It has been nearly six months since I posted last, thanks in large part to the overwhelming volume of work I've had bearing down on me as a result of my research, etc. Now seems like as good of a time as any to discuss some of the interesting developments in my world.
The aviation injury project stands at about 1900 cases total- including those cases for which I only have partial data- and I've made it through a good number of those especially considering that I do not get paid for my time and efforts. This month also marks the end of the project being conducted under the auspices of Saginaw Valley State University and I would like to take this opportunity to thank the faculty, administration and staff for their unwavering and enthusiastic support of my research. I am forever in their debt. The project will be transferring to Embry-Riddle Aeronautical University when I transfer as a student as of October roughly if everything transitions smoothly. At least that's the plan at the moment....as anyone in academia is aware, plans are always subject to change.
Sadly, the slowly increasing death toll in aircraft crashes has come to include another friend of mine as a result of a crash a couple of weeks ago in West Virginia. William Huff- a great guy and a competent pilot who flew out of the airport across the road from Gina and I's apartment- died after he was apparently incapacitated either by hypoxia or, less likely, some form of a medical event. While deaths like his are not something my research is geared towards preventing, the loss of someone I know yet again reminds me why I do the work I do. Fair winds and clear skies my friend, you're cleared to land.
The past few months have been punctuated by a lot of cases like this- tragic deaths, sometimes avoidable. The loss of the Dash 8 in Buffalo and the crash of the Air France Airbus triggered a lot of talk in the media about how the crash rate has spiked and what does this mean. As someone who spends a considerable amount of time wading through statistics and such, I would like to point out that while this appears to be a "bad year" if one pays attention to the media that it really has not been markedly worse than last year in terms of the number of lives lost. The fact that we have seen a handful of commercial crashes in a short time is not in and of itself indicative of a larger problem as some of the news agency have tried to imply, directly or indirectly. Like so many things in this country, the media grabs hold of something like a terrier with a rat and shakes the crap out of it until it gets bored and moves on. We went a couple of years without losing a schedule commercial flight- before the Buffalo crash, there had not been a Part 121 crash (Part 121 refers to the section of the federal regulations pertaining to airline operations) since the loss of Comair 5191 at Lexington, Kentucky on August 27, 2006. That is a record that is enviable but at the same time, the absence of crashes actually 'primed' the nation to see the loss of the Colgan Air Dash 8 in a different light than the same crash would have been seen in the late 1980s or early 1990s when crashes were more commonplace. It seemed all the more shocking and unexpected because of the 'out of the blue' nature since we had not heard about crashes for quite some time.
That said, the problem is that while we strive to have a perfect record we are going to fall short inevitably. Planes will continue to crash despite our best efforts and people will continue to die in those crashes. That is simply the risk you take getting on an aircraft, just as you risk dying in a car accident every time you get behind the wheel. This fact often disheartens people and I have seen several would-be colleagues (all young and very talented researchers) decide against assisting with my research because of this. It is quite easy to look at the loss of several hundred people a year and either dismiss it as not worth the trouble- it's a drop in the bucket compared to the tens of thousands killed annually in car accidents- or insurmountable as Everest in winter. However, a concerted effort- in which I hope to play some role- can bring those numbers down and allow more people to go home to their families in something other than a casket.
In a first for my blog, I would like to take a couple of moments and comment on something related to my research but at the same time separate from it that I have not touched on before. It's the "human side" of crashes, the emotional aspects of the crash and the often lifelong effects on those who survive, the families of the victims and the responders. While not all crashes are part of my research (and even if they were, I could not divulge which ones are and which ones are not even if I wanted to), there are some crashes that I feel are often forgotten as simply footnotes in the annals of history. The thing is that is a disservice to every person who died, every person who suffered and those who loved those involved.
We in the aviation safety community try to learn what we can from each crash and then pass that knowledge along to the pilots, the companies and the industry as a whole to avoid repeating the same mistakes again. As the saying goes, the definition of insanity is doing the same thing over and over and expecting a different result. Perhaps the lessons learned and the lives saved by those lessons and their application should be considered the best memorial possible for lives shattered by tragedy, as at least those deaths were not in vain. Cold comfort to those who will never hold a loved one again and feel the warmth of their embrace, but at least it is something to cling to in trying times.
