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#21 Nov 27, 2008
I understand many of your points. Patients probably aren't receiving inferior care. The care they are receiving, though, is probably not at the level of care they should be getting. What about patients who need emergent surgery, like surgery needed immediatley to save the patient? Will a local facility be able to provide that? Can a local facility offer neurosurgical consultation in a timely manner if needed? Transferring patients takes time, and is not what is best for the patient.
Agreed, paramedics do tend to run a lot of fluid. Research does show that trauma patients should be receiving continuous fluids after injury. I am not as knowledgeable about field protocols that are specific, so please correct me if I am wrong...butI beleive that paramedics are permited to give certain types of medications in the field that EMT-B or EMT-I cannot (right?). I do believe we should aim for the highest level of pre-hospital care.
Injury is time related, so how do we transport patients from the eastern shore, western Maryland, southern Maryland, etc.? I understand that some flights are unnecessary, however, there are flights that are important for the well being of the patients. Most patients arriving to a trauma center come by ambo, not by helicopter. There are days that no helicopter flys into the trauma center at all.
Mechanism of injury is not something that Dr. Bass or Dr. Scalea has thought of. These guidelines are not set my Maryland, these are standards that are in use all over the country that were designed by the American College of Surgeons. Maybe those guidelines must be revised.
How do you feel about the current guidelines for medevac transport, post late September? Maybe more research should be done before we change the entire system, that would probably be the best approach.
If we get rid of some MSP Aviation, private companies will transport trauma patients as well if they are within a closer proximity to the scene. Is this bad for the patient? No. Will it cost the patient an arm and a leg (figure of speech, not actually)? Probably.
When it comes down to it, ground providers call for aviation. Should we better train the ground providers on more effective use of the system? Triage has one goal: to get the patient to an appropriate facility, in the right amount of time. Some patients do require medevac transport because of the distance from a trauma center, others can be driven. We count on our ground providers to make the right decision, so why is the blame being placed on the MSP Avition? When they arrive they will transport the patient to a trauma center, they don't deny patients.
#22 Dec 2, 2008
Sorry for the delay responding, I did not realize this went to a second page.
The percentage of patients who meet the trauma criteria that have not been changed, trauma criteria that are not based on damage to the car, is less than 5%.
The need for immediate surgery for the patients who are being transported for damage to their cars, rather than for real injuries, is theoretical. It is a big "What if?" It is not based on research.
research is not clear on whether fluids should be administered after trauma, but the research that has been done does not support routine administration of IV fluids. Many protocols require this, but protocols also required helicopter transport of apparently uninjured patients.
Maryland protocols need to be improved significantly.
I agree that we should aim for the highest level of prehospital care. The use of helicopters to bring paramedics to the patient allows the state to ignore any need for paramedics in underserved areas, because they feel that all that needs to be done is to call for a helicopter. don't improve care, but fly everyone. This is bad patient care.
I think the state should be working on improving the level of care delivered by ground ambulance providers, not saying something like, "Just call a helicopter."
Decreasing flights, so that they flights will be appropriate, should not affect these areas. The exception to this is the patients who would be flown based on the damage to the vehicle, rather than for their injuries. They may not even have injuries. The patients who are being flown appropriately will continue to be flown.
The American College of Surgeons guidelines are not for helicopter flight, but for transport to a trauma center. The research is showing that there is little reason to use most of them. Each state uses its own version of these guidelines and other states do not seem to fly anywhere near as many patients as Maryland does.
I believe that there is not research to support maintaining the system the way it has been. Without research to support it, continuing things unchanged would only continue a tremendous waste.
Why would private helicopters be transporting patients who do not need to be flown? If the guidelines are permanently changed, there should not be any increase in need for assistance from private helicopters. The need for assistance could decrease.
If the system is cut back to what is appropriate, there would not be a greater need for private helicopters.
The cost to the patient should not be an issue. Do we need to set up MSP cardiac catheterization labs so that heart attack patients do not have to pay for care?
Shock Trauma will be billing patients at a rate that is higher than other hospitals?
Perhaps their motto should be, "We will fly you for free, but once we get you in the door, we will make that savings seem insignificant."
