problem doctors to state medical boards. The medical board should be the ones determining if the complaint is valid.

After the verdict, the nurses’ lawyers pivoted quickly to the lawsuit[2] they have filed in federal court against the county, the hospital and various officials, charging that the firings and indictments amounted to a violation of due process and their First Amendment rights.[1]

Texas, it turns out, has laws that protect whistle-blowers — but only from civil suits. Criminal prosecution is another matter entirely. After the medical board received the nurses’ anonymous complaint, its investigators gave a copy to Dr. Arafiles. That complaint alleged that he’d given patients inappropriate care, including sewing a rubber tip not intended to be attached to humans onto a patient’s crushed finger (a case that the Texas Department of State Health Services had red-flagged). Too, the complaint noted, Arafiles urged patients to buy Zrii, a questionable nutrition supplement sold via a pyramid-marketing structure.[3]

Last month Andrew Wakefield was publicly humiliated for his fraud. Let’s hope they follow that up with criminal charges.

This month another scam artist, Rolando G. Arafiles Jr., is publicly humiliated for endangering patients, as well. Likewise, let’s hope that after the civil trial, there are criminal charges filed against this witch doctor and his minions.

White Coat has written about this –

Nurse Acquitted

Respectful Insolence has written a lot about this –

Report a bad doctor to the authorities, go to jail? It might really happen for Anne Mitchell, RN in Winkler County, Texas

Dr. Rolando Arafiles: Antivaccine rhetoric topped off with colloidal silver for the flu and Morgellons disease

Report a bad doctor to the authorities, go to jail? The trial, day two

Report a bad doctor to the authorities, go to jail? The cranks weigh in

Winkler County Nurse Anne Mitchell is not guilty, not guilty, not guilty, not guilty!


^ 1 Whistle-Blowing Nurse Is Acquitted in Texas
By Kevin Sack
Published: February 11, 2010
New York Times

^ 2 Anne Mitchell and Vickilyn Galle, plaintiffs, vs. Winkler County Memorial Hospital; Stan Wiley, individually and in his official capacity as administrator of the Winkler County Memorial Hospital; Robert L. Roberts, Jr., individually and as Sheriff of Winkler County, Texas; Rolando G. Arafiles, Jr., individually; Scott M. Tidwell, individually and in his official capacity as County Attorney; and Mike Fostell, individually and in his official capacity as District Attorney, defendants.
US District Court for the Western District of Texas, Pecos Division.
Free Full Text PDF

^ 3 Medical emergency – In reporting a doctor’s mistakes, a West Texas nurse risked going to prison
Houston Chronicle Editorial
Feb. 11, 2010, 7:53PM


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


^ 1 United States Federal Budget for Fiscal Year 2011
Free PDF

^ 2 Advantages of medevac transport challenged
Baltimore Sun
October 5, 2008


Trauma Triage Criteria

I will be writing a bit about the use of mechanism of injury as a way to assess patients. An oddity is that mechanism of injury presumes that there is an injury based on possible forces applied to the body. These forces may not have been applied to the body. Even if the forces were applied to the body, they might not have resulted in any injury, or any detectable injury. Because of this, mechanism of injury should only be used to guide assessment, not as a substitute for assessment.

This post will be sort of a reference for people to find trauma triage criteria I refer to in later posts. One problem with trauma triage criteria is that they are referred to as being promoted by the ACS (American College of Surgeons). If I go to their web site, I cannot find them, at least not using the kind of search terms I would expect to turn them up. Why does an organization work so hard at establishing standards for trauma triage, but then seem to make it difficult to find this authoritative information. Although, if you want their opinion on what laws we should pass, that is a significant portion of the information they make available to the public.

There is one reason to make it difficult to find the specific trauma triage criteria to refer to. A lot of these criteria do not work. The amount of damage to the exterior of a car may be meaningless in estimating whether the occupants are injured. The injuries to truck occupants may much more predictable from the exterior damage, since truck safety tends to follow the Mongo principle. Collision avoidance is ignored, while the vehicle is made as large as possible, assuming that there is no other Mongo out there.

As an introduction, below are the Pennsylvania Trauma Triage Criteria. I use these because I am familiar with them, they are available on line, and because Pennsylvania is one state that has been doing a lot to change its protocols to what can be supported by science.

