List Archives

Tue Mar 30 00:18:23 BST 2010

Was this not just addressed a couple of weeks ago?

Norman

Norman McSwain MD
Professor - Tulane Univ. SOM
Trauma Director - Spirit of Charity Trauma Center
504 988 5111

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Driscoll, Ian R CPT
MIL USA USAMEDCOM
Sent: Monday, March 29, 2010 4:46 PM
To: trauma-list at trauma.org
Subject: close the pericardium after negative window?

Hello all:

I'm preparing a presentation on subxiphoid pericardial windows and would
like some thoughts from the experienced surgeons on this list regarding
whether or not to close the pericardium after a negative pericardial
window.  I have always been told to excise a window and never to close
the resulting pericardial defect.  

Thank you,

Ian R. Driscoll, MD
CPT, MC, USA
Resident, Department of General Surgery
Walter Reed Army Medical Center
6900 Georgia Ave. NW
Washington, DC 20307-5001
(202) 782-4968

----- Original Message -----
From: trauma-list-request at trauma.org
Date: Monday, March 29, 2010 7:00
Subject: trauma-list Digest, Vol 81, Issue 39
To: trauma-list at trauma.org

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> When replying, please edit your Subject line so it is more specific
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> Today's Topics:
> 
>   1. RE: Professionalism in Air Ambulance Standards (Gross, Ronald)
>   2. Respiratory protection (Sahaj Khalsa)
>   3. Re: Air Ambulannce Standards (Dr Timothy Hardcastle)
>   4. Re: Professionalism in Air Ambulance Standards (Stephen Richey)
>   5. Re: Air Ambulannce Standards (Stephen Richey)
>   6. RE: Professionalism in Air Ambulance Standards (Pret Bjorn)
>   7. RE: Respiratory protection (Pret Bjorn)
> ----- Original Message -----
> From "Gross, Ronald" <
> Date Sun, 28 Mar 2010 21:17:13 -0400
> To "'Trauma-List [TRAUMA.ORG]'" <
> Subject RE: Professionalism in Air Ambulance Standards
> " No one else seems to be concerned about the safety aspect"
> 
> Please read this post again, sent by me at 1937 hrs:
> " A couple of thoughts:
> 1.  " finding an acceptable three-way balance between medical 
> necessity, profit and safety"  
> There is NO balance.  This is linear.  Safety first, patient care 
> second, and profits last.
> 
> I rest my case.
> 
> Ron
> 
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org [mailto:trauma-list-
> bounces at trauma.org] On Behalf Of Stephen Richey
> Sent: Sunday, March 28, 2010 8:21 PM
> To: Trauma-List [TRAUMA.ORG]
> Subject: Re: Professionalism in Air Ambulance Standards
> 
> How so?  My mind is made up simply that *something* needs to be 
> done.  I am
> making suggestions as to what we might look at to find what that 
> somethingmight be.  I don't have all the answers, neither do you 
> nor anyone else on
> this list.  Like Dr. Mattox point outs, what is needed is a 
> collaborativeeffort and putting forward ideas is how we figure 
> what is the best course of
> action.  No one else seems to be concerned about the safety aspect 
> and that
> the only solution we should concern ourselves with is the medical 
> necessityof flights.  That only addresses half the issue and if 
> the other side of the
> issue (safe operations) is not addressed voluntarily with a little 
> push from
> the medical community outside of HEMS then it will be eventually 
> forced upon
> HEMS by the FAA and that WILL destroy the industry and that is not 
> somethingany of us want.   If you have a specific issue you would 
> like to debate with
> me in regards to my suggestions, please let me know.
> 
> I only become defensive (for a lack of a better term) when someone 
> does not
> want to look beyond what is already being done.  The key is 
> keeping an open
> mind.  If we can find the solution here in the US, then so be it 
> but we
> should not limit ourselves simply because "states are different".  
> The basis
> of science is to not assume things like "The country  to country 
> comparisonis unsound" especially when the field of aviation safety 
> research has proven
> that international cooperation is essential in advancing the field.
> 
> 1.  " finding an acceptable three-way balance between medical
> > necessity, profit and safety"
> > There is NO balance.  This is linear.  Safety first, patient 
> care second,
> > and profits last.
> >
> >
> Exactly, but one has to remember these are profit-based 
> organizations; there
> is only one charity aeromedical operation in the US and they are 
> fixed wing
> and non-emergent.  Therefore the companies remaining solvent has 
> to be
> factored into the mix.  That's what I meant by "balance".  We have 
> to find
> cost-effective ways to improve safety and many of the changes that 
> wouldimprove safety are attitude-based changes rather than 
> technological fixes.
> It turns my stomach to admit it, but it's the truth that we have 
> to concern
> ourselves with the bottom line.
> 
> 
> BTW, my apologies for the use of profanity.  It won't happen again.
> 
> " Unfortunately some- including a couple of persons on this own 
> list- want
> > to
> > ignore that in a desire to maintain the status quo or assume 
> their own
> > state's experience is a good basis for the entire nation."
> > Pray tell just who on this list wish to do this?
> > --
> >
> 
> It was a reference to the several really nasty off-list e-mails I have
> gotten since this thread started.   Since they are keeping the 
> messages off
> the list, I don't think it's appropriate to name names.  It was 
> not Dr. Krin
> nor any of the other regular contributors to the list.
> 
> Could this sort of approach be a reason why some seem to want to 
> crank on
> > you, as opposed to others such as Mattox and Krin, who you seem 
> to think are
> > afforded some sort of protection.  Just as an FYI, both of those 
> gents, and
> > I too have been cranked on many occasion, so consider that a 
> mute point.
> 
> 
> 
> Copy that sir.   Let's move on like you suggested and I will do my 
> best to
> contribute to the proposal.