Memorials in the more traditional sense- tangible, permanent structures of glass, marble, granite, and bronze- are often what people think of when the phrase "paying tribute" is brought up. I can not say I disagree with this. I have gone and lain flowers on monuments for two or three crashes when I realized I was in the area on business or personal trips over the years to pay tribute to those lost despite having never known anyone on board the aircraft. It just seems like the decent thing to do given what I spend a large part of my free time doing.
Yet, one thing that sticks with me is that many of the truly watershed moments of darkness in aviation history have never had this level of respect given to them. One such example is the crash of Eastern Airlines Flight 401 in the Everglades on the night of 29. December 1972. 103 people lost their lives in what was the first crash of a wide-body commercial airliner. It is considered one of the classic case studies in crew resource management (CRM, also called "cockpit resource management" by some) due to a minor technical glitch and the breakdown of situational awareness as the crew sought a solution to the issue. It is a perfect example of how crashes are often not simple events but the end result of a multitude of small issues that compounded to bring the aircraft down. In this case, the aircraft descended unnoticed until just before impacting the pitch blackness of the Everglades west of Miami. Despite the fact that the crash occurred nearly eight years to the day before I was born, it has always held a special place in my mind because it was one of the first cases I looked into when I became interested in aviation safety.
There is a blog much like this one put together by a group of survivors of the crash and other like-minded individuals who are working to not let the memory of that night fade like it has for so many other crashes. The blog can be found at: http://ealflt401.blogspot.com/
I recommend that anyone reading this blog donate money to the cause of erecting a memorial to the lives lost and those left behind and the heroes of that night. If you absolutely feel the need to have something to show for your donation, the tribute group sells baseball caps and tote bags to help raise money (I have yet to do so, but it is my intention to purchase one of the caps myself). Not only is it a decent thing to do to remember those who have died tragically but all of us who fly with any degree of regularity would be well advised to remember that out of this case came many changes in how aircraft are operated that play major roles in explaining we do not lose aircraft as regularly as we used to. Your own life may have been saved without your ever realizing it because of the loss of this flight and what was learned from it. At very least, keep the victims and their families in your thoughts and prayers.
Wednesday, August 12, 2009
Tuesday, March 3, 2009
Response to A Post on Rogue Medic's Blog
My friend and colleague, Rogue Medic, has long been one of the best bloggers on the science- and lack thereof- underpinning EMS. He has also been a really staunch critic of the current sad state of aeromedical transport in this nation. His latest post Medevac Helicopter Improvement Act of 2009 - Maryland SB 650 drew some comments from a person calling himself "Gray". What follows is taken from the post that Rogue Medic posted based upon my responses to Gray and my rejection and disproving of his incorrect conjectures.
=================================Guest Post on Medevac Helicopter Improvement Act of 2009 - Maryland SB 650
The Erstwhile Medic writes Strange Dichotomies and Random Occurrences, although he does not write often. The HEMS (Helicopter EMS) problems are important to him. Several of his friends have died in HEMS crashes. His writing is from a different perspective and his responses to the comments by Gray are all significantly different from mine. I asked him if I might post his response (the body of the post) to Gray's comments (in the quote format) on Medevac Helicopter Improvement Act of 2009 - Maryland SB 650. My response to Gray was More Helicopter EMS Politics and Pork in Maryland. The Erstwhile Medic occasionally refers to my comments in that post. MSP is Maryland State Police Aviation.
"Do they operate very closely with favored hospital service providers? Count on it."
OK....and the fact that the vast majority of MSP transports goes to one hospital (Shock Trauma) doesn't seem to be favoritism despite the presence of several other hospitals that could quite readily handle complicated traumas and medical cases? Let's not forget we are talking about a hospital that has refused to take part in the standard American College of Surgeons trauma center accreditation process out of hubris (which, in case you are not aware, means it is NOT a trauma center in the legal sense). You still want to talk conflict of interest?
