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Wed Feb 4 20:00:05 GMT 2009

ThinkSharp and the Sacco Triage Method have been discussed on the List
before.  In 2005, I detailed my concerns as follows:

"The Sacco Triage Method (STM) strikes as an over-solution, a digital
Rube Goldberg device.  It's an entrepreneurial snazzification of an
inherently and importantly simple process.  It concerns or annoys me on
several levels:

"1. It's reasonable to speculate that a purely physiologic triage
instrument may produce increased survival in large-scale mass casualty
incidents; but the AEM article discusses no more than a mathematical
model (which is not proven by a PRCT, or even supported by a respectable
moulage exercise).

"2. In Dr. Sacco's research, I'm troubled by the assumption that a
longitudinal survey of a state trauma system bears any useful
resemblance to an MCI patient mix.  Are a thousand traumas distributed
across a state system over ten years inherently comparable to a thousand
victims of a civilian disaster on a single summer afternoon?  I have
serious doubts.

"3. Which begs the observation: in spite of decades of meticulously
documented real-world disasters suggesting otherwise, Sacco convened a
Delphi panel to support the assumption of significant deterioration
among "delayeds."  Hell, he projected a five-fold impact on
survivability!  Can anybody cite even one recent REAL disaster where
other triage methods bred close to this degree of preventable death?

"4. Getting back to #1:  Outside of large-scale disasters, physiologic
triage alone completely ignores anatomic imperatives important to daily
triage in a multi-hospital community: when thirty folks are dying, any
OR will probably do; but when one guy has a cord injury with spinal
shock and bradycardia, you'd better know which hospital has the
neurosurgeons.

"5. I'm ever wary of gizmos.  I like tools that can't break, or work
even when they do.  PDA's and wireless communications and database
systems have never failed to disappoint me under fire.  Using one
complex system to simplify another seems to me an invitation to regret.
Paying tens of thousands of dollars for it (while half of the ambulances
in Maine need new tires), doubly so. 

"6. Finally, and perhaps mostly, I'm saddened by the commercialization
of triage.  Had Dr. Sacco made a case in the journals for his RPM
formula, and published the severity indices instead of marketing them as
a "secret formula," then I might be happier to play with his software
product.  But the fact that he's put together a PR strategy even before
the unqualified publication of his numbers makes it hard for me to shake
the impression of shameless hucksterism."

I see nothing in this recent report which changes my mind.  ThinkSharp
has at least 3.9 million reasons to stir up community outrage in
Maryland.  I'd be tempted to side with MIEMMS until the rest of the
story is known.  

Pret Bjorn, RN
Bangor, ME USA

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of janeangelasmith
Sent: Tuesday, February 03, 2009 11:39 AM
To: trauma-list at trauma.org
Subject: Fw: Maryland EMS (MIEMSS) Is Pressed To Share Triage Study

I would think that those in "power" would do their utmost to have
"emergency
care" at its highest level of efficiency so that "to triage" would not
have
hurtful consequences for anyone.  Who knows who will be "triaged".  It
could
be one of us one day.

Jobs to help boost our economy and keep more people safe.

Hoarding information eventually hurts the hoarders who will possibly one
day
need "emergency care" or "triaging".

----- Original Message -----
From: James Richardson <jimmnn at comcast.net>
To: 'Trauma &amp; Critical Care mailing list' <trauma-list at trauma.org>
Cc: <Paramedicine at yahoogroups.com>; <EMS-L at EMS-L.org>
Sent: Monday, February 02, 2009 9:06 PM
Subject: Maryland EMS (MIEMSS) Is Pressed To Share Triage Study