> 
> 
> ---
> Stephen Richey, CRT
> 
> "A man's moral worth is established only at the point where he is 
> ready to
> give up his life in defense of his convictions."- Henning von Tresckow
> --
> trauma-list : TRAUMA.ORG
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> ----- Original Message -----
> From Sahaj Khalsa <
> Date Sun, 28 Mar 2010 20:11:47 -0600
> To "Trauma-List [TRAUMA.ORG]" <
> Subject Respiratory protection
> Hello,
> 
> I am interested in any information the members of the list may 
> have on PAPR
> (Positive Air Powered Respirator) type devices and their use in the
> pre-hospital environment.
> 
> As a paramedic with a beard, I am unable to wear an N-95 mask and 
> need an
> alternative, one that will allow stethoscope use.
> 
> If anybody has information and would like to provide it off-list, 
> my email
> is: sahajs at gmail.com
> 
> Thanks,
> 
> Sahaj Khalsa
> 
> ----- Original Message -----
> From "Dr Timothy Hardcastle" <
> Date Mon, 29 Mar 2010 07:53:23 +0200 (SAST)
> To "Trauma-List [TRAUMA.ORG]" <
> Subject Re: Air Ambulannce Standards
> Ken
> 
> I have remained silent till now as this appears to be a uniquely 
> Americanproblem. In South Africa there are a limited number of air-
> ambo operators
> - around 5 if I am correct. They all will only fly if the pilot is 
> happy;will not fly without an independant medical call review and 
> all run
> monthly M&M's to discuss any call issues. The one large national 
> operatoris non-profit, government supported and Red Cross owned, 
> while the rest
> are private, with two national services (Discovery and Netcare) - the
> others are private subcontractors to the large private service or do
> international trans-border repatriation flights (ISOS / Europe-Assist)
> 
> To date, I am aware of only one pilot error crash in South African
> air-ambo history and that was fully investigated and the service dealt
> with - there was a protocol breach in dispatch and pilot error - 
> it was a
> rural flight.
> 
> In South Africa the Air Ambo industry is regulated strictly by the 
> Cat138regulations and the Civil Aviation Authority.
> 
> So , maybe come up with a proposal between yourself and Stephen, 
> Pret and
> Ron and the rest of us in other countries can offer taccit support!
> 
> Cheers
> Tim
> Dr T C Hardcastle
> M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
> Principal Specialist Trauma Surgeon /
> Honorary Senior Lecturer UKZN Dept Surgery
> Deputy Director - IALCH Trauma Service
> Durban, South Africa
> 
> > I have made a first cut at a strawman document regarding air 
> ambulance> transport.
> > I have thoughts on each point which I will add later.   I would
> > appreciate
> > each of you who have made comment to add your comments regarding the
> > completeness of the items in my outline.     It would be my  
> intent that a
> > combined group of stakeholders (EMS, industry, Trauma centers,  
> regulatory> agencies, reimbursement groups, government, Obstetric 
> centers, Heart
> > centers, etc.
> > etc. etc.) to have this outline as an agreed upon outline of  
> principles> to
> > be addressed.
> >
> > We together can do this.    The time is now.
> >
> > Kenneth L. Mattox, MD
> > Houston
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/
> 
> 
> 
> ----- Original Message -----
> From Stephen Richey <
> Date Mon, 29 Mar 2010 02:40:06 -0400
> To "Trauma-List [TRAUMA.ORG]" <
> Subject Re: Professionalism in Air Ambulance Standards
> OK....let's not turn this into a political debate about health 
> care reform
> since this does not involve that.
> 
> The practices are pretty much the same for airlines around the 
> world (with a
> few exceptions where officials are paid to look the other way and 
> theirsafety records reflect it....Russia, Indonesia and Brazil 
> jump to mind)
> regardless of political doctrine.   How is comparing non-governmental
> agencies and even governmental organizations in say Germany or 
> Australia and
> the level of oversight not a valid comparison to the mix of 
> governmental and
> non-governmental HEMS operations here in US?
> 
> If it works, it works and the reason you claim the comparisons are not
> "valid" or "sound" are simply smoke screens and smack of some form of
> selection or confirmation bias.  It seem they don't meet* your* 
> definitionsof valid and sound because it doesn't fit *your* view 
> of how things should
> be (correct me if I am wrong...just taking a guess here based off 
> the little
> information I have to work from), regardless of how the rest of 
> the world
> and, in particular, the rest of the aviation safety community 
> views it.   If
> you were a philosophy minor, you should be quite well aware of 
> this fact.
> Heck, if you're a scientist (and physicians are scientists last 
> time I
> checked) you should be aware of the existence and associated 
> problems that
> stem from such actions.
> 
> To say that we shouldn't learn from our colleagues in other 
> nations simply
> because we don't like the politics of the source is akin to my 
> turning a
> blind eye to the advances in trauma care that came out of Shock-
> Trauma in
> the 1960s, 1970s and 1980s simply because I think the hamstringing of
> prehospital care in the state through an over-reliance on HEMS to 
> transportmore trauma patients than can be supported by the 
> evidence.   You (and most
> of the people on this list) would take gross offense at that and 
> rightfullyso because they earned a hearty thank you for being in 
> no small way partly
> responsible for kick starting a focus on trauma care in the US.  
> Or if I
> were to say that Tom Scalea doesn't deserve a lot of respect for 
> being one
> hell of a doc simply because of the things he said in the 
> aftermath of the
> Trooper 2 crash.  He does deserve a lot of respect and is one hell 
> of a doc
> (if I get hurt, he's in the top five or ten docs I want taking 
> care of me
> along with Dr. Mattox, Dave Crippen, Dr. Gross, Dr. Thompson et al 
> ) and I
> still look up to him regardless of what I think of his politics 
> and apparent
> adherence to the disproved beliefs still hanging around from the 
> days R.
> Adams Cowley ruled the roost in Baltimore.
> 
> We can and should learn from all of our colleagues regardless of 
> where they
> are located or the political system under which they operate.  
> That is all I
> am suggesting regardless if those suggestion come from Annapolis 
> or Athens,
> Baltimore or Berlin, Houston or Karachi, Manhattan or Moscow, 
> Indianapolisor Innsbruck.  The comparisons I am suggesting are 
> valid, the data available
> is applicable and the lessons are real and easy enough to apply 
> should be we
> have the desire to make it so.  What more do you expect?  What 
> more can you
> reasonably ask for?
