Someone Explain To Me Again…

Justagirl–I hope your sister’s OK. I can’t imagine working a family member. Much as I hate to Monday-morning quarterback (did my stint in QA, hated it), this looks to me like a classic case of medics getting scared when kids are involved.When we get scared, we call in more resources, whether they’re appropriate or not.I’m making a few assumptions here, but it seems like this tragedy could have been prevented (on the medical side) by familiarizing dispatch and ground crews with EMS for Kids, PALS, and general pediatrics training. We all get nervous around kids–that’s why we pay the pediatricans big bucks–but field crews can’t afford to let personal discomfort interfere with appropriate patient care.From the news article it also sounds like some issues existed regarding the landing site –but I don’t think this blog is the forum for that discussion.

Justagirl–I hope your sister’s OK. I can’t imagine working a family member. Much as I hate to Monday-morning quarterback (did my stint in QA, hated it), this looks to me like a classic case of medics getting scared when kids are involved.When we get scared, we call in more resources, whether they’re appropriate or not.I’m making a few assumptions here, but it seems like this tragedy could have been prevented (on the medical side) by familiarizing dispatch and ground crews with EMS for Kids, PALS, and general pediatrics training. We all get nervous around kids–that’s why we pay the pediatricans big bucks–but field crews can’t afford to let personal discomfort interfere with appropriate patient care.From the news article it also sounds like some issues existed regarding the landing site –but I don’t think this blog is the forum for that discussion.

Ron,Some factors that affect HEMS, that are not much of a factor in non-medical helicopter flights.Pressure on the pilot to fly into bad weather. In NJ the State Police EMS helicopters are named North Star and South Star, based on which part of the state they cover. The nickname that many have for them is <>Day Star<>, since they have pretty restrictive requirements governing flights. Many people put pressure on pilots to fly, even though the pilot should not and even though the critics have no understanding of the risks.Landing in places where a helicopter does not ordinarily land.The pressure to try to get to the scene/hospital quickly and fly into, rather than around, bad weather.Use at night with a single pilot and without the electronics that would be required on similar commercial helicopters.Then, there is the old argument that people use, when appealing to emotion, instead of reason.<>It’s for the kids.<>

ted,This most recent crash was not at a landing site, the helicopter was half way to its destination when it clipped the tower.Also this discussion reminded me of a some magazine articles I read years ago. It’s not only the civilian HEMS world that feels pressure to fly. The military suffers from the same issue, here’s there take on it:< HREF="http://www.safetycenter.navy.mil/media/approach/issues/julaug06/default.htm" REL="nofollow">http://www.safetycenter.navy.mil/media/approach/issues/julaug06/default.htm<>

Actually, this is the article I was really going for:< HREF="http://www.safetycenter.navy.mil/media/approach/issues/julaug05/Culture_of_Safety.htm" REL="nofollow">http://www.safetycenter.navy.mil/media/approach/issues/julaug05/Culture_of_Safety.htm<>