These criteria appear to be mostly consistent with the rest of the country. The first category is Physiologic Criteria – the patients with mental status or vital signs changes that may indicate a serious injury.

The most notable differences from the rest of the country are the uses of mental status and respirations. Pennsylvania does not use respirations (less than 10 or greater than 29).

Another difference is that Pennsylvania only uses Patient does not follow commands for the mental status criterion. If the patient does not remember events, or does not know where he is, or does not know what day/month/year it is, there is no reason to rush the patient to a trauma center – and certainly no reason to fly the patient to a trauma center. Here are the Pennsylvania trauma protocols.[1]

Trauma Triage Criteria
Assess patient for any one of the following

Physiologic Criteria:

• Patient does not follow commands (GCS Motor ≤ 5)

• Hypotension, even a single episode (SBP adults or SBP

Physiologic criteria identify the patients generally considered to be the most seriously injured, but they often do not do a good job of predicting outcome or need for a trauma center, so Pennsylvania adds a twist to this. I left that for the end.

Anatomic Criteria:

• Penetrating injury to head, neck, torso and extremities proximal to elbow or knee (unless obviously superficial)

• Chest injuries with respiratory distress (for example, flail chest)

• Two or more proximal long-bone (humerus or femur) fractures

• Pelvic fractures

• Limb paralysis (spinal cord injury)

• Amputation proximal to wrist or ankle

Anatomic criteria are less serious and less likely to predict outcome.


Requires immediate transport to a trauma center (Level 1 or 2), if possible

Otherwise if possible, transport to a Level 3 trauma center if patient can arrive at the Level 3 center before an air ambulance can arrive to the patient’s location.

Notify Trauma Center ASAP (including category and ETA)

Mechanism of Injury:

• Falls

  • Adult: > 20 feet (one story = 10 feet)
  • Peds: > 10 feet or 2-3 x height of child

• High Risk Auto Crash

  • Passenger compartment intrusion: > 12 in. occupant side or > 18 in. into compartment any side
  • Ejection (partial or complete) from automobile
  • Death in same passenger compartment

• Auto vs. Pedestrian/ Bicyclist: Thrown, run over, or >20 mph impact

• Motorcycle crash > 20 mph

Other factors combined with traumatic injuries:

• Age 55 years

• Combination of trauma with burns

• Crushed/ degloved/ mangled extremity or finger amputation

• Known bleeding disorder or taking coumadin/ heparin

• Pregnancy (>20 weeks)

Mechanism is the topic I will be addressing. These criteria are often useless. Pennsylvania has eliminated, or modified, many of bad ones and has created a Other factors combined with traumatic injuries category.



Contact medical command (if required in EMS region)


Transport to Trauma Center (Level 1, 2, or 3) (if possible)

Everything that does not fall into the above –



Frequently reassess for Category 1 or 2 criteria

Contact medical command, if doubt about appropriate destination

Otherwise if possible, transport to a Level 3 trauma center if patient can arrive at the Level 3 center before an air ambulance can arrive to the patient’s location.

Pennsylvania is trying to find the right way to restrict the use of helicopters in EMS, but there are still some taking the Mongo approach. Assuming that EMS cannot assess patients, so we must fly everything that might be bad. They are essentially saying, What if . . .?

Rather than try to improve the ability of EMS to care for patients, they adopt the motto – When In Trouble Or In Doubt Run In Circles Scream And Shout. Calling for a helicopter may be part of the screaming and shouting.

These are the EMS leaders. Many have graduated from medical school. Many have decades of experience in the hospital. They have access to this information, but it is like changing the direction of a large ship with Larry, Moe, and Curly at the helm. Change is slow.

In contrast to trauma, where about 5% of the patients meeting trauma criteria end up in surgery soon after arrival, there is the opposite approach to cardiac care. There is tremendous resistance to having EMS call STEMI (ST segment Elevation Myocardial Infarction) alerts, even though the erroneous STEMI alerts may only be about 5% with competent EMS.

With trauma, there are many other reasons to go to a trauma center, besides immediate need for surgery, but that is the excuse given for flying patients with minor injuries – What if EMS misses a serious injury? These patients can often be transferred later on.