> 
> By the way, just for the sake of clarification, was the 'trash mouth'
> comment solely in response to the poor choice of words or the fact 
> that I
> was criticizing Maryland's approach to trauma triage?  If I recall
> correctly, you're from there (if I am mistaken, I apologize).  If 
> you would
> like references to back up my comments on the resistance to change 
> on the
> part of MIEMMS and MSP (especially MSP), I can provide references 
> from the
> press.
> 
> In closing, I would like to apologize to you personally for 
> whatever offense
> you took from my earlier post.  Not my intention at all and for 
> that I am
> sincerely sorry.  If I made you disagree with me, that is one 
> thing, but I
> never intend to offend.
> 
> On Sun, Mar 28, 2010 at 9:31 PM, < wrote:
> 
> > As a student of Copi's logic back in my philosophy minor days I can
point
> > out that being "valid" and being "sound" are two completely
different
> > things.  Many valid arguments are unsound. Soundness stems from the
> > truthfulness and facts of the argument's premise. Simply put, the
government
> > oversite and financial backing of foreign governments to their
respective
> > program is simply not comparable to programs in the states....well,
until
> > Obama completes his socialist transformation that is.dn
> > Sent from my Verizon Wireless BlackBerry
> >
> > -----Original Message-----
> > From: Stephen Richey <
> > Date: Sun, 28 Mar 2010 19:19:38
> > To: Trauma-List [TRAUMA.ORG]<
> > Subject: Re: Professionalism in Air Ambulance Standards
> >
> > Bullshit.  What precisely is unsound about it? If country to country
> > standards are not valid, then why are FAA regulations being adjusted
to
> > bring us in line with the European practices? Why are there
international
> > conferences on aviation safety to share what has been learned in
other
> > countries if it is not applicable?
> >
> > Most importantly, if there is so much variability between states,
why do
> > we
> > not have separate aviation regulations for every individual state?
Safe
> > practices are safe practices are safe practices.  It's a cop out to
say
> > "Oh,
> > well my state uses state police helicopters!"  as if that excuses
them from
> > following safe practices.  It does not matter who does the flying.
In
> > fact,
> > the best example of how not to respond to safety failures resulting
in
> > fatal
> > crashes is Maryland in the aftermath of the Trooper 2 crash.  (For
the sake
> > of disclosure, I was friends with the pilot at the controls during
that
> > crash.)
> >
> > They not only had one of the worst habit of abusing HEMS in the
country,
> > they also snubbed their nose at hearings to advance safety and when
> > legislators tried to launch an independent non-MIEMMS investigation
the
> > Maryland State Police simply used mass protest from its uneducated
> > supporters to maintain the *status quo*.  Even one of my heroes, Tom
> > Scalea,
> > flat out defended flying patients with minor injuries simply because
of
> > tradition and superstition.  Hearing him say that in the press was
like
> > being kicked in the testicles.
> >
> > As for some states not having any crashes, then why do we not figure
out
> > what they are doing to keep a perfect record?  We can certainly look
from
> > state to state to find  practices that do not work.  State to state,
> > country
> > to country, let us find what works and what does not.  The fact that
we
> > have
> > borders on a map between these entities is no reason to turn a blind
eye
> > and
> > continue to have to attend funerals of friends and colleagues.
> >
> >
> >
> > On Sun, Mar 28, 2010 at 7:21 PM, < wrote:
> >
> > > US-300,000,000 people.  Each state is like its own country. The
country
> > to
> > > country comparison is unsound. Some states have had zero. Some
states use
> > > state police helo.dn
> > > Sent from my Verizon Wireless BlackBerry
> > >
> > > -----Original Message-----
> > > From: Stephen Richey <
> > > Date: Sun, 28 Mar 2010 18:58:49
> > > To: Trauma-List [TRAUMA.ORG]<
> > > Subject: Re: Professionalism in Air Ambulance Standards
> > >
> > > There was actually a study done that showed simply using twin
engine
> > > helicopters did not induce greater safety, but that is not the
issue. I
> > > don't recall the date of the article, but I will do my best to
find it
> > and
> > > forward it to you.  It would be the inclusion of a second pilot,
which
> > > would
> > > necessitate a helicopter with greater maximum takeoff weight, that
would
> > > likely improve safety.  There simply are not enough HEMS operators
in the
> > > US
> > > flying dual pilot to make an adequate comparison at the moment.
There
> > are
> > > other countries where it is a standard for commercial helicopters
to fly
> > > dual pilot, not to mention the standard of the US military (and
most
> > > military forces) to fly dual pilot and their notable safety record
> > despite
> > > flying in some of the most hostile environments on the planet.
> > >
> > > The lesson we should be learning is to apply those things that
work in
> > > other
> > > countries and other high-risk environments.  Germany for instance-
> > despite
> > > a
> > > very high level of HEMS operations- has had one fatal helicopter
crash in
> > > 11
> > > years (Thies KC, Sep D, Derksen R. How safe are HEMS-programmes in
> > Germany?
> > > A retrospective analysis. Resuscitation. 2006 Mar;68(3):359-63.
Epub 2006
> > > Feb 7.).  Similarly the HEMS crash rates for Australia and other
> > countries
> > > remain at less than half that of the US rate. (Holland J, Cooksley
DG.
> > >  Safety of helicopter aeromedical transport in Australia: a
retrospective
> > > study.  Med J Aust. 2005 Jan 3;182(1):17-9.).  Our recommendations
should
> > > include those things that work in those countries that HEMS are
not
> > > employing here or are, in fact, flat out doing the opposite of.
That is
> > > the
> > > bullet that will take down the crash rate *while not destroying
the HEMS
> > > industry*.  If we simply fix the issue with inappropriate
transport, we
> > > risk
> > > reducing the fatal crash rate but risk not fixing the underlying
issues
> > > that
> > > may come back to harm our colleagues in the future if the industry
were
> > to
> > > find a way around the medical necessity clauses we seek to
advance.
