More on flying trauma patients...

[FormerEMSLT297]

As someone who works in MD and has read and followed the investigation thru news and other channels allow me to clarify a few things:

1. The visibilty when the flight was accepted met MSP's nighttime rules for VFR flight.

The SYSCOM dispatcher, who takes all State requests for medevacs would not have even taken the information from the requesting FD if it did not, they then pass the mission to the pilot who again checks the weather, and agrees to fly.

Keep in mind that they were able to land at an off site LZ with no problems and load 2 patients.

It had rained a lot in the 24 hours or so before the crash and after they took off from the scene they found weather had rolled in and they could not make PG Hosp. According to the NTSB, the pilot did everything ride, he executed IFR proceudres climbed out to 2,000 feet and attempted to shoot an instrument approach to Andrews, he was having problems with his instruments and could not capture the glideslope, he requested a PAR but AAFB only had one controller on duty and the they could not do a PAR approach, before any further radio calls were made the aircraft impacted into Walker Mill Park.

Was it instrument failure, equipment failure, did the engine fail, Controller error, or pilot error that contributed or caused this crash?.... the NTSB report will be out in about a year, until then speculation is pointless, we will just have to wait and see.

I mean right now we dont even know but he coiuld have been on final and struck a bird, and lost control from that, until the report comes out even just needs to wait and see.

[UMSTUDENT]

It depends upon the focus of such protocols. Are they there to establish a minimum standard of care? Or are they there to provide for a rigid framework of technical practice? I don't care how big or small your state is, statewide protocols are an albatross around the neck of the profession. Physics don't change, but protocols do not address physics. Protocols address the art of medical practice. And the educational preparation and competency of individual practitioners do indeed vary from location to location. One only need look at the providers within their organisation in order to understand that concept. In any organisation, there will be practitioners who you respect and look up to for a higher standard, and those who you you hesitate to ever leave alone with a patient because they function on a lower level. If you establish statewide protocols that restrain the former from providing the best possible care to their patients, the patients and the profession lose. If you establish statewide protocols that don't encourage the latter to elevate their game, again, both the patients and the profession lose. So now, apply that to the system in city "A", whose medics typically graduate from a two-year college programme, versus the medics next door in city "B", whose firemen attend a thirteen-week patch factory, and did not want to do so in the first place. Who benefits from statewide protocols in this case? Not the patients. And certainly not the profession.

Essentially Dust is entirely correct. The career departments within the metropolitan regions have essentially drained the rural areas of much of their talent because of their ability to pay decent salaries. However, there are places within the state (rural) that utilize third-service EMS and who provide a better quality of service...at least clinically. What is astounding is that these places are still mostly volunteer with supplemental career services. The people who have stuck around are there for the right reasons and could definitely benefit from more progressive protocols. This is purely because of the quality of the provider...

[JakeEMTP]

Here's some good that has come out of this tragedy. Ground crews will now have to make contact with a MD at the trauma centre before calling for a helicopter. Good news for EMS professionals, bad news for the whackers, or is it monkeys? You know, call for a helicopter because that's the way it's always been done.

http://www.baltimoresun.com/news/nation/ba...0,6602002.story

Personally, I see it as a step backwards for EMS in general. More "mother may I" protocols due to abuse of HEMS and a lack of understanding of what really warrants a flight..

Dr. Bledsoe makes a good point. Instead of instilling this new protocol, why not just change the criteria for helicopter transport? :?

[UMSTUDENT]

Here's some good that has come out of this tragedy. Ground crews will now have to make contact with a MD at the trauma centre before calling for a helicopter. Good news for EMS professionals, bad news for the whackers, or is it monkeys? You know, call for a helicopter because that's the way it's always been done.

http://www.baltimoresun.com/news/nation/ba...0,6602002.story

Personally, I see it as a step backwards for EMS in general. More "mother may I" protocols due to abuse of HEMS and a lack of understanding of what really warrants a flight..

Dr. Bledsoe makes a good point. Instead of instilling this new protocol, why not just change the criteria for helicopter transport? :?