Most hospitals that operate helicopters have the facilities to handle those patients they are having brought in. Otherwise, why would they want someone to be brought in to a referral hospital that they can not manage? It would be a bad business practice and probably would get them investigated by the federal regulators overseeing Medicare and Medicaid quite quickly.
"Is their objective life saving or profit?"
So long as proper care is being delivered, does it really matter if they squeak out a small margin of profit? The last time I checked, we still lived in a capitalist society and the desire to make money so long as you are not engaged in unethical activities is not something that is frowned upon.
"For more than 65 years Marylanders have depended on MSP for emergency medical transport in rural areas."
For a few thousand years, people believed disease was caused by displeasure of the gods or evil spirits or black magic. How about actually arguing the validity of aeromedical transport and the lack of safety associated with it instead of just trying to post a bunch of political grandstanding?
"With the statewide increase in population density and frequency of serious injury traffic crashes MSP has demonstrated its competency in saving lives during that golden hour."
Actually, it has never done anything of the sort. It has NEVER offered any data other than bluster to try to support the number of flights and the massive expenditures. The only data on the subject that has come to my attention indicates that the flights are a huge waste of money and an undue risk to everyone involved.
"Do we have names and dates of the lives saved? No."
In other words, let's make a play to emotion, and not muddy the waters with data or facts!
"But we know how those whose lives have been saved would vote on this issue."
If we don't know who has been saved or if there are significant numbers of them, how can you say you know how they would vote? I can wave a metal detector over a trauma victim and convince them that is what allowed them to survive. Just because most people are gullible and will assume that the more technology that you involve in trauma care the better, it doesn't mean they are correct or that leading them to believe it when you know that is not the case (or don't have the evidence to know either way) is unethical and reprehensible.
"Do we value human life enough to continue saving lives, or should we just write that off as a public service, ignoring the vote of the people to fund the service?"
- Show quoted text -
"Do rural residents deserve a lesser availability of emergency transport than urban residents? I don't think so."
No, but there are better ways to deliver patients to hospitals and this is coming from someone who worked in EMS in an area twenty to thirty minutes from the closest hospital and sixty to ninety minutes from the closest designated trauma center. The primary town I served had a population of about 2,500 and the township I worked in as a volunteer had a grand total of 2,000 residents thereby making even the 'rural' parts of Maryland look like downtown Baltimore by comparison.
A lot of people of people actually do well when taken by ground to hospitals other than Shock Trauma and only a small minority of patients taken from scenes to trauma centers actually need services only available there.
"Maryland taxpayers voted for the MSP program, and know it is invaluable, a source of pride and comfort."
As I said before, a significant percentage of people are stupid (or at very least, easily led by the nose by special interest groups) and when they are told "Do this or you will die!" you can get them to approve just about anything. I hate to toe the line of Godwin's Law, but given sufficient latitude and a lack of criticism (and what does occur is quashed immediately because of politics and personal pet projects) you can get even intelligent people to believe things that are completely unreasonable.
Rogue Medic said it best, comfort and pride is something otherwise known as "pork".
"Citing examples of patients flown to Baltimore and walking out of the hospital the next day is a plus: a life saved. That is the idea."
So the fact that you wasted money on the flight (even if it is taxpayer money, that is still not a free ticket to spend money with wild abandon) and endanger the crew, the patient(s), the personnel on the landing site, etc. The fact that someone did not die does not mean you saved a life. It means you are unable to disimpact your head from your rectum for long enough to realize the amount of completely ridiculous bullshit your post consisted of.
By your standard, I could send those people to urgent care clinic ("doc in the box) by personal vehicle and achieve the same outcome without the expense and risks of a flight. Actually, for most of them you could give them a ride home in a MSP patrol car and they would still not have any bad outcomes. Why not transport them by ground?