> > >
> > >
> > > On Sun, Mar 28, 2010 at 6:28 PM, Ian Seppelt <
> > > wrote:
> > > >
> > > > As a hypothetical for the USA:
> > > >
> > > > If something like 'twin engine IFR capable' was mandated for
HEMS, what
> > > prortion of US operations would meet that standard?
> > > >
> > > > Ian
> > > >
> > > > On 29/03/2010, at 4:29 AM, Mohammed al Malik <
> > > wrote:
> > > >
> > > >>
> > > >> You are seeing the diplomatic Mattox who displays the same
approach of
> > a
> > > mixture of data, practicality, insight, understanding and wisdom
from the
> > > podium of the Las Vegas Trauma, Critical Care, and Acute Care
Surgery
> > > course.     In his discussion of Dr. Johannigman's air ambulance
talk he
> > > was
> > > respectful and even there called on us to develop standards,
starting
> > with
> > > an air ambulance data base and registry.    Here in Southern
California,
> > > with its full freeways, mountains, deserts, and distances, we do
need air
> > > ambulances, but not to be used for minor conditions.  Because of
the
> > > helicopter crashes during the past three years,  I was getting
fearful
> > that
> > > the government would create unreasonable mandates.   I am hopeful
that
> > > logic
> > > and effective recommendations can be made using the outline of
issues
> > > created by Dr. Mattox and posted here for us to build on.   Let us
not
> > make
> > > it too long, but each of the areas from industry and economics to
data
> > and
> > > indications for use are essenti
> > > >>
> > > >> al.  I really like the part where the sending emergency rooms
of a
> > > region
> > > and the EMS agencies, including helicoper companies can and should
be
> > part
> > > of a data driven regional quality review process.    Bravo, the
playing
> > > field is being leveled and we all compete professionally in this
table
> > top
> > > practicum.
> > > >>
> > > >>
> > > >>
> > > >> Mohammed al Malik, M.D.
> > > >>
> > > >> Los Angeles
> > > >>
> > > >>> From: KMATTOX at aol.com
> > > >>> Date: Sun, 28 Mar 2010 13:17:54 -0400
> > > >>> Subject: Re: Air Ambulannce Standards
> > > >>> To: trauma-list at trauma.org
> > > >>>
> > > >>> We are all here together to build on foundations and
principles to
> > > create,
> > > >>> and not destroy. As we enter health economics reform era, it
is
> > > >>> important that we use resources and personal wisely, and
eliminate
> > > waste
> > > and
> > > >>> misuse. No one could have stated those principles more
eloquently
> > than
> > > you as
> > > >>> have others on this list server. There is ALWAYS a discussion
table.
> > > >>> ALL stakeholders should always be at such professional tables.
One of
> > > the
> > > >>> great beauties of this list server is that it is a VIRTUAL
table
> > where
> > > >>> everyone is equal and respected.
> > > >>>
> > > >>> k
> > > >>>
> > > >>>
> > > >>>
> > > >>>
> > > >>> In a message dated 3/28/2010 12:09:42 P.M. Central Daylight
Time,
> > > >>> p.bjorn at tds.net writes:
> > > >>>
> > > >>> As always, your comments mean a lot to me. Thanks. I'd be
honored to
> > > >>> help
> > > >>> you move toward the establishment of useful standards and
practices,
> > if
> > > >>> there's room at the table. If there's a table.
> > > >>>
> > > >>> And while I'm at it:
> > > >>>
> > > >>> I regret giving any impression that I hold "established
beliefs that
> > > HEMS
> > > >>> is
> > > >>> necessary in nearly every community in the US." I assure the
List, if
> > > it's
> > > >>> not already evident, that nothing could be farther from the
truth.
> > > Indeed,
> > > >>> when efforts began to establish a helicopter program in Maine
more
> > than
> > > a
> > > >>> decade ago, I was invited to the planning committee -- not
because I
> > > had
> > > >>> any
> > > >>> special experience or insight, but because I was one of the
loudest
> > > voices
> > > >>> of opposition. And it wasn't merely a matter of 'keeping your
enemies
> > > >>> closer.' Norm Dinerman felt that it'd be good for the whole
program
> > to
> > > have
> > > >>> someone along on the tours to ask the hard questions that
aerophiles
> > > might
> > > >>> not think of.
> > > >>>
> > > >>> (That he would build such a role into the process speaks
volumes of
> > his
> > > >>> leadership, and of the fundamental philosophies of
LifeFlight.)
> > > >>>
> > > >>> Helicopter EMS, in my view, was complex, expensive and
dangerous.
> > > >>> Moreover,
> > > >>> it was obscenely overused. Too often we were tempted to skip
the
> > > question
> > > >>> of whether we NEED to fly in favor of whether we CAN. Twelve
years
> > > later,
> > > >>> these concerns are still valid. But in the process of trying
to
> > > convince
> > > >>> my
> > > >>> colleagues not to buy a helicopter, I discovered that there
are
> > clearly
> > > >>> circumstances where HEMS can be a useful -- nay, essential --
> > component
> > > of
> > > >>> effective critical care systems.
> > > >>>
> > > >>> The story of LifeFlight in Maine has produced scores of
compelling
> > > >>> examples.
> > > >>> Many of course manifest as patients who surely would not have
> > survived
> > > >>> without an aircraft. But to anyone paying attention, the wins
extend
> > > well
> > > >>> beyond the individual.
> > > >>>
> > > >>> LifeFlight has objectively, undeniably improved the EMS
culture in my
> > > >>> state.
> > > >>> There is not an agency anywhere in Maine more active with
respect to
> > > >>> internal and external education, protocol development, or PI.
You
> > will
> > > not
> > > >>> find a more engaged, dedicated or selfless group of
professionals
> > > anywhere.
> > > >>> And none of them are getting rich off it. The financial
mission of
> > the
> > > >>> organization (at least to the extent that it is evident to me)
is to
> > > >>> survive, so as to serve.