You're sort-of right. Providers must only consult for Category C (mainly mechanism) and D (High-Risk Populations). Category A (Screwed-up) and B (Not necessarily dying, but debilitating injuries) can still be flown without consultation. Maryland's system utilizes the basic criterion developed from the American College of Surgeons based on what I belive is ISS (Injury Severity Scores) and relative morbidity and mortality associated with these scores. The system isn't as Mickey Mouse as people would like to believe.

The biggest problem in Maryland involves these Category C and D traumas that are often flown. This often isn't necessarily because of "whackers," but mainly because there are really only 3-4 great trauma centers in the state. The rest are a joke. One of the things that has not happened in our state is a true effort to increase the reliability and effectiveness of the centers who receive these designations from the state. It's important to note that Shock Trauma (Level 0), Hopkins, and Washington Hospital Center (Level I) are all within Beltways.

Next you must realize that Maryland's biggest tax base (the blue and white collar, suburban middle class) live almost entirely within satellite communities either in the immediate Metropolitan Counties (Baltimore County, Montgomery, or PG) or within the further Satellite counties (Frederick, Howard, Anne Arundel, Washington, Charles). For the most part, these areas lack effective trauma centers. Even if you lived what would appear to be 15 minutes from say Washington Hospital Center, you are more like 25-30 minutes given traffic and sprawling urban development. In response to this a lot of communities have developed community Level II and III trauma centers. While some of these centers are excellent, others have a reputation for being less than stellar...even within their own communities. In more rural areas (Frederick, Washington, etc) the community will actually request to avoid these hospitals. Lack of competition has made this problem even worse.

So...what is far more common is for providers who know this to seek helicopter transport to the urban centers knowing their patients will actually receive the attention they need. This has died off in recent years as it seems MSP has made an effort (observationally) to divvy up business among the local centers. The problem is that these are the real issues within the state and no one seems to address them. The state seems to let these things slip as part of the hospital's responsibility to provide good care. Instead the state could use their power to designate these hospitals and provide benchmarks and incentives to improve them. If you don't meet criteria A, B, C we axe your designation and you loose business. Providers in rural areas have for years advocated allowing providers to send active MIs, strokes, and other time sensitive patients via air to hospitals equipped to handle them. Instead, Maryland has allowed some of these rural hospitals to become cath labs that lack cardiothoracic support or the volume to really reach true profecienccy. The saving grace appears to be that these hospitals must contract with larger centers to provide experienced interventional cardiologist.

Yes, I know that the answer isn't neccesarily more helicopter transports, but hey, if you can fly tons of rule-out trauma then why not offer the service to medical patients who might actually benefit from it?

[Dustdevil]

The system isn't as Mickey Mouse as people would like to believe.

The "system" is only as good as it's weakest link. Maryland has has one of the highest populations -- as well as the best funded -- volly whackers in the country. That's a huge weak link. So, no matter how great the "system" is on paper, it is the actual execution of that system that is the problem.

The biggest problem in Maryland involves these Category C and D traumas that are often flown. This often isn't necessarily because of "whackers," but mainly because there are really only 3-4 great trauma centers in the state. The rest are a joke.

That's really a non-sequitor. What does it matter how many level 0 trauma centres there are, or where they are located, when we are talking about patients who don't need them? The trauma centres are irrelevant to this equation. The problem is that those doing triage in the field are either incompetent, or they're whackers. Or both.

This new requirement for medical control approval of MOI-based air evac is a huge step. Let's just hope that the physicians within the system are objective enough to be of help in this matter. Unfortunately, many of them are fully indoctrinated products of the Maryland system, and may find it as difficult to divorce themselves from the dogma and follow the evidence as it will be for those in the field.

[UMSTUDENT]

The "system" is only as good as it's weakest link. Maryland has has one of the highest populations -- as well as the best funded -- volly whackers in the country. That's a huge weak link. So, no matter how great the "system" is on paper, it is the actual execution of that system that is the problem.

That's really a non-sequitor. What does it matter how many level 0 trauma centres there are, or where they are located, when we are talking about patients who don't need them? The trauma centres are irrelevant to this equation. The problem is that those doing triage in the field are either incompetent, or they're whackers. Or both.

