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Tue Oct 7 18:30:53 BST 2008

Article from:
http://www.hometownannapolis.com/cgi-bin/read/2008/10_07-35/COL

Eric Hartley: Shock trauma flights don't need fixing

 By ERIC HARTLEY Staff writer
Published October 07, 2008

Almost by definition, a news conference in the wake of a tragedy consists of
public officials standing at a lectern and saying the right things: We're
reviewing our policies. We'll be making some changes.

But sometimes, if you stick around for a while after those blinding
television lights are switched off, you can hear what they really think.
That's why I walked over to talk to Dr. Thomas Scalea yesterday afternoon.

Minutes before, Dr. Robert Bass, director of the Maryland Institute for
Emergency Medical Services Systems, had announced some changes in the wake
of the Sept. 28 state police helicopter crash that killed four people and
fueled a debate over alleged overuse of medevac flights. He said paramedics
will now have to consult with a trauma center before flying some patients
without obviously life-threatening injuries.

So what did Dr. Scalea think this would accomplish? Standing in a corner of
the small room, he said simply: "I don't believe it is necessary."

Dr. Scalea is physician-in-chief at the Maryland Shock Trauma Center in
Baltimore, where the news conference was being held. He said the new rule
was an understandable reaction to a tragedy.

"I think it's something to make the public feel better."

But he said it's hard for him to imagine recommending against flying someone
to shock trauma. He said his attitude when paramedics call is, "You are
there, and I am here," meaning they are actually seeing the patients, and he
is not.

So he didn't say it, but the move is mostly an empty gesture.

And an unnecessary one. Here's why: The chance you will be struck by
lightning during your lifetime is about 1 in 5,000, according to the
National Weather Service. It is much, much less likely you will crash while
on a Maryland State Police medevac helicopter flight. Dr. Scalea said about
100,000 successful flights were made between the last fatality in 1986 and
the one nine days ago.

Some of the questions being raised about the medevac flights are valid:

Is a state police-run system the best, or could it be privatized in some
way? At the least, why not bill insurance companies as other states do?

Legitimate concerns were raised long before the crash about how taxpayer
dollars are being spent, especially when state police want $140 million to
replace the 12-helicopter fleet.

Dr. Scalea, Dr. Bass and others said they welcomed a review of the system.
But decisions on overhauling trauma care shouldn't be made rashly - and
certainly not based on a 1-in-100,000 shot. It's wise to be careful when
"fixing" something that's not really broken. Remember what physicians are
told: "First, do no harm."

At times during the news conference, Dr. Scalea barely concealed his
frustration. He choked up over the loss of life in the crash, but seemed
puzzled, almost angry, at having to defend a system that's a model for the
world. More than 96 percent of people who come to shock trauma live. ("I'm
trying not to take it personally, but I am Italian," he joked later.)

Much has been made of the fact that about half of people admitted to the
shock trauma center are released within 24 hours. Some argue this proves too
many people are being flown there. Dr. Scalea said it's "a great sound bite"
- but not much more.

Humans being humans and medicine being an inexact science, we're never going
to get every call right, selecting 100 percent of those who need advanced
trauma care but no one else. So there's really no choice but to
"over-triage" - and yes, that means flying patients who in the end don't
need it.

"You send too many, you're accused of wasteful spending. You send too few,
and patients die," Dr. Scalea said. "How many people can die next year to
save that money? Is it five? Is it 10? Is it 20? ... We will not let people
die to save money."

The attractive idea that you can save money by sending people with seemingly
minor injuries to local hospitals, then drive them to shock trauma later if
needed is "unsophisticated" because time is the enemy, he said.

It makes sense to reassess after a tragedy. But as Dr. Scalea pointed out,
guidelines on when to medevac patients are based on American College of
Surgeons standards and already are reviewed frequently by a scientific panel
and updated as needed, most recently last year.

"The idea that 'Oh, my God, the helicopter crashed, so we're going to review
the system for the first time' is ridiculous," he said.

And really, wouldn't the best tribute to the public safety officers who died
in the line of duty be to get out there and save more lives?

-- 
Stephen L. Richey, CRT
Aviation Injury Research Project Leader
Saginaw Valley State University
Work E-mail: slrichey at svsu.edu
Home Office Phone: 248-366-4452

"It is the characteristic excellence of the strong man that he can bring
momentous issues to the fore and make a decision about them. The weak are
always forced to decide between alternatives they have not chosen
themselves."- Dietrich Bonhoeffer

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