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Mon Mar 2 03:44:08 GMT 2009

Interesting discussion, but I believe that there is one point that is not
being addressed entirely.

As a Paramedic in a rural state (NM) that has one trauma center, bed
availability is a huge issue.  If a patient who I diagnose (yes, I strongly
believe that pre-hospital providers diagnose, which I know is contriversial)
as having a closed head injury is taken to my local hospital (which has no
neuro capability), they may then wait for hours to get a receiving doc and
facility to accept them.  We have seen patients in this circumstance flown
as far away as Denver or Lubbock, hours after their injury, because of the
dearth of beds and physicians.  As a result, if they are assessed, by EMTs
(who I believe do a better job at this than we are being given credit for)
as needing services that are not available at their local hospital, or at a
hospital within 90 miles, doesn't it make sense to take the risk to
transport them by rotor to a facility that can handle their specific needs?
I have personally experienced that I can get a patient to a closer (30
miles) facility by ground than by air, but beyond that distance, I believe
(as much as I hate to admit it) that rotor is faster.

I strongly disagree with the idea of using MOI as a criteron for determining
mode of transport, that is why we are taught and are teaching assessment of
patients in Paramedic school.

Sahaj Khalsa

On Sun, Mar 1, 2009 at 8:30 PM, Stephen Richey <stephen.richey at gmail.com>wrote:

> On Sun, Mar 1, 2009 at 10:08 PM, Forrest Robleto <farcpr at gmail.com> wrote:
>
> > One of our squads has a definite traffic problem.  Compounded by the fact
> > that the traffic in the other direction is usually not heavy which leads
> to
> > higher speeds and nasty MVA's.  The chief there regularly flies trauma
> > patients during the 5-6PM time slot.   Other times they can make it
> > themselves in pretty good time.
>
>
> The problem with that is (and I'm guessing you're talking suburbs or the
> edge of an urban area) the availability of landing zones.  Do you have
> predesignated sites for such activities?  If not, I would highly suggest
> that you and your superiors think about taking such a step.  It is the
> least
> you owe to your patients and to our colleagues on the aeromedical side of
> things.  Your primary concern seems to be the care delivered to the
> patients, while my primary concerns are that as well as the safety of
> everyone involved and whether the slight chance of improving the former is
> worth serious and obvious increases in risk with regards to the latter.
>
> >
> >
> > We teach EMT's that trama patients require a trauma center.  That if you
> > take the severe trauma patient to a non trauma hospital that they may not
> > get the care they need and will likely be transferred to the trauma
> center.
> > If that isn't correct we need to change what we are teaching.
>
>
> The problem is that such as an approach- while cautious in terms of triage-
> leads to exactly the sort of mess we had (and probably still have) in
> Maryland that led to the Trooper 2 fiasco.  EMS personnel are notoriously
> bad at deciding which patients need to go to a trauma center versus which
> can be treated at a "non-trauma center" and it only seems to get worse when
> you add helicopters (and the companies promoting their use to the mix).   A
> lot of people get flown for expediency's sake rather than medical necessity
> (such as the two girls on board Trooper 2). Look at the numbers of people
> flown into trauma centers and released directly from the ED or within 24
> hours?
>
> Even in the case of "shock" as diagnosed by EMS personnel how many of those
> patients actually go on to need surgery in the first hour or even first six
> hours after hospital admission?  I am guessing that the number is not as
> high as you might suspect , but I don't have any studies to cite on this at
> the moment.   That is one of the reasons I stand behind my "take them to
> the
> closest decent hospital and if they need to be referred out if they need
> more aggressive care".  This approach is exactly what is used in many
> combat
> settings with great results.
>
> I am not arguing there are not occasional situations where helicopter
> transport is the obvious best course of action, but I am simply trying to
> figure out how the "He's been hurt, so he needs a trauma center but the
> traffic is bad" is a completely and incontrovertible dispatch criteria.
> It's just that you (and a lot of other people) are missing a couple of
> steps
> in the decision making process here.
>
> >
> >
> >
> > V/R
> >
> > Forrest Robleto
> > R House Health & Safety
> > www.RHouseTraining.com <http://www.rhousetraining.com/>
> > FRobleto at RhouseTraining.com
> > 609-792-9047
> >
> >
> >
> >
> > W. C. Fields  - "I never drink water because of the disgusting things
> that
> > fish do in it."
> >
> > On Sun, Mar 1, 2009 at 9:54 PM, Stephen Richey <stephen.richey at gmail.com
> > >wrote:
> >
> > > Two hours to the trauma center versus how long to a non-trauma center?
> > > Notifying the closest hospital (to give them time to get a surgeon,
> etc)
> > > and
> > > going there was my suggestion, not a two hour trudge to a trauma
> center.
> > > Granted, if I were the EMS provider and I honestly felt the patient
> would
> > > not survive the trip to the nearest hospital then I would likely call
> for
> > a
> > > helicopter.   I've done exactly that on a handful of occasions and had
> to
> > > disimpact my former medical director (who is as much of an
> > anti-helicopter
> > > person as you paint me to be) from my ass every time because if we did
> so
> > > it
> > > was on us to justify taking such a drastic step as a scene response.
> >  That
> > > would be why I could count the number of people I've flown off scenes
> as
> > a
> > > civilian EMS provider on both hands (eight to be precise).
> > >
> > > And the hour estimate was all inclusive, not just the preflight and
> > > unloading.  I would wager that is a safe estimate for a majority of
> > > flights,
> > > especially if you are talking as far out from the hospital as you are
> > > proffering in this situation.  In many cases, just trying to find a
> > landing
> > > zone can be challenging, especially in less than ideal weather.
> > >
> > > On Sun, Mar 1, 2009 at 9:36 PM, Forrest Robleto <farcpr at gmail.com>
> > wrote:
> > >
> > > > I gave you an example of a two hour drive or a twelve minute flight
> for
> > a
> > > > teenager in shock and you still opted to forgo the helicopter.  One
> > hour
> > > > preflight and unloading time?  Don't we have to unload the ambulance?
> >  If
> > > > you don't think you are closed minded on this subject you are fooling
> > > > yourself.
> > > >
> > > > My point was there are some folks who are against the flights no
> matter
> > > > what. And although they may be overused they do have a legitimate
> use.
> > > >
> > > >
> > > > V/R
> > > >
> > > > Forrest Robleto
> > > > R House Health & Safety
> > > > www.RHouseTraining.com <http://www.rhousetraining.com/> <