This new requirement for medical control approval of MOI-based air evac is a huge step. Let's just hope that the physicians within the system are objective enough to be of help in this matter. Unfortunately, many of them are fully indoctrinated products of the Maryland system, and may find it as difficult to divorce themselves from the dogma and follow the evidence as it will be for those in the field.

We're not in disagreeance. The "system" I was referring to was the trauma decision tree, not the entire Maryland system which is plagued with problems.

Maryland has plenty of rules in place already about flying stuff, but as you've said, people make poor decisions.

As for your comment about inappropriately flying category C and D trauma patients, perhaps I'm unclear. Absolutely it is wrong to be flying these paients and absolutely this is a poor choice by ground providers, but my point is that some have justified it by the poor performance of area hospitals. I'm simply saying that there are multiple psychosocial factors in why providers fail to follow protocol and make these decisions.

I mean we both understand that the majority of the individuals out there making decisions are not always making those decisions based on hard medicine. When a provider takes a level III trauma center a simple femur fracture and that center then turns around, calls a private helicopter, and then sends that patient to Shock Trauma anyway you begin to wonder about the overal competence of the hospital. The reality is often not so simple...we both understand this. Level III trauma centers must often call in orthopods or trauma surgeons from home, generally with a 30 minute ETA. Occassionally these surgeons are either out-of-range or simply unavailable to respond to the hospital, thus an otherwise "simple" trauma will get a private helicopter bill to fly someplace they could have already been sent. Providers start working around the system. Is it right? No, but it happens. The problem can be fixed from multiple angles.

Category C and D patients do occassionally have life threatening issues, although a more competent clinician will generaly pick-up on these things and either advance their category or make a more appropriate transport decision. The problem here is the word "competent."

[Arizonaffcep]

[UMSTUDENT]

[Arizonaffcep]

Ok...that makes sense. I'm fairly familiar with their hx (read some very interesting books and articles on them). I had just never heard of the level 0 thing.

[flight-lp]

As for your comment about inappropriately flying category C and D trauma patients, perhaps I'm unclear. Absolutely it is wrong to be flying these paients and absolutely this is a poor choice by ground providers, but my point is that some have justified it by the poor performance of area hospitals. I'm simply saying that there are multiple psychosocial factors in why providers fail to follow protocol and make these decisions.

I mean we both understand that the majority of the individuals out there making decisions are not always making those decisions based on hard medicine. When a provider takes a level III trauma center a simple femur fracture and that center then turns around, calls a private helicopter, and then sends that patient to Shock Trauma anyway you begin to wonder about the overal competence of the hospital. The reality is often not so simple...we both understand this. Level III trauma centers must often call in orthopods or trauma surgeons from home, generally with a 30 minute ETA. Occassionally these surgeons are either out-of-range or simply unavailable to respond to the hospital, thus an otherwise "simple" trauma will get a private helicopter bill to fly someplace they could have already been sent. Providers start working around the system. Is it right? No, but it happens. The problem can be fixed from multiple angles.

Category C and D patients do occassionally have life threatening issues, although a more competent clinician will generaly pick-up on these things and either advance their category or make a more appropriate transport decision. The problem here is the word "competent."

So why aren't these individuals transported by ground instead of helicopter? If they do not meet acceptable criteria to fly to point "A" from point "B", then why would they be acceptable to fly from point "C" to point "B", especially after seeing a physician? The problem here lies in the hands of the hospitals, just because the capability isn't there doesn't mean you stick them on a helo. Or, another option would be to just take them the appropriate trauma center in the first place and completely bypass the worthless hospitals that can't deal with these issues. Common sense should prevail here, it is not rocket science.

However, Dust hits the nail on the head concerning the initial ground providers. This is directly the area that needs to be addressed. Between incompetence and plain old laziness, bad decisions are being made at the expense of others' lives. Until we can get these knuckleheads to start using their heads, or get flight crews to start refusing flights, then the toll shall continue.......................