> > > >>>
> > > >>> I'm beginning to rant. Sorry. But let's leave it that I hope
you're
> > > >>> intending to FIX HEMS, not destroy it. If that's really what
you're
> > > after,
> > > >>> I beg you for a seat at the meeting.
> > > >>>
> > > >>> Pret
> > > >>>
> > > >>>
> > > >>> -----Original Message-----
> > > >>> From: trauma-list-bounces at trauma.org
> > > >>> [mailto:trauma-list-bounces at trauma.org]
> > > >>> On Behalf Of KMATTOX at aol.com
> > > >>> Sent: Sunday, March 28, 2010 11:30 AM
> > > >>> To: trauma-list at trauma.org
> > > >>> Subject: Re: Air Ambulannce Standards
> > > >>>
> > > >>> I like Pret's critical analysis and he is right. Such input is
> > > >>> essential
> > > >>> if this community is to develop a practical and usable
strawman
> > > document
> > > >>> which will be accepted by the stakeholders. I do believe that
it is
> > > >>> better
> > > >>> for this to be developed by professionals such as those on
this list
> > > >>> server, than the government agencies.
> > > >>>
> > > >>> k
> > > >>>
> > > >>>
> > > >>>
> > > >>> --
> > > >>> trauma-list : TRAUMA.ORG
> > > >>> To change your settings or unsubscribe visit:
> > > >>> http://www.trauma.org/index.php?/community/
> > > >>>
> > > >>> --
> > > >>> trauma-list : TRAUMA.ORG
> > > >>> To change your settings or unsubscribe visit:
> > > >>> http://www.trauma.org/index.php?/community/
> > > >>
> > > >>
_________________________________________________________________
> > > >> Hotmail is redefining busy with tools for the New Busy. Get
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> > > your inbox.
> > > >>
> > >
> > >
> >
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ON:WL:en-US:WM_HMP:032010_2
> > > >> --
> > > >> trauma-list : TRAUMA.ORG
> > > >> To change your settings or unsubscribe visit:
> > > >> http://www.trauma.org/index.php?/community/
> > > >
> > > > --
> > > > trauma-list : TRAUMA.ORG
> > > > To change your settings or unsubscribe visit:
> > > > http://www.trauma.org/index.php?/community/
> > >
> > >
> > >
> > > --
> > > Stephen Richey, CRT
> > >
> > > "A man's moral worth is established only at the point where he is
ready
> > to
> > > give up his life in defense of his convictions."- Henning von
Tresckow
> > > --
> > > trauma-list : TRAUMA.ORG
> > > To change your settings or unsubscribe visit:
> > > http://www.trauma.org/index.php?/community/
> > > --
> > > trauma-list : TRAUMA.ORG
> > > To change your settings or unsubscribe visit:
> > > http://www.trauma.org/index.php?/community/
> > >
> >
> >
> >
> > --
> > Stephen Richey, CRT
> >
> > "A man's moral worth is established only at the point where he is
ready to
> > give up his life in defense of his convictions."- Henning von
Tresckow
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/
> >
> 
> 
> 
> -- 
> Stephen Richey, CRT
> 
> "A man's moral worth is established only at the point where he is
ready to
> give up his life in defense of his convictions."- Henning von Tresckow
> 
> ----- Original Message -----
> From Stephen Richey <
> Date Mon, 29 Mar 2010 02:43:55 -0400
> To "Trauma-List [TRAUMA.ORG]" <
> Subject Re: Air Ambulannce Standards
> Like I said, all I care about is the safety of the crews.  The medical
> necessity of the flights?  I will leave that side of the debate- 
> beyond a
> superficial level- to thosewith a more vested interest.
> 
> On Sun, Mar 28, 2010 at 8:37 PM, Gross, Ronald
<Ronald.Gross at baystatehealth.org> wrote:
> 
> > Steve, we've all buried friends.  All the more reason to fix it now.
> > Typed (poorly) with my thumbs on my Blackberry!
> >
> > ----- Original Message -----
> > From: trauma-list-bounces at trauma.org <
> > To: Trauma-List [TRAUMA.ORG] <
> > Sent: Sun Mar 28 20:23:23 2010
> > Subject: Re: Air Ambulannce Standards
> >
> > Amen to that sir.  I've buried too many friends over the years which
is why
> > I get so fired up about this.
> >
> > On Sun, Mar 28, 2010 at 7:37 PM, Gross, Ronald <>
Ronald.Gross at baystatehealth.org> wrote:
> >
> > > " Unfortunately, in the interest of safety there are going to be a
few
> > > operations that will be effectively "destroyed" by any logical and
> > concerted
> > > effort to push for reasonable and safe HEMS operations."
> > >
> > > It is better that these operations be administratively destroyed,
rather
> > > then destroyed by crashes.  That way the people "lost" from the
industry
> > can
> > > find jobs elsewhere, and families were not destroyed in the
process.
> > >
> > > Ron
> > >
> > > -----Original Message-----
> > > From: trauma-list-bounces at trauma.org [mailto:
> > > trauma-list-bounces at trauma.org] On Behalf Of Stephen Richey
> > > Sent: Sunday, March 28, 2010 3:06 PM
> > > To: Trauma-List [TRAUMA.ORG]
> > > Subject: Re: Air Ambulannce Standards
> > >
> > > On Sun, Mar 28, 2010 at 1:09 PM, Pret Bjorn < wrote:
> > >
> > > >
> > > > I regret giving any impression that I hold "established beliefs
that
> > HEMS
> > > > is
> > > > necessary in nearly every community in the US."  I assure the
List, if
> > > it's
> > > > not already evident, that nothing could be farther from the
truth.
> > > >
> > >
> > > *Mea culpa on that comment.  Sorry for being a little overzealous
in the
> > > rebuttal of my stances.  There was a little more that spurred on
the
> > venom
> > > in my response to you yesterday, but I've sent you an e-mail
explaining
> > > that
> > > and it's not  germane to this discussion.  Suffice to say, it
seems like
> > we
> > > both misunderstood where the other stands on the issues at hand.