> http://www.rhousetraining.com/>
> > > > FRobleto at RhouseTraining.com
> > > > 609-792-9047
> > > >
> > > >
> > > >
> > > >
> > > > Groucho Marx  - "I have had a perfectly wonderful evening, but this
> > > wasn't
> > > > it."
> > > >
> > > > On Sun, Mar 1, 2009 at 9:08 PM, Stephen Richey <
> > stephen.richey at gmail.com
> > > > >wrote:
> > > >
> > > > > On Sun, Mar 1, 2009 at 8:18 PM, Forrest Robleto <farcpr at gmail.com>
> > > > wrote:
> > > > >
> > > > > > Ian,
> > > > > >
> > > > > > You're correct of course.  Given all the variability the EMT on
> the
> > > > scene
> > > > > > often has to make a tough decision.  But sometimes it's not all
> > that
> > > > > tough,
> > > > > > if you have a shocky teenager from an MVA and traffic has you two
> > > hours
> > > > > > from
> > > > > > the trauma center and it's a 12 minute flight, most of the
> > variables
> > > go
> > > > > > away.
> > > > >
> > > > >
> > > > > Let's not forget that that "12 minute flight" is going to be more
> > like
> > > an
> > > > > hour given the dispatch time, the preflight, the response to the
> > scene,
> > > > the
> > > > > on-scene assessment and treatment by the helicopter crew, the
> return
> > to
> > > > the
> > > > > hospital and then unloading of the victim.   Perhaps the best
> option
> > is
> > > > to
> > > > > transport them to the closest hospital and have the helicopter meet
> > you
> > > > > there (assuming you really think it is necessary to transfer them
> > out)?
> > > > >
> > > > > >
> > > > > >
> > > > > > I know that helo's are inherently dangerous but so are motor
> > > vehicles.
> > > > >  The
> > > > > > ambulance is not the safest means of travel.
> > > > >
> > > > >
> > > > > Actually, compared to the other alternative (helicopters), ground
> > > > > ambulances
> > > > > are a relatively safe mode of transportation.
> > > > >
> > > > > >
> > > > > >
> > > > > > There are some folks who are predisposed to downplay the
> usefulness
> > > of
> > > > > the
> > > > > > medical helicopter out of hand.  There are times when it's right
> > and
> > > > > times
> > > > > > when it's not but I knew that Stephen would pickup on the family
> > > > arriving
> > > > > > first statement.
> > > > > >
> > > > >
> > > > > I don't dismiss their utility out of hand.  Remember, I flew
> > > aeromedical
> > > > > transfers while in the Air Force.   They have their place, just
> like
> > > any
> > > > > other tool.  The problem is that I see them being used as a very
> > risky
> > > > and
> > > > > very expensive alternative to proper triage and treatment in many
> > > areas.
> > > > > The one thing that (for lack of a better phrase) pisses me off
> about
> > > the
> > > > > 'we
> > > > > need helicopters in our rural area because our EMTs are bad and we
> > > can't
> > > > > afford medics" argument is that it is exactly that sort of
> sentiment
> > > that
> > > > > holds EMS back.  If your EMTs are bad- retrain them and fire the
> ones
> > > who
> > > > > can't or won't come up to an acceptable level of competency (even
> if
> > > they
> > > > > are volunteers, you can still fire them).  The utility of medics is
> > > still
> > > > > questionable in trauma and even in other settings, so the best
> thing
> > > that
> > > > > can be done in a lot of situations is to push for top notch BLS
> care
> > > and
> > > > > supplement that with a handful of medics (even if it is on an
> > > "intercept"
> > > > > basis from a regional ALS service rather than "local" medics) based
> > on
> > > > the
> > > > > call volume.
> > > > >
> > > > >
> > > > > > He is to helo's what Lou Dobb's was to aliens.
> > > > > >
> > > > >
> > > > > Thank you?  I think.....not really sure what you are referring to.
> >  If
> > > > that
> > > > > is referring to the fact that I take the stance that until I have
> > > > credible
> > > > > proof that an otherwise outlandish claim- be it that exposing a lot
> > of
> > > > > people to a greater risk for what appears to be no benefit to most,
> > > > minimal
> > > > > benefit to a handful and great benefit to one in several thousand
> or
> > to
> > > > the
> > > > > existence of aliens, Sasquatch, etc- is defensible I will be
> > skeptical,
> > > > > then
> > > > > I agree and believe that you paid me a compliment.  If you are
> trying
> > > to
> > > > > peg
> > > > > me as someone who is closeminded and unwilling to see alternative
> > > > > positions,
> > > > > then you have taken my prior posts in completely the wrong manner.
> > > > >
> > > > >
> > > > > --
> > > > > Stephen L. Richey, CRT
> > > > >  --
> > > > > trauma-list : TRAUMA.ORG <http://trauma.org/> <http://trauma.org/>
> <http://trauma.org/>
> > > > > To change your settings or unsubscribe visit:
> > > > > http://www.trauma.org/index.php?/community/
> > > > >
> > > > --
> > > > trauma-list : TRAUMA.ORG <http://trauma.org/> <http://trauma.org/>
> > > > To change your settings or unsubscribe visit:
> > > > http://www.trauma.org/index.php?/community/
> > > >
> > >
> > >
> > >
> > > --
> > >  Stephen L. Richey, CRT
> > > --
> > > trauma-list : TRAUMA.ORG <http://trauma.org/> <http://trauma.org/>
> > > To change your settings or unsubscribe visit:
> > > http://www.trauma.org/index.php?/community/
> > >
> > --
> > trauma-list : TRAUMA.ORG <http://trauma.org/>
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/
> >
>
>
>
> --
> Stephen L. Richey, CRT
> --
> trauma-list : TRAUMA.ORG <http://trauma.org/>
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>

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