With heart attacks, the opposite approach is taken. What if you wake up a cardiologist and it is not a STEMI?

With one approach, we have specialized trauma centers to keep round-the-clock trauma surgery available, no matter how little it is used. While, with the other approach, we seem to go out of our way to delay care and to come up with idiotic excuses for those delays.

Is the sleep of a trauma surgeon less valuable that the sleep of a cardiologist?

Is the life of someone having a heart attack less valuable than the life of someone with minor injuries?

There is another category for Trauma in Pennsylvania. This is the group of patients too serious for the trauma triage criteria listed above. From page 20/97 on the PDF.

A. Extremely critical patients that are rapidly worsening:

1. Patients with the following conditions should be transported as rapidly as possible to the closest receiving hospital:

a. Patients without an adequate airway, including patients with obstructed or nearly obstructed airways and patients with inhalation injuries and signs of airway burns).

b. Patients that cannot be adequately ventilated.

c. Patients exsanguinating from uncontrollable external bleeding with rapidly worsening vital signs (for example, a patient with severe hypotension and rapid bleeding, from a neck or extremity laceration, that cannot be controlled.).

d. Other patients, as determined by a medical command physician, whose lives would be jeopardized by transportation to any but the closest receiving hospital.

2. The receiving facility should be contacted immediately to allow maximum time to prepare for the arrival of the patient.


[1] Pennsylvania Statewide Basic Life Support Protocols
Effective November 1, 2008
Sections 180 and 181
Pages 20/97 to 25/97 on the PDF page counter.
Page with link to the full text PDF of the protocols.


Comment on Emergency Medical Services Intervals and Survival in Trauma – Assessment of the “Golden Hour” by Anonymous

In this, and other posts, when I refer to paramedics, I am referring to basic EMTs as well, unless I am describing something that is outside of the basic EMT scope of practice. In the comments to Emergency Medical Services Intervals and Survival in Trauma – Assessment of the “Golden Hour”, Anonymous wrote –

Interesting research on an issue I have anecdotally observed for years. We’ve all got to stop treating speed in transport as an end in itself, and start treating it as a means to improve outcomes in patients who can truly benefit from it.

This is just an example of one of the big problems of EMS – we act as if the patient is there to serve the protocol/old wives’ tale/need for excitement, when the reality is that we are there to serve the patient.

This is about the medical care of the patient, not about how cool the rescue squad/fire company/ambulance company is.

On a related note, back in 2000, I was lobbying my regional EMS counsel to stop letting people fly patients based on mechanism alone. Why use an expensive and (potentially) dangerous resource to shave 15 minutes off of what is fundamentally a non-critical transport? Treat the patient, not the vehicle was my mantra.

I will have several post on mechanism.

There is more than one problem, here.

You have the control freaks, who believe that we cannot teach EMS to properly assess patients. These are the ones who will claim that a doctor refusing pain medicine to a patient in severe pain, but without any contraindications/relative contraindications to the use of fentanyl/morphine/dilaudid, must know something the paramedic doesn’t know and that because of this psychic ability that comes with a doctor’s license, the abuse of the patient is not an example of why we should have standing orders for pain management. This is a bright shining example of the glorious doctor protecting the patient from the reckless and irresponsible paramedics.

There are endless examples of this error of logic. There are the rare cases that do support the idea of limiting what a paramedic may do on standing orders. However, these are actually examples of reckless and irresponsible medical directors authorizing dangerous paramedics to treat patients. If the medical director would not permit dangerous medics to work, the medical director would not have to be constantly stopping his minions from harming patients. The competent medical director does not allow dangerous medics to work as paramedics. The patients come first.

The other problem is from the You can’t be too safe freaks. They believe that you can avoid mistakes by creating more and more rules. They believe that anything bad that happens must be because some evil person broke the rules and must be punished severely. Or the mistake is because we need more rules. One excellent example of this is a set of protocols that tries to come up with a rule for every possible patient presentation. They think that, if we can just think of everything that can go wrong, we can write rules to prevent the mistakes.[1]

What they do not realize is that they are making the biggest mistake possible. They are viewing the possibility that the paramedic may make a mistake as the problem to be prevented. Yes, it is a problem, but their solution is to prevent the paramedic from thinking. They think that the paramedic is the weak link in the system. The weak link in the system is the reliance on rules, rather than critical judgment.