Rogue,Interesting post. I haven’t had the leisure to read your entire blog, but I’ve bookmarked you and will be back. Your first graph is very interesting, and the comments beneath it are more so. I agree with you that the data source is questionable. Ten ground ambulance crashes were reported in 2007–that number seems unrealistically low. When I was working the streets we averaged (insert rough guess here) about 5 wrecks per year in New Orleans, and I don’t think we were such bad drivers that we accounted for half of all wrecks nationwide. In my (admittedly limited) Google search I was unable to come up with a definitive database for EMS-related accidents. In fact, I found a couple of articles that indicated that there wasn’t one. Perhaps that’s the first step to resolving this issue–accurate record keeping.Regarding the research, you’re right. The research doesn’t support my statement. It also doesn’t support yours. There are too few studies, and EMS is too diverse, to make a call at this point. In the absence of hard data, we tend to over-treat. I don’t like it any more than you do, but the only way to change it is with hard data.I respect you for that. It looks like you’re trying to drag EMS–kicking and screaming–into the era of evidence-based medicine. Keep up the good work.Anyway, I see the facts as such: (feel free to disagree):–victims of trauma may or may not have severe injuries–if these injuries exist, they may or may not be apparent in the field EVEN TO A SKILLED AND THOROUGH ASSESSMENT–major trauma can occur after minimal force (populations such as geriatrics, pediatrics, pregnant, etc are at particular risk) and may be absent even after severe force–but that’s not the way to bet–major trauma (whether recognized or not) is best treated by rapid field recognition, stabilization of airway, breathing, external bleeding, and fractures (more or less in that order) and RAPID transport to an ED with an available trauma surgeon–SOMETIMES that transport can occur more quickly in a helicopter, keeping in mind spin-up and spin-down times, difficulty of patient care en route (all my experience is in a BO-105), etc. Rural Montana, for example, should see more helicopter transports per capita than, say, Washington DC.–16 air wrecks nationwide in 2007 (I consider the air data more reliable than the ground due to FAA involvement) is still a relatively small number. The risk/benefit calculation for a given patient may well be in favor of helicopter transport–The increasing rate of air-med related fatalities as compared to all air fatalities may simply be related to increased air transport. It may also be related to the decreasing number of pilots with combat experience as the Vietnam-era pilots are retiring. Watch the trends over the next few years to see what effect Gulf War vets have on this statistic.Your pulse ox comment is interesting–I’ve found “sick” patients (albeit rarely) based solely on a sub-optimal pulse ox reading. Usually a pulse ox of 85 in an otherwise healthy-looking patient just means probe malpositioning. But every once in a while it’s the only clue you get to something more sinister. Remember that diseases are ever-evolving and that you see trauma in its very earliest stages, and that an ambulance DOES NOT HAVE THE TOOLS to appropriately assess a trauma patient. There’s a reason that EDs do delayed FAST scans and serial abdominal exams. Regarding anecdotes, no they’re not good evidence. They are clues to where to look for good evidence. My point is that, lacking definitive prospective placebo-controlled studies (which are effectively impossible in this situation) they may be some of the best evidence available.No, helicopters are not needed in all trauma victims. The need for helicopters is not standardized–some communities will need more than others. This will relate to the training and experience of the ground medics, that of the transport medics, expectations of patient care requirements en route, and relative transport times. The safety rating of ground v. air transport needs to be examined. Better pre-hospital trauma assessment tools are required to maximize patient survival and appropriate resource management.