We need much better oversight of ground providers. Having them fly anyone, who might be bad, is not oversight. Maryland's ground EMS system needs to make a lot of progress to catch up with the rest of the country.
I do not blame MSP Aviation.
This is the fault of Dr. Bass and Dr. Scalea. They have a responsibility to provide for the care the people who need medical care in Maryland. They are throwing money away by flying patients inappropriately. In stead of flying everyone, they should be assuring that the ground providers are well trained with appropriate oversight and more up to date protocols.
#23 Dec 3, 2008
Maryland is not flying patients who are perfectly fine. Patients who are flown to the trauma centers do have injuries. These injuries may not always be life-threatening, but they are injuries that need to be assesed.
So when Syscom calls into a trauma center, saying Trooper __ is enroute, then the Trooper calls the medic line for an update and says this patient is being transported for mechanism...what is the trauma center to do? Should the trooper deny flying the patient when they arrive at the scene? This does not relate to the trauma center or MSP Aviation. It is the decision of ground providers. Thankfully, most mechanism only patients are brought by ground, especially now that they must consult.
I'm not saying that patients who are brought for mechanism only always require emergent surgery. However, it is something we see time to time. Not all medicine can be based off of research, rather it should be based off of experience.
However, research has been shown that fluids following trauma is essential in resuscitation and the body's ability to compensate. Do all trauma patients need fluids? No. Do most? Yes. Especially with blunt trauma to the torso, blunt spinal injury, brain trauma, etc.
Of course many mechanism patients will not actually have any injuries, but what about the ones that actually do have life threatening injuries that aren't apparent? Take the change on flying too little and risk loosing some people, or send too many and risk being accused of over triage?
The recommendations set by the State are only that, recommendations. Do they have to fly the patient? No. The State recommeds the consideration of helicopter transport "if of clinical benefit."
Do you have any examples of this "waste?" Is the waste you are talking about flying patients to a trauma center based on our State's criteria?
The problem with private helicopters is that they will absolutley fly any patient they can. Because there is money to be made. They will fly you, but have your credit card on hand!
Trauma care is in no way comparable to other areas of medicine.
Shock Trauma does not bill patients at higher levels than other hospitals do. More tests may be needed than during an average "medical" hospital stay, and that is where additional costs come into play.
Dr. Scalea makes decision very often that restrict some patients from being transported to the Shock Trauma center. He does what is best for the patient. If that means coming by helicopter or land to Shock Trauma, then that is what is going to happen. If that means Hopkins, send them there. Dr. Scalea has no say in the training of ground proviers. I'm sure he does give his input, but when it comes down to it, that is not his area.
This system has been accused of being an "empire" ever sense the 70s...however, I think it has been working pretty well. As Dr. Cowley said, "People are not interested in excellence, they want control." I would define excellence as rapidly transporting trauma patients to an equipped trauma center by the fastest means possble (if that is to fly, then request a medevac; if that means drive, start the engine). Our system came from a genuine interest in the patient and that is where we still stand today, and if that means overtriage...then so be it. Maryland will continue to invest a genuine interest in its citizens and continue to overtriage when necessary.
#24 Dec 7, 2008
Should the trooper/medic refuse transport?
Why not? To do otherwise only encourages abuse of the helicopter transport system. This is the way the ground providers have been taught by Dr. Cowley, Dr. Scalea, and Dr. Bass, but there is no good reason to fly patients with no injuries or only minor injuries. There never has been.
Medicine needs to have a strong foundation in research. Research, when well done, trumps experience. Well done research is experience.
Individual experience is only anecdote - the least reliable basis for treatment.
The research on fluids after trauma does not support this treatment. There may be a benefit in maintaining a systolic pressure at 60, or maybe 70, or even 80, but the research has not made it clear. The research does suggest that fluids do more damage than good.
The waste is the waste of lives, waste of money, waste of personnel. Where is the benefit? Where are the mechanism patients saved by helicopters?
Interesting that Dr. Cowley provided that quote, since that is what many consider to be his greatest weakness, his need for control.
There is not a need to transport the patient by the fastest means possible, except for some of the critically injured patients. Less than 5% of critically injured patients end up in surgery right away. As medicine improves, and trauma is only one part of medicine, the need for surgery seems to decrease.
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