For my
> > > part of it, I am sorry.  *
> > >
> > >
> > > > I'm beginning to rant.  Sorry.  But let's leave it that I hope
you're
> > > > intending to FIX HEMS, not destroy it.  If that's really what
you're
> > > after,
> > > > I beg you for a seat at the meeting.
> > > >
> > >
> > > *That is an admirable goal and hope you get your seat at the
meeting
> > Pret.
> > > We all want to fix HEMS.  I don't believe there is a single one of
us who
> > > wants to destroy the industry because it has its place.  The issue
is
> > > finding out what that place actually is and how to best fill it.
> > > Unfortunately, in the interest of safety there are going to be a
few
> > > operations that will be effectively "destroyed" by any logical and
> > > concerted
> > > effort to push for reasonable and safe HEMS operations.  The
essential
> > part
> > > of that void will be filled by more responsible providers.*
> > >
> > > --
> > > Stephen Richey, CRT
> > >
> > > "A man's moral worth is established only at the point where he is
ready
> > to
> > > give up his life in defense of his convictions."- Henning von
Tresckow
> > > --
> > > trauma-list : TRAUMA.ORG
> > > To change your settings or unsubscribe visit:
> > > http://www.trauma.org/index.php?/community/
> > >
> > >
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> > > contain confidential and privileged information for the use of the
> > > designated recipients named above. If you are not the intended
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> > > you are hereby notified that you have received this communication
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> > error
> > > and that any review, disclosure, dissemination, distribution or
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> > > it or its contents is prohibited. If you have received this
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> > > error, please reply to the sender immediately or by telephone at
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> > > http://www.trauma.org/index.php?/community/
> > >
> >
> >
> >
> > --
> > Stephen Richey, CRT
> >
> > "A man's moral worth is established only at the point where he is
ready to
> > give up his life in defense of his convictions."- Henning von
Tresckow
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
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> >
> 
> 
> 
> -- 
> Stephen Richey, CRT
> 
> "A man's moral worth is established only at the point where he is
ready to
> give up his life in defense of his convictions."- Henning von Tresckow
> 
> ----- Original Message -----
> From "Pret Bjorn" <
> Date Mon, 29 Mar 2010 05:18:54 -0400
> To "'Trauma-List [TRAUMA.ORG]'" <
> Subject RE: Professionalism in Air Ambulance Standards
> Jeez, you can't take your eye off a thread for a minute around here.
> Suddenly I've got a couple of dozen messages piled up.  Got to set 
> asidesome reading time.
> 
> But in pursuit of fairness, I must point out that I used the "BS" word
> first.  It was tucked in to the end of a paragraph behind an artful
> adjective; but I set the precedent nonetheless.  (It could be that 
> folkshave just given up on my potty mouth, I suppose.)
> 
> I'll take halfsies on the blowback, and extend my apologies to the 
> list.
> Pret
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org [mailto:trauma-list-
> bounces at trauma.org]On Behalf Of Gross, Ronald
> Sent: Sunday, March 28, 2010 7:44 PM
> To: 'Trauma-List [TRAUMA.ORG]'
> Subject: RE: Professionalism in Air Ambulance Standards
> 
> Stephen,
> Why is it that you cannot discuss issues on this list without the 
> use of
> profanity.  I hate to say it, but I would bet that if you were 
> making your
> very same arguments in front of your CEO and COO I'd be willing to 
> bet that
> you would probably use another word for "Bullshit". Perhaps 
> "Nonsense", or
> "C'mon now, you can't be serious", or if you were really angry, I bet
> "That's garbage" might emanate from your lips.
> Could this sort of approach be a reason why some seem to want to 
> crank on
> you, as opposed to others such as Mattox and Krin, who you seem to 
> think are
> afforded some sort of protection.  Just as an FYI, both of those 
> gents, and
> I too have been cranked on many occasion, so consider that a mute 
> point.RIG
> 
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org [mailto:trauma-list-
> bounces at trauma.org]On Behalf Of Stephen Richey
> Sent: Sunday, March 28, 2010 7:20 PM
> To: Trauma-List [TRAUMA.ORG]
> Subject: Re: Professionalism in Air Ambulance Standards
> 
> Bullshit.  What precisely is unsound about it? If country to country
> standards are not valid, then why are FAA regulations being 
> adjusted to
> bring us in line with the European practices? Why are there 
> internationalconferences on aviation safety to share what has been 
> learned in other
> countries if it is not applicable?
> 
> Most importantly, if there is so much variability between states,  
> why do we
> not have separate aviation regulations for every individual state? 
> Safe
> practices are safe practices are safe practices.  It's a cop out 
> to say "Oh,
> well my state uses state police helicopters!"  as if that excuses 
> them from
> following safe practices.  It does not matter who does the flying. 
> In fact,
> the best example of how not to respond to safety failures 
> resulting in fatal
> crashes is Maryland in the aftermath of the Trooper 2 crash.  (For 
> the sake
> of disclosure, I was friends with the pilot at the controls during 
> thatcrash.)
> 
> They not only had one of the worst habit of abusing HEMS in the 
> country,they also snubbed their nose at hearings to advance safety 
> and when
> legislators tried to launch an independent non-MIEMMS 
> investigation the
> Maryland State Police simply used mass protest from its uneducated
> supporters to maintain the *status quo*.  Even one of my heroes, 
> Tom Scalea,
> flat out defended flying patients with minor injuries simply 
> because of
> tradition and superstition.  Hearing him say that in the press was 
> likebeing kicked in the testicles.
> 
> As for some states not having any crashes, then why do we not 
> figure out
> what they are doing to keep a perfect record?  We can certainly 
> look from
> state to state to find  practices that do not work.  State to 
> state, country
> to country, let us find what works and what does not.  The fact 
> that we have
> borders on a map between these entities is no reason to turn a 
> blind eye and
> continue to have to attend funerals of friends and colleagues.