Rogue,Interesting post. I haven’t had the leisure to read your entire blog, but I’ve bookmarked you and will be back. Your first graph is very interesting, and the comments beneath it are more so. I agree with you that the data source is questionable. Ten ground ambulance crashes were reported in 2007–that number seems unrealistically low. When I was working the streets we averaged (insert rough guess here) about 5 wrecks per year in New Orleans, and I don’t think we were such bad drivers that we accounted for half of all wrecks nationwide. In my (admittedly limited) Google search I was unable to come up with a definitive database for EMS-related accidents. In fact, I found a couple of articles that indicated that there wasn’t one. Perhaps that’s the first step to resolving this issue–accurate record keeping.Regarding the research, you’re right. The research doesn’t support my statement. It also doesn’t support yours. There are too few studies, and EMS is too diverse, to make a call at this point. In the absence of hard data, we tend to over-treat. I don’t like it any more than you do, but the only way to change it is with hard data.I respect you for that. It looks like you’re trying to drag EMS–kicking and screaming–into the era of evidence-based medicine. Keep up the good work.Anyway, I see the facts as such: (feel free to disagree):–victims of trauma may or may not have severe injuries–if these injuries exist, they may or may not be apparent in the field EVEN TO A SKILLED AND THOROUGH ASSESSMENT–major trauma can occur after minimal force (populations such as geriatrics, pediatrics, pregnant, etc are at particular risk) and may be absent even after severe force–but that’s not the way to bet–major trauma (whether recognized or not) is best treated by rapid field recognition, stabilization of airway, breathing, external bleeding, and fractures (more or less in that order) and RAPID transport to an ED with an available trauma surgeon–SOMETIMES that transport can occur more quickly in a helicopter, keeping in mind spin-up and spin-down times, difficulty of patient care en route (all my experience is in a BO-105), etc. Rural Montana, for example, should see more helicopter transports per capita than, say, Washington DC.–16 air wrecks nationwide in 2007 (I consider the air data more reliable than the ground due to FAA involvement) is still a relatively small number. The risk/benefit calculation for a given patient may well be in favor of helicopter transport–The increasing rate of air-med related fatalities as compared to all air fatalities may simply be related to increased air transport. It may also be related to the decreasing number of pilots with combat experience as the Vietnam-era pilots are retiring. Watch the trends over the next few years to see what effect Gulf War vets have on this statistic.Your pulse ox comment is interesting–I’ve found “sick” patients (albeit rarely) based solely on a sub-optimal pulse ox reading. Usually a pulse ox of 85 in an otherwise healthy-looking patient just means probe malpositioning. But every once in a while it’s the only clue you get to something more sinister. Remember that diseases are ever-evolving and that you see trauma in its very earliest stages, and that an ambulance DOES NOT HAVE THE TOOLS to appropriately assess a trauma patient. There’s a reason that EDs do delayed FAST scans and serial abdominal exams. Regarding anecdotes, no they’re not good evidence. They are clues to where to look for good evidence. My point is that, lacking definitive prospective placebo-controlled studies (which are effectively impossible in this situation) they may be some of the best evidence available.No, helicopters are not needed in all trauma victims. The need for helicopters is not standardized–some communities will need more than others. This will relate to the training and experience of the ground medics, that of the transport medics, expectations of patient care requirements en route, and relative transport times. The safety rating of ground v. air transport needs to be examined. Better pre-hospital trauma assessment tools are required to maximize patient survival and appropriate resource management.

Anon 6:38 and 7:08–thanks for setting me straight about the nature of the accident. Just goes to show I don’t know what I’m talking about where flight operations are concerned.RM–You nailed it. “It’s for the kids” is the dumbest argument in the history of rational debate.

Anon 6:38 and 7:08–thanks for setting me straight about the nature of the accident. Just goes to show I don’t know what I’m talking about where flight operations are concerned.RM–You nailed it. “It’s for the kids” is the dumbest argument in the history of rational debate.

Ted,The problem is in the way I mislabeled the chart. It should read EMS crash <>fatalities<> and HEMS crash <>fatalities<>. I have updated the chart and added a bit about LODD to explain what I did not make clear.Part of the problem with the field assessment is the inconsistency of the training and oversight of EMS. We should not be flying patients so that medical directors will feel comfortable putting dangerous medics on the street. They can just call a helicopter is a bad excuse for bad medics. And I do not know of any good excuses.And from here I am going to make this a post on my blog, but not tonight, because I have this problem with keeping things brief. I will try to get a post up in the next week about mechanism and the research. There is a lot of research on the topic. One problem is the lack of experimental control for variables that are controllable.<>It’s for the kids<>, isn’t the dumbest argument. I think that goes to <>He hit me first<>, but there are many candidates for this title.

, but there are many candidates for this title.

I dunno…”he hit me first”, if the “he” in question is well-handled and there are plenty of witnesses, may be the BEST argument.The rest of it, I’ll take to your blog. Maybe that’ll encourage AD to write some more Star of Life if he wants his blog to get hits.

I dunno…”he hit me first”, if the “he” in question is well-handled and there are plenty of witnesses, may be the BEST argument.The rest of it, I’ll take to your blog. Maybe that’ll encourage AD to write some more Star of Life if he wants his blog to get hits.

During rush hour, the drive from Sandwich to CMH would be over 2 hours, and Sandwich might have called for the transport earlier in the evening. Just a thought. At midnight, it’s still well over an hour- Childrens is just north of downtown.