We should be taking advantage of the ability of the paramedic to think. We should be providing an environment that encourages critical judgment, an environment that develops the ability to use critical judgment. The decision to prevent paramedics from doing this is dangerous and encourages patient abuse.

Critical judgment is about figuring out what is best for the patient in this case, initiating treatment while constantly reassessing for changes, and changing treatment as indicated by reassessments. This is what is best for the patients.

Critical judgment is not about herding protocol monkeys.

You mention using helicopters to shave 15 minutes off of flight time, but I often see helicopters used where they delay transport. I used to work in a trauma center. The patients from a multipatient scene transported by ground would almost always arrive before those transported by air. There was only rarely a justification, such as entrapment. This was just use of a helicopter to delay treatment, but follow a protocol and/or become tumescent about a helicopter.

The medical command doctors, who want to know about the damage to the vehicle, generally do not have any experience working as auto body repair technicians and are not going to be repairing the car. The damage to the vehicle should only be in the radio report if it is relevant. One of the problems with being on the other end of the radio is that it is difficult to shut up and listen to the people on scene describe what is relevant. A report that estimates the amount of body damage is meaningless. An actual thorough physical assessment is valuable. Mechanism is only useful when it helps to guide us to find things that we might have otherwise missed in our assessments. Mechanism is dangerous when it encourages us to transport the patient in a way that increases the risk to the patient.

The response I got was rooted in a fear of liability. Better to have a few patients flown unnecessarily than to have one critical patient “slip through the cracks.” It was never really clear to me who our medical director was more worried about form a liability standpoint: the EMTs who might forget to call the helicopter, or the rent-a-docs moonlighting in the local ER who might be forced to treat a critical trauma patient (the likes of which many of them haven’t seen since med school).

Over-triage is important. We need to be erring on the side of caution, when there is good evidence to support that approach. Just sending everyone by helicopter to the trauma center is not rational over-triage. We need to use critical judgment. Mechanism is not critical judgment. Mechanism ignores critical judgment.

There is a balance of over-triage and under-triage that minimizes the number of slipped through the cracks patients and minimizes the increased risk that we inflict on patients in order for doctors to feel they are protecting their malpractice insurance. Maybe we need to have some lawyers go after the protocol writers, when patients with minor injuries are killed (or injured) in helicopter crashes and ambulance crashes, just because the protocols state to do everything so quickly that it endangers patients.

I suppose the “err-on-the-side-of-caution” approach is all well and good so long as you’re not the one paying for the unnecessary helicopter ride, and so long as truly critical patients are not being turned away because the bird is wasting time on non-critical transports.

I think that we should have the trauma centers, or insurance companies, deciding if the helicopter ride is appropriate. If it is not appropriate, the ambulance company and medical director should pay the bill. In places like Maryland, that use taxpayer dollars to pay for the helicopter ride, just so that nobody ever feels that they have a reason to avoid calling a helicopter, we should have the ambulance company and the medical director reimburse the state for the waste of taxpayer dollars.

Who knows when or if common sense will ever prevail. The only thing I know for sure is that when you ask me why I decided to fly a patient out, my response will be something other than “you should have seen the car.”


The scary thing is that so many doctors are not smart enough to recognize this.


^ 1 MIEMSS Maryland Medical Protocols
Effective July 1, 2008
348 pages of trying to predict everything that can go wrong.
Free PDF


Emergency Medical Services Intervals and Survival in Trauma – Assessment of the “Golden Hour”

ResearchBlogging.orgThere is a very important paper due to be published in the Annals of Emergency Medicine.[1] I expect that there will be a lot of criticism of this paper. There will be many reasons for being cautious in implementing the suggestions of the authors, but bad research is not one of them.

One of the difficult things about this paper is that the authors are very good about identifying potential confounding influences. They explain that there are many factors that may have affected the results. They are thorough in pointing out the many different ways they analyzed the data to try to minimize any potential confounding influences. While many may look at this study, see the amount of doubt the authors express throughout the study, and conclude that there is too much uncertainty to pay any attention to this study, they would be wrong to do so.