For the cost of the helicopters, one could likely put a considerable number of ground ambulances into service and ACTUALLY save lives by ensuring rapid access to automated external defibrillators, timely treatment of asthma attacks before they become severe and other measures that have been proven to be effective, safe and not exorbitantly expensive. It is quite likely that you could vaccinate and provide other free preventative health care to every child in Maryland for the cost of the MSP fleet. Ask any public health professional- the best way to save lives is to prevent the circumstances that take them in the first place.
"MSP's aviation team may be second to none...."
I agree with a few stipulations including some that I have previously expressed in other blogs and comments as well as those that Rogue Medic pointed out. So I will start out by pointing out how the key word in that sentence is the word "may" as it is a true sign that the statement is solely your opinion.
-The "second to none" is one of those empty "atta-boys" that people extend to any person, group or practice that they deem to support without regard to
-The fact that they have ONLY had two crashes does not make them "second to none". In fact, there are several services I can name (University of Missouri Staff For Life, Clarian Health Lifeline, etc) that have never had a crash thereby making them superior in regards to safety (thus far) to MSP Aviation.
-The fact that they were not CAMTS certified- even though I am skeptical of whether the CAMTS standards really mean much- which is the industry gold standard precludes the ability to call MSP Aviation "second to none".
-The fact that the Maryland EMS system is often used as an example of how bureaucracy interferes with providing exceptional prehospital care and the fact that the excessive reliance upon helicopters is ranked high on most peoples' list of reasons for this invalidates your empty assertion that
-The fact that they fly single pilot instrument flight rules operations despite the fact that this is specifically prohibited by several countries (Canada for instance) means that from the perspectives of safety and proactivity, MSP Aviation again falls well short of "second to none".
I will say that I flew with Steve (the pilot of Trooper 2) on a few occasions and viewed him as one of the best helicopter pilots I have ever flown with. The fact that he died on a flight that was dispatched to avoid inconveniencing a few EMS personnel in Charles County is something I will never forget and that you seem to be ignoring.
"... while simultaneously wanting it to be still better."
Then why have they fought tooth and nail to avoid having to change ANY of their practices or to adopt standards unless they have no choice but to do so?
Wanting to be better is admirable, but what really matters is actually striving for that. The administration knew of issues (abuse of the system by ground providers as well as issues that downed helicopters from other services) that could have been addressed to make the system better. "Wanting it to be still better" is something that is said when confronted by the widows and orphans of the crew you lost and the family of the patient you lost. It is one of those empty pointless and self-serving statements one issues when trying to cover their butt legally, morally and professionally. The "wants" of the MSP Aviation administration (and the leadership of other services) is cold comfort for those of us who have buried and continue to mourn the loss of friends. The actions are what matters and I have yet to see any efforts that were initiated by MSP that led to improvements in safety and efficacy. Even those changes brought about outside agencies and organizations have been resisted with every resource and man the MSP Aviation division can muster.
"That is MSP's tradition: excellence, integrity, & respect for human life."
I don't believe I can disagree with those aspirations, other than the point out there is a lot of room for improvement in a very badly broken system.
"Emergency life saving should not be relegated to profiteers."
Monday, November 24, 2008
More BS from the Maryland Institute of EMS Systems
Md. medevac flights down significantly since crash
SOURCE: http://www.examiner.com/a-1709092~Md__medevac_flights_down_significantly_since_crash.html
Nov 24, 2008 5:54 PM (48 mins ago) By BEN NUCKOLS, AP
Linthicum, Md.- Far fewer patients have been flown to Maryland trauma centers in the eight weeks since the fatal crash of a state police helicopter, the head of the agency that coordinates state's emergency response said Monday.Dr. Robert Bass spoke before a panel that will recommend changes to Maryland's medevac program on Tuesday. He said part of the decrease in flights since the crash can be attributed to a new protocol under which paramedics consult with trauma surgeons before deciding whether certain patients who don't have obvious injuries should be flown.
But Bass also said he was concerned that some patients who need to be flown are instead being taken to hospitals by ambulance.
"I think people are apprehensive," Bass said, adding that emergency care providers "don't want to be looked at as being people who abused the system."
Why would they worry about that? The system is to abuse the system.