During rush hour, the drive from Sandwich to CMH would be over 2 hours, and Sandwich might have called for the transport earlier in the evening. Just a thought. At midnight, it’s still well over an hour- Childrens is just north of downtown.

Dr. Scalea is quoted as saying, “The American College of Surgeons’ recommended rate of over-triage is up to 50%, a range consistent with our experience in Maryland. In making triage decisions, we must err on the side of the patient.”Rogue Medic seems to be saying (if he will forgive me for trying to summarize his argument) is that the better course is to Er LESS in all cases, rather than tolerate error “just in case.” I have to say, Rogue Medic’s position seems to be the scientifically defensible one. I side with him on this.

Dr. Scalea is quoted as saying, “The American College of Surgeons’ recommended rate of over-triage is up to 50%, a range consistent with our experience in Maryland. In making triage decisions, we must err on the side of the patient.”Rogue Medic seems to be saying (if he will forgive me for trying to summarize his argument) is that the better course is to Er LESS in all cases, rather than tolerate error “just in case.” I have to say, Rogue Medic’s position seems to be the scientifically defensible one. I side with him on this.

The patient was originally designated to go to a much closer hospital, but they couldn't take her.  That's when the decision was made to go downtown.This tragedy will cause the local air medical community to do what other areas are already doing.  Take a good look and decide if there needs to be a tightening of the criteria for flying. I personally think that there needs to be a differentiation between transferring for immediate acute care (ie: trauma, interventional cardiology or stroke) and transferring for admission (even with a sick patient).  I'm not making a judgement about the Air Angels case, because I don't know anything more than what I read online.  But having worked both critical care ground and air (both rotor and fixed wing), I know that I have flown patients who were stable enough to go by standard ALS ground, much less critical care ground.  And anybody who has ever done critical care can probably remember a patient that could have gone by UPS.

The patient was originally designated to go to a much closer hospital, but they couldn't take her.  That's when the decision was made to go downtown.This tragedy will cause the local air medical community to do what other areas are already doing.  Take a good look and decide if there needs to be a tightening of the criteria for flying. I personally think that there needs to be a differentiation between transferring for immediate acute care (ie: trauma, interventional cardiology or stroke) and transferring for admission (even with a sick patient).  I'm not making a judgement about the Air Angels case, because I don't know anything more than what I read online.  But having worked both critical care ground and air (both rotor and fixed wing), I know that I have flown patients who were stable enough to go by standard ALS ground, much less critical care ground.  And anybody who has ever done critical care can probably remember a patient that could have gone by UPS.

Country Rat,Let me rephrase it a little and see if you still agree. I do not disagree with the statement that we must <>try<> to err on the side of the patient. I think it <>is<> a mistake to try to claim that doing <>too much<> is good for the patient.I do not think that people see the danger of too much treatment and presume that doing something is better than doing <>nothing<>. <>Nothing<> being defined as whatever is less aggressive than what <>they<> think is appropriate.It is a common saying, <>Don’t just do something – Stand there.<>We can’t just write a Goldilocks Protocol and have it tell everyone what is <>just right.<> We need thinking providers with an understanding of assessment and the authority to use critical judgment.If we do not have knowledgeable providers, how do we know that they are making good decisions? A medical command phone call? Hardly.

We need thinking providers with an understanding of assessment and the authority to use critical judgment.If we do not have knowledgeable providers, how do we know that they are making good decisions? A medical command phone call? Hardly.

All I can say is that there are way to many Jesus nuts coming loose,I would like to know why? where can I find data on these loses(http://en.wikipedia.org/wiki/Jesus_nut

All I can say is that there are way to many Jesus nuts coming loose,I would like to know why? where can I find data on these loses(http://en.wikipedia.org/wiki/Jesus_nut

Rogue Medic:I still agree with you.

Rogue Medic:I still agree with you.