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Thu Feb 5 18:27:05 GMT 2009

----- 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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Subject: Maryland EMS (MIEMSS) Is Pressed To Share Triage Study