Bass noted that the decision to fly the two patients who were in the helicopter that crashed Sept. 28 and killed four of the five people aboard "was completely consistent with protocols."
The two young women had been in a car accident and showed no obvious signs of trauma, but the state protocol calls for patients to be flown if their vehicles have sustained heavy damage, because such damage can cause internal injuries.
One of the car accident victims, 17-year-old Ashley Younger, was killed, along with the helicopter pilot, an in-flight paramedic and an emergency medical technician. The other car accident victim, 18-year-old Jordan Scott, survived the helicopter crash.
Scott spoke to reporters Monday at the University of Maryland Shock Trauma Center, where she is still being treated. She had her right foot amputated and suffered a broken neck, among numerous other injuries, and will face 6 to 12 months of rehabilitation, doctors said.
All from the helicopter crash....and to think she would have been home the night of the car accident had they not flown her.
"I just wish that someone would find what's wrong with all these helicopters and fix them," Scott said, "so this won't ever happen again and no one would have to go through what I've been through."
Between the crash and Monday, 226 patients had been airlifted statewide, Bass said. At that pace, 1,679 patients would fly on medevac helicopters in a year. In the most recent fiscal year, 4,114 patients were flown to trauma centers, state aeromedical director Douglas J. Floccare told the board.
"This is a difficult period," Floccare said. "There is some skittishness" about requesting medevac service.
The seven-member board gave little indication of what changes it might recommend. Dr. Robert C. MacKersie, director of trauma services at San Francisco General Hospital and the board chair, described its job as to "take what is undoubtedly a very good system and make it a lot better.
Some lawmakers have criticized the panel for not being sufficiently independent and for meeting in private before announcing its recommendations Tuesday. It was assembled by the state Emergency Medical Services board, which would also have the final say on whether to implement the panel's recommendations.
Ah, yes, there is the key: "Thank you Dr. Bledsoe for your constructive criticism. Now kindly get out and shut up. We don't care what you say, we don't have to listen to anyone."
"Thanksgiving is coming early. We're being served a pile of turkey," said state Sen. E.J. Pipkin, R-Cecil. "This is a public relations stunt that we're watching here today."
Pipkin said he wanted the legislature to examine the state's emergency services program and possibly act to reduce the number of flights.
"I believe we can move more resources to the ground emergency personnel, and be able to let them treat people on the scene before we pick them up and fly," Pipkin said.
Bass, however, said he trusted that the panel would not sugarcoat its recommendations.
Yes, but he makes no guarantees he won't simply ignore them.
"They clearly are willing to express their points of view," he said.
Panel member Dr. John A. Morris, trauma director at Vanderbilt University Medical Center, questioned the state's practice of including just one paramedic with flight training on its helicopters. Sometimes, as in the fatal crash, a second emergency medical technician who treated the patient on the ground will come along for the ride.
Yes, the major flaw here is the lack of a second medic or a flight nurse. How could we have missed that?
"That is a prescription for sub-optimal performance, both on the medical side of the equation and on the aviation safety side," Morris said later. "This is not pickup basketball. This is the NBA."
No, it's more like the bush league, but we'll forgive you that error. The NBA actually abides by regulations and punishes those who violate them, rather than just ignoring them if it might keep the games from being exciting and fun.
More than a dozen people, most of them medical or emergency services professionals, spoke during the public comment section of the meeting, and most of them expressed their support for the medevac program.
Yes, because the dissenters have about as much chance of being able to get in to speak as Bill Clinton has a chance to get invited to deliver the keynote address at the next Republican National Convention.
However, Mick Naven, who helped develop a scoring system for trauma patients called the Sacco Triage Method, claimed that the state's system for evaluating patients frequently resulted in unnecessary flights.
"It's both shocking and dangerous to know that in 2008, we're not using medical evidence to make these decisions," Naven said.
Bass said more study was needed to determine how the Sacco Triage Method could be integrated into the decision about whether to fly or to drive a patient to a trauma center.