> Md. EMS Is Pressed To Share Triage Study
>
> By Rosalind S. Helderman
> Washington Post Staff Writer
> Monday, February 2, 2009; B01
>
> As Maryland lawmakers wrestle with the future of the state's emergency
> medical service following the fatal crash of a state helicopter taking
> accident victims to a hospital, a private company has come forward
with a
> new concern about the independent agency.
>
> The company accuses state EMS leaders of dragging their feet in
releasing
> the results of a study of a new method for triaging patients in mass
> casualty incidents, a method that company leaders believe could save
lives.
>
> In a Jan. 19 letter, Thomas B. McCord, the chief executive of Bel
Air-based
> ThinkSharp, wrote that the Maryland Institute for Emergency Medical
Services
> System, the group that oversees all emergency medicine in the state,
had
> displayed "disregard, disbelief and delay" about the results of the
April
> 2007 study that the company conducted jointly with the state group.
>
> "To me, it's just wrong to sit on this information for this long,"
McCord
> said in an interview about the 22 months that have passed since the
study
> was done. "No matter what your reasons are -- it's wrong."
>
> Institute Executive Director Robert R. Bass said the agency is still
> interested in publishing a paper with ThinkSharp on the test of the
> company's triage method and said the delay stemmed from discussions
about
> what the paper should say. He said that the method requires further
study
> and that some paramedics have found the method to be confusing and
difficult
> to use.
>
> Maryland has one of the nation's most centralized systems for
conducting
> emergency medicine. All state ambulance services and hospitals are
overseen
> by the institute, which is led by a director hired by an 11-member
board
of
> gubernatorial appointees. The system has long been considered a
national
> model for coordination between first responders and hospitals.
>
> However, the agency also oversees the Maryland State Police medical
> helicopter program, which has been under scrutiny since the Sept. 27
crash
> that killed four people in Prince George's County. Flights since the
crash
> have decreased significantly, with no immediate adverse impact on
trauma
> victims, leading some lawmakers to question the size of the program.
They
> say they believe that the institute, once a national leader, has
become
> resistant to change.
>
> "These are the most politically wired interest groups in the state,
and
they
> are aligned to prevent change," said Sen. E.J. Pipkin (R-Queen
Anne's),
who
> is pushing a bill to replace Bass with a Cabinet secretary who answers
to
> the governor. "Whether it's this company or another, I think the
question
> they raise about MIEMSS are valid," he said.
>
> The helicopter issue has also highlighted national discussions about
how
> triage decisions are made. The family of a car accident victim killed
in
the
> helicopter crash has questioned whether her injuries warranted an
airlift
in
> the first place.
>
> ThinkSharp developed the triage method under study and estimates that
it
> would cost Maryland about $3.9 million over three years to adopt it.
The
> method is designed to use statistical data of survivability rates of
people
> with certain symptoms to help paramedics decide the order in which to
> dispatch injured patients to hospitals in mass casualty events.
Examples
of
> such an event include train accidents and natural disasters, plus more
> routine accidents in rural areas where a serious car crash could swamp
> emergency resources and force workers to prioritize care.
>
> Paramedics are trained to use a variety of factors, including physical
> condition of a patient and how an injury occurred to assign patients a
> color-coded tag -- red, yellow or green. Red indicates immediate need
of
> attention, green signals minor injuries. But some studies have shown
> inconsistency in paramedics' tagging decisions.
>
> ThinkSharp's method is designed to eliminate guesswork by assigning
each
> patient a number, derived by adding up scores tied to different
physical
> symptoms. The scores are based on a mathematical formula developed by
> William J. Sacco, a statistician long involved in trauma care, and are
> designed to take into account the chances that a patient treated
quickly
> will survive given different patient characteristics, such as pulse.
>
> "In the middle of an incident, people get excited," said William B.
Long,
> trauma medical director at Legacy Emanuel Hospital in Portland, Ore.
Long,
> who has done some work on contract for ThinkSharp, supports the
method.
"We
> were looking for ways to get a mathematical, better way to determine
how
to
> treat people -- to take away some of the anxiety."
>
> After agreeing that the method held promise, ThinkSharp and the state
agency
> organized a drill in April 2007. Paramedics first used the current
protocol,
> then ThinkSharp's Sacco method, to decide the order in which to send
dozens
> of "patients" to hospitals.
>
> Later analysis showed that under the current protocol, paramedics sent
only
> two of the 13 most seriously injured patients to the hospital in the
first
> 13 ambulances they dispatched. Under ThinkSharp's method, the 13 most
> seriously injured patients were sent to the hospital in the first
seven
> ambulances dispatched.
>
> "The results of the MIEMSS exercise are overwhelming," McCord said.
"People
> who had never seen it before or used it before actually did far better
than
> the protocol they've used since 1995."
>
> He said he believes the nearly two years that have passed since the
drill
> was conducted is an unreasonably long time for the state agency to
agree
to
> a draft of a paper on the study to submit for publication in academic
> journals.
>
> But surveys from the drill also showed that after brief training,
first
> responders thought the current protocol was easier to use and remember
than
> ThinkSharp's method. Paramedics' concerns are problematic for the
method,
> Bass said.
>
> "Triage needs to be something that is easy to teach, easy to remember
and
> logistically easy to do in the field," he said.
>
> ThinkSharp officials said their method is no more confusing than the
> protocol paramedics learn now. They said that during the 2007 drill,
the
> first responders received only 20 minutes of training in the new
method --
> the same amount of time devoted to a refresher session for the current
> protocol.
>
> Bass said the delay is a result of negotiations between the state
agency
and
> ThinkSharp on what, exactly, the study showed -- but he said that even
after
> the results are published, Maryland would be unlikely to adopt the
method
> without a national consensus that the technique is better. He said
adopting
> a method different from what other states use would be challenging
because
> it would make sharing first responders in a major crisis difficult.
>
> "We're not saying this concept doesn't have validity," Bass said.
"What
> we're saying is that there isn't any consensus at the national level
that
> this is the way to go, and if we went that way, it would incur
additional
> expense and put us out of step with the rest of the nation."
>
>
>

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Maryland EMS (MIEMSS) Is Pressed To Share Triage Study