Trusting in the certainty of those promoting the Golden Hour is the true error. Anxious exhortations to Panic! and Faster! and Panic faster! are not substitutes for good patient care.

The Golden Hour has been around for decades. This is the idea that seriously injured patients need to receive definitive care within 60 minutes of that serious injury.

The amount of information used by Dr. R Adams Cowley to concoct the Golden Hour could fit onto a cocktail napkin. According to legend, it was dreamed up in a bar, so maybe it did fit onto a cocktail napkin. The Golden Hour is not science. The Golden Hour is marketing, and very successful marketing. There are still plenty of people citing the Golden Hour as their excuse for all sorts of mistreatment of patients – But we have to get them to the trauma center inside the Golden Hour. A more appropriate term is the Bogus Hour.

The commonly used 8 minute response time (or 8 minutes 59 second response time in some places) limit (in at least 90% of responses) is based on the AHA’s (American Heart Association’s) Chain of Survival. The interesting thing is that cardiac arrest survival appears to be the only condition that has good science supporting a short response time.

To date, patients with out-of-hospital cardiac arrest remain the only field-based patient population with a consistent association between time (response interval) and survival.18,19[2]

The authors of this study probably looked at far more data on trauma time intervals than any other study. They evaluated the data in as many different ways as they could think of, to see if there were any ways that there could be a connection between prehospital time and survival. In spite of all of these different ways of evaluating the data, the conclusion based on all of the evidence is – time does not make a significant difference in survival for unstable trauma patients.

This was not a study just looking at all trauma patients, the patients meeting only anatomic criteria were not included. The same is true for patients only meeting mechanism criteria. In other words, they excluded most of the patients transported to trauma centers.


Because these patients do not have serious enough injuries to expect time to make a difference. Even though these patients are rushed to trauma centers, their injuries have not resulted in unstable vital signs/level of consciousness. Therefore, they are not considered to have significant injuries for the purposes of this study.

Here are some representative anatomic criteria and mechanism criteria for trauma triage –

Anatomic Criteria:
• Penetrating injury to head, neck, torso and extremities proximal to elbow or knee (unless obviously superficial)
• Chest injuries with respiratory distress (for example, flail chest)
• Two or more proximal long-bone (humerus or femur) fractures
• Pelvic fractures
• Limb paralysis (spinal cord injury)
• Amputation proximal to wrist or ankle[3]

None of these qualify to get the patient into the study – shooting, stabbing, nibbled at by a lion, – unless the patient has signs of being unstable.

Mechanism of Injury:
• Death of another occupant in same vehicle
• Auto vs. pedestrian (bicycle) injury with significant impact
• Pedestrian thrown or run over
• Extrication time > 20 minutes
• Falls from > 20 feet
• Ejection from vehicle
• Vehicle rollover
• High-energy vehicle crash (e.g. significant intrusion into
passenger compartment)
• Motorcycle crash with separation of rider from motorcycle
Other factors combined with traumatic injuries:
• Age 55 years
• Combination of trauma with burns
• Known heart disease, CHF, or COPD
• Known bleeding disorder or taking coumadin/ heparin
• Pregnancy (>20 weeks)
• Rigid or diffusely tender abdomen
• Amputation of fingers with possibility of reattachment[3]

These are the kind of criteria that Maryland was using to fly patients. When they had their fatal crash last year, these mechanism criteria required permission from medical command to fly patients. Flights dropped by about two thirds and outcomes do not appear to have changed. Few of these criteria are useful for predicting instability. This study was only concerned with patients who really are unstable, not those with significant damage to their cars or trucks.

So, what is unstable in the study?

The criteria from the study –

Injured patients with one or more of the following criteria were included: systolic blood pressure (SBP) less than or equal to 90 mmHg, Glasgow Coma Scale (GCS) score less than or equal to 12, respiratory rate less than 10 or greater than 29 breaths/min, or advanced airway intervention (tracheal intubation, supraglottic airway, or cricothyrotomy). “Injury” was broadly defined as any blunt, penetrating, or burn mechanism for which the EMS provider(s) believed trauma to be the primary clinical insult.[2]

And still they have 10 physiologically unstable patients per day, if averaged over a year – with a few left over. Remember, this is after excluding most of the patients who would automatically be flown to trauma centers, because the authors do not believe that those patients are injured enough for time to make a difference in their outcomes.