Sunday, November 23, 2008
EMS Forums
In the spirit of my last post and given the fact that many of us turn to the Internet for information, I would like to do a critique of the more popular EMS forums out there. Several of these forums tend to be less than stellar and one must
Arguably the best forum out there, albeit one that is probably the least frequently posted upon is FieldMedics. I post here and there are quite a few others who are extremely knowledgeable and eager to advance the field. I highly suggest that anyone who wishes to learn and teach join the Fieldmedics family.
At the opposite end of the spectrum is EMTCity, which is a perfect example of the old adage about how even if you have 10,000 monkeys you still will not produce Shakespeare. When the forums originally started, I posted on it quite frequently but the person who runs the site decided that quantity of members was more important than the quality of the information. After that decision was made, the quality of the posts declined in a rapid and dramatic fashion. While there are a few persons on there who are knowledgeable and progressive, the majority tend to just want to chatter and maintain the status quo. Any resistance to this (including to the aeromedical operations), the response one gets is nothing short of personal attacks and related ineffectual arguments.
The other forum with which I am familiar is EMTLife (www.emtlife.com), which I describe as the "warm and fuzzy" EMS site as it is more geared towards a sense of community than anything. It is probably the best balance one could expect in a field that is torn between adrenaline junkies who simply want more skills and academics who want to determine which interventions are really necessary. However, the moderators get a little heavy-handed in deleting posts, locking threads at times but for the most part it is done only when the threads are no longer going to be productive.
Arguably the best forum out there, albeit one that is probably the least frequently posted upon is FieldMedics. I post here and there are quite a few others who are extremely knowledgeable and eager to advance the field. I highly suggest that anyone who wishes to learn and teach join the Fieldmedics family.
At the opposite end of the spectrum is EMTCity, which is a perfect example of the old adage about how even if you have 10,000 monkeys you still will not produce Shakespeare. When the forums originally started, I posted on it quite frequently but the person who runs the site decided that quantity of members was more important than the quality of the information. After that decision was made, the quality of the posts declined in a rapid and dramatic fashion. While there are a few persons on there who are knowledgeable and progressive, the majority tend to just want to chatter and maintain the status quo. Any resistance to this (including to the aeromedical operations), the response one gets is nothing short of personal attacks and related ineffectual arguments.
The other forum with which I am familiar is EMTLife (www.emtlife.com), which I describe as the "warm and fuzzy" EMS site as it is more geared towards a sense of community than anything. It is probably the best balance one could expect in a field that is torn between adrenaline junkies who simply want more skills and academics who want to determine which interventions are really necessary. However, the moderators get a little heavy-handed in deleting posts, locking threads at times but for the most part it is done only when the threads are no longer going to be productive.
EMS Education- Much left to be desired
The discussion of the reliance of EMTs and paramedics upon technology and other myths came up during the comments about the post on the Rogue Medic's blog about pulse oximetry. This touched upon one of my sources of greatest annoyance with the field in general: the lack of proper education and distaste amongst many for efforts to increase standards. What follows is a modified and expanded version of my comments on there.
One of the other persons commenting on the use of pulse oximetry and oxygen therapy by EMS personnel hit the nail on the head- the distinct lack of an emphasis on education and then the failure to stay up to speed on the current standards of care that permeates EMS. It is the reliance upon assumptions, myths and other unscientific stances that hold us back. Part of this is given the attitude that we have to keep EMS at an elementary level and maintain a status quo to allow for the volunteers and part-timers who don't have the time or might be scared off by demands for hours upon hours of review and practice. Personally, I advocate exactly the opposite approach in that we should be more worried about the quality of the personnel available than spending our time fretting over not having enough warm bodies to fill the trucks. A small number of well trained EMS professionals (even if they are volunteers) is going to be a better asset to their community than a larger number of not so well trained or just plain stupid undereducated EMTs.
While such an approach would seem to be counterproductive given the difficulty in recruiting and retaining EMS personnel in many areas, this shortfall can not be allowed to be an excuse for the furthrance of sub-standard care. In the long run, marginalization of the cowboys, the half-hearted, the immature adrenaline junkies and the less than professional amongst our ranks will only serve to advance the career field. This can be accomplished most easily by increasing the standards to a point where only those with true dedication and requisite intelligence are willing to strive to achieve them.