> 
> 
> 
> On Sun, Mar 28, 2010 at 7:21 PM, < wrote:
> 
> > US-300,000,000 people.  Each state is like its own country. The
country to
> > country comparison is unsound. Some states have had zero. Some
states use
> > state police helo.dn
> > Sent from my Verizon Wireless BlackBerry
> >
> > -----Original Message-----
> > From: Stephen Richey <
> > Date: Sun, 28 Mar 2010 18:58:49
> > To: Trauma-List [TRAUMA.ORG]<
> > Subject: Re: Professionalism in Air Ambulance Standards
> >
> > There was actually a study done that showed simply using twin engine
> > helicopters did not induce greater safety, but that is not the
issue. I
> > don't recall the date of the article, but I will do my best to find
it and
> > forward it to you.  It would be the inclusion of a second pilot,
which
> > would
> > necessitate a helicopter with greater maximum takeoff weight, that
would
> > likely improve safety.  There simply are not enough HEMS operators
in the
> > US
> > flying dual pilot to make an adequate comparison at the moment.
There are
> > other countries where it is a standard for commercial helicopters to
fly
> > dual pilot, not to mention the standard of the US military (and most
> > military forces) to fly dual pilot and their notable safety record
despite
> > flying in some of the most hostile environments on the planet.
> >
> > The lesson we should be learning is to apply those things that work
in
> > other
> > countries and other high-risk environments.  Germany for instance-
despite
> > a
> > very high level of HEMS operations- has had one fatal helicopter
crash in
> > 11
> > years (Thies KC, Sep D, Derksen R. How safe are HEMS-programmes in
> Germany?
> > A retrospective analysis. Resuscitation. 2006 Mar;68(3):359-63. Epub
2006
> > Feb 7.).  Similarly the HEMS crash rates for Australia and other
countries
> > remain at less than half that of the US rate. (Holland J, Cooksley
DG.
> >  Safety of helicopter aeromedical transport in Australia: a
retrospective
> > study.  Med J Aust. 2005 Jan 3;182(1):17-9.).  Our recommendations
should
> > include those things that work in those countries that HEMS are not
> > employing here or are, in fact, flat out doing the opposite of.
That is
> > the
> > bullet that will take down the crash rate *while not destroying the
HEMS
> > industry*.  If we simply fix the issue with inappropriate transport,
we
> > risk
> > reducing the fatal crash rate but risk not fixing the underlying
issues
> > that
> > may come back to harm our colleagues in the future if the industry
were to
> > find a way around the medical necessity clauses we seek to advance.
> >
> >
> > On Sun, Mar 28, 2010 at 6:28 PM, Ian Seppelt <
> > wrote:
> > >
> > > As a hypothetical for the USA:
> > >
> > > If something like 'twin engine IFR capable' was mandated for HEMS,
what
> > prortion of US operations would meet that standard?
> > >
> > > Ian
> > >
> > > On 29/03/2010, at 4:29 AM, Mohammed al Malik <
> > wrote:
> > >
> > >>
> > >> You are seeing the diplomatic Mattox who displays the same
approach of
> a
> > mixture of data, practicality, insight, understanding and wisdom
from the
> > podium of the Las Vegas Trauma, Critical Care, and Acute Care
Surgery
> > course.     In his discussion of Dr. Johannigman's air ambulance
talk he
> > was
> > respectful and even there called on us to develop standards,
starting with
> > an air ambulance data base and registry.    Here in Southern
California,
> > with its full freeways, mountains, deserts, and distances, we do
need air
> > ambulances, but not to be used for minor conditions.  Because of the
> > helicopter crashes during the past three years,  I was getting
fearful
> that
> > the government would create unreasonable mandates.   I am hopeful
that
> > logic
> > and effective recommendations can be made using the outline of
issues
> > created by Dr. Mattox and posted here for us to build on.   Let us
not
> make
> > it too long, but each of the areas from industry and economics to
data and
> > indications for use are essenti
> > >>
> > >> al.  I really like the part where the sending emergency rooms of
a
> > region
> > and the EMS agencies, including helicoper companies can and should
be part
> > of a data driven regional quality review process.    Bravo, the
playing
> > field is being leveled and we all compete professionally in this
table top
> > practicum.
> > >>
> > >>
> > >>
> > >> Mohammed al Malik, M.D.
> > >>
> > >> Los Angeles
> > >>
> > >>> From: KMATTOX at aol.com
> > >>> Date: Sun, 28 Mar 2010 13:17:54 -0400
> > >>> Subject: Re: Air Ambulannce Standards
> > >>> To: trauma-list at trauma.org
> > >>>
> > >>> We are all here together to build on foundations and principles
to
> > create,
> > >>> and not destroy. As we enter health economics reform era, it is
> > >>> important that we use resources and personal wisely, and
eliminate
> > waste
> > and
> > >>> misuse. No one could have stated those principles more
eloquently than
> > you as
> > >>> have others on this list server. There is ALWAYS a discussion
table.
> > >>> ALL stakeholders should always be at such professional tables.
One of
> > the
> > >>> great beauties of this list server is that it is a VIRTUAL table
where
> > >>> everyone is equal and respected.
> > >>>
> > >>> k
> > >>>
> > >>>
> > >>>
> > >>>
> > >>> In a message dated 3/28/2010 12:09:42 P.M. Central Daylight
Time,
> > >>> p.bjorn at tds.net writes:
> > >>>
> > >>> As always, your comments mean a lot to me. Thanks. I'd be
honored to
> > >>> help
> > >>> you move toward the establishment of useful standards and
practices,
> if
> > >>> there's room at the table. If there's a table.
> > >>>
> > >>> And while I'm at it:
> > >>>
> > >>> I regret giving any impression that I hold "established beliefs
that
> > HEMS
> > >>> is
> > >>> necessary in nearly every community in the US." I assure the
List, if
> > it's
> > >>> not already evident, that nothing could be farther from the
truth.