Editor’s Capsule Summary

What is already known on this topic

The “golden hour” concept in trauma is pervasive despite little evidence to support it.

What question this study addressed

Is there an association between various emergency medical services (EMS) intervals and in hospital mortality in seriously injured adults?

What this study adds to our knowledge

In 3,656 injured patients with substantial perturbations of vital signs or mental status, transported by 146 EMS agencies to 51 trauma centers across North America, no association was found among any EMS interval and mortality.

How this might change clinical practice

This study suggests that in our current out-of-hospital and emergency care system time may be less crucial than once thought. Routine lights-and-sirens transport for trauma patients, with its inherent risks, may not be warranted.[2]

So, if time is not making a difference in survival, maybe we should stop killing people just to get patients to the hospital a little bit faster.

Some more details from the paper –

. . . total EMS time was not associated with mortality . . . for every minute of total time . . . When the sample was assessed with 10-minute increments for total EMS time, there was no evidence of increased mortality with increasing field times . . . Similar results were obtained when total times were grouped by quartile . . . We were also unable to demonstrate independent associations between mortality and any other EMS interval for the overall sample . . . [2]

No matter how they broke down the time intervals, there was no detectable change in outcome.

For categorized response interval, there was no association with mortality for patients with a 4- to 8-minute interval . . . or greater than 8-minute interval . . . compared with patients with a response less than 4 minutes.[2]

The same for response times.

In multivariable logistic regression models, there was no demonstrable association between time and mortality for any subgroup.[2]

Although some seriously injured individuals may require time-dependent EMS interventions to survive (eg, airway obstruction, respiratory arrest, external hemorrhage at a compressible site), faster application of such interventions may not have a measureable effect on outcomes for most trauma patients.[2]

There may be isolated patients, who benefit from less prehospital time, but there are not enough to make any detectable difference in the outcomes of these unstable patients. No difference in the cumulative outcomes. No difference in any of the subgroup analyses. No difference in any of the time subgroups. How many people are being injured and killed, just to get EMS crews there faster, because in EMS we just know that faster is better. Are we killing more people trying to get to the occasional patient who might benefit from a more rapid response, or a more rapid transport, than we are helping?

That little bit faster is insignificant, except psychologically. Perhaps we should refer those in need of lights, sirens, speed, and helicopters for CISM (Critical Incident Stress Management) in stead. Oops, that is also a treatment that lacks evidence to support it.[4]

The authors conclude with this bit of common sense –

In the setting of a perceived “emergency,” the public may not necessarily value whether faster EMS time and expeditious care have been shown to save lives for the majority of clinical conditions. However, meeting these expectations costs money (eg, establishment of fire houses and positioning of EMS crews to achieve predefined response intervals), can place EMS providers, patients, and the nearby public at risk,20-22 and is a common reason (ie, emergency vehicle crashes) for tort claims against EMS agencies.58[2]

The big questions are –

Will more than a handful of people in EMS pay any attention to this?

Will we wait until lawyers force us to do what is right?

Why do we continue to choose mythology and expert opinion over science?

Dr. Bledsoe provides his own commentary on this trauma paper.[5] Peter Canning also writes about this.[6]

Footnotes –

[1] Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort.
Newgard CD, Schmicker RH, Hedges JR. at al.
Ann Emerg Med. 2009;(in press, may end up with a 2010 publication date)
PMID: 19783323 [PubMed – as supplied by publisher]

[2] This is the same as footnote [1].

[3] Statewide BLS Protocols Effective November 2008
Page with link to the full text PDF of the protocols.

[4] Critical Incident Stress Debriefing and Mythology
Rogue Medic
November 10, 2009

[5] Speed and Time in Prehospital Trauma Care
The EMS Contrarian
by Bryan E. Bledsoe

[6] The Golden Hour
Street Watch

Newgard CD, Schmicker RH, Hedges JR, Trickett JP, Davis DP, Bulger EM, Aufderheide TP, Minei JP, Hata JS, Gubler KD, Brown TB, Yelle JD, Bardarson B, Nichol G, & Resuscitation Outcomes Consortium Investigators (2009). Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort. Annals of emergency medicine PMID: 19783323