> > Indeed,
> > >>> when efforts began to establish a helicopter program in Maine
more
> than
> > a
> > >>> decade ago, I was invited to the planning committee -- not
because I
> > had
> > >>> any
> > >>> special experience or insight, but because I was one of the
loudest
> > voices
> > >>> of opposition. And it wasn't merely a matter of 'keeping your
enemies
> > >>> closer.' Norm Dinerman felt that it'd be good for the whole
program to
> > have
> > >>> someone along on the tours to ask the hard questions that
aerophiles
> > might
> > >>> not think of.
> > >>>
> > >>> (That he would build such a role into the process speaks volumes
of
> his
> > >>> leadership, and of the fundamental philosophies of LifeFlight.)
> > >>>
> > >>> Helicopter EMS, in my view, was complex, expensive and
dangerous.
> > >>> Moreover,
> > >>> it was obscenely overused. Too often we were tempted to skip the
> > question
> > >>> of whether we NEED to fly in favor of whether we CAN. Twelve
years
> > later,
> > >>> these concerns are still valid. But in the process of trying to
> > convince
> > >>> my
> > >>> colleagues not to buy a helicopter, I discovered that there are
> clearly
> > >>> circumstances where HEMS can be a useful -- nay, essential --
> component
> > of
> > >>> effective critical care systems.
> > >>>
> > >>> The story of LifeFlight in Maine has produced scores of
compelling
> > >>> examples.
> > >>> Many of course manifest as patients who surely would not have
survived
> > >>> without an aircraft. But to anyone paying attention, the wins
extend
> > well
> > >>> beyond the individual.
> > >>>
> > >>> LifeFlight has objectively, undeniably improved the EMS culture
in my
> > >>> state.
> > >>> There is not an agency anywhere in Maine more active with
respect to
> > >>> internal and external education, protocol development, or PI.
You will
> > not
> > >>> find a more engaged, dedicated or selfless group of
professionals
> > anywhere.
> > >>> And none of them are getting rich off it. The financial mission
of the
> > >>> organization (at least to the extent that it is evident to me)
is to
> > >>> survive, so as to serve.
> > >>>
> > >>> I'm beginning to rant. Sorry. But let's leave it that I hope
you're
> > >>> intending to FIX HEMS, not destroy it. If that's really what
you're
> > after,
> > >>> I beg you for a seat at the meeting.
> > >>>
> > >>> Pret
> > >>>
> > >>>
> > >>> -----Original Message-----
> > >>> From: trauma-list-bounces at trauma.org
> > >>> [mailto:trauma-list-bounces at trauma.org]
> > >>> On Behalf Of KMATTOX at aol.com
> > >>> Sent: Sunday, March 28, 2010 11:30 AM
> > >>> To: trauma-list at trauma.org
> > >>> Subject: Re: Air Ambulannce Standards
> > >>>
> > >>> I like Pret's critical analysis and he is right. Such input is
> > >>> essential
> > >>> if this community is to develop a practical and usable strawman
> > document
> > >>> which will be accepted by the stakeholders. I do believe that it
is
> > >>> better
> > >>> for this to be developed by professionals such as those on this
list
> > >>> server, than the government agencies.
> > >>>
> > >>> k
> > >>>
> > >>>
> > >>>
> > >>> --
> > >>> trauma-list : TRAUMA.ORG
> > >>> To change your settings or unsubscribe visit:
> > >>> http://www.trauma.org/index.php?/community/
> > >>>
> > >>> --
> > >>> trauma-list : TRAUMA.ORG
> > >>> To change your settings or unsubscribe visit:
> > >>> http://www.trauma.org/index.php?/community/
> > >>
> > >> _________________________________________________________________
> > >> Hotmail is redefining busy with tools for the New Busy. Get more
from
> > your inbox.
> > >>
> >
> >
>
http://www.windowslive.com/campaign/thenewbusy?ocid=PID27925::T:WLMTAGL:
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> L:en-US:WM_HMP:032010_2
> > >> --
> > >> trauma-list : TRAUMA.ORG
> > >> To change your settings or unsubscribe visit:
> > >> http://www.trauma.org/index.php?/community/
> > >
> > > --
> > > trauma-list : TRAUMA.ORG
> > > To change your settings or unsubscribe visit:
> > > http://www.trauma.org/index.php?/community/
> >
> >
> >
> > --
> > Stephen Richey, CRT
> >
> > "A man's moral worth is established only at the point where he is
ready to
> > give up his life in defense of his convictions."- Henning von
Tresckow
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/
> >
> 
> 
> 
> -- 
> Stephen Richey, CRT
> 
> "A man's moral worth is established only at the point where he is
ready to
> give up his life in defense of his convictions."- Henning von Tresckow
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
> 
> ----------------------------------------------------------------------
> CONFIDENTIALITY NOTICE: This email communication and any attachments
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> designated recipients named above. If you are not the intended
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> you are hereby notified that you have received this communication in
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> 
> 
> ----- Original Message -----
> From "Pret Bjorn" <
> Date Mon, 29 Mar 2010 05:37:08 -0400
> To "'Trauma-List [TRAUMA.ORG]'" <
> Subject RE: Respiratory protection
> Wow.  What's your budget?  
> 
> If you're wearing a hood for droplet precautions, then consider it
> disposable: the things are a b*tch to decontaminate.
> 
> I'm not aware of any hardware that is built for this purpose.  
> It'll be
> interesting to see if the manufacturers pursue the hirsute market. 
> Surely
> if anything arrives on the shelf, someone on the List will find it 
> for you.
> 
> Best of luck.
> 
> 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 Sahaj Khalsa
> Sent: Sunday, March 28, 2010 10:12 PM
> To: Trauma-List [TRAUMA.ORG]
> Subject: Respiratory protection
> 
> Hello,
> 
> I am interested in any information the members of the list may 
> have on PAPR
> (Positive Air Powered Respirator) type devices and their use in the
> pre-hospital environment.
> 
> As a paramedic with a beard, I am unable to wear an N-95 mask and 
> need an
> alternative, one that will allow stethoscope use.
> 
> If anybody has information and would like to provide it off-list, 
> my email
> is: sahajs at gmail.com
> 
> Thanks,
> 
> Sahaj Khalsa
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