Improving the quality of the candidates we allow to enter EMS and increasing the education standards demanded of them is the only way we can assure the demise of our colleagues relying upon crutches- be them pulse oximetry and other technology or knee jerk over-treatment- and thereby give our patients the best of care possible. We owe them nothing less and nothing more.
If anyone has any comments, please feel free to let me know.
One of the other persons commenting on the use of pulse oximetry and oxygen therapy by EMS personnel hit the nail on the head- the distinct lack of an emphasis on education and then the failure to stay up to speed on the current standards of care that permeates EMS. It is the reliance upon assumptions, myths and other unscientific stances that hold us back. Part of this is given the attitude that we have to keep EMS at an elementary level and maintain a status quo to allow for the volunteers and part-timers who don't have the time or might be scared off by demands for hours upon hours of review and practice. Personally, I advocate exactly the opposite approach in that we should be more worried about the quality of the personnel available than spending our time fretting over not having enough warm bodies to fill the trucks. A small number of well trained EMS professionals (even if they are volunteers) is going to be a better asset to their community than a larger number of not so well trained or just plain stupid undereducated EMTs.
While such an approach would seem to be counterproductive given the difficulty in recruiting and retaining EMS personnel in many areas, this shortfall can not be allowed to be an excuse for the furthrance of sub-standard care. In the long run, marginalization of the cowboys, the half-hearted, the immature adrenaline junkies and the less than professional amongst our ranks will only serve to advance the career field. This can be accomplished most easily by increasing the standards to a point where only those with true dedication and requisite intelligence are willing to strive to achieve them.
Improving the quality of the candidates we allow to enter EMS and increasing the education standards demanded of them is the only way we can assure the demise of our colleagues relying upon crutches- be them pulse oximetry and other technology or knee jerk over-treatment- and thereby give our patients the best of care possible. We owe them nothing less and nothing more.
If anyone has any comments, please feel free to let me know.
Sunday, November 2, 2008
Sacred Cows, Reticent Physicians and Other Things That Get Good People Killed
Anyone who knows me will tell you there are a few key things about my personality one has to keep in mind when wading into a debate with me. The first of these is that I have something bordering on a photographic memory for minutiae bullshit detail. As one of my professors put it, "When it comes to his areas of interest, Steve never forgets a key fact....and he never lets you forget it either." This is one reason why I have repeatedly been able to dismantle the arguments of those who disagree with me on sundry topics, from aviation to medicine.
The second is summed up by the second clause of the professor's statement: I hold everyone to the same standards- extreme as they may be- that I hold myself to. If you are not at the top of your game, then please find the door or I will do the debate equivalent of tearing your heart out of your chest and taking a bite out of it like some form of evidence-based practice espousing latter day Aztec priest.
The final point one has to recognize about my personality is that I believe in absolute personal responsibility so far as it is possible. That is one of the reasons I am such a staunch and unyielding detractor of the current medical director of the Maryland Institute of Emergency Medical Services, Dr. Robert Bass. He is a perfect example of why Mark Twain famously stated that political appointees and politicians should be changed like diapers: often and for the same reason. Perhaps no state in the country has as flawed set of EMS operations as Maryland does. The rampant abuse of helicopter transport, the regressive "mother-may-I?" protocols and the Mafia-like grasp MIEMSS exacts upon the state's prehospital care providers have done nothing to further the delivery of state-of-the-art care, unless you believe that medical care has not advanced since the death of R Adams Cowley (circa October 1991).
Last week, Dr. Bass further demonstrated his blatant disregard for the lives of the EMS personnel who practice under his authority, those of the patients those professionals are charged with tending to and the reputations of his state and all those associated with prehospital emergency care in it. I refer my readers to an article in the Washington Post (http://www.washingtonpost.com/wp-dyn/content/article/2008/11/01/AR2008110101884.html) in which he was paraphrased as stating:
"He said the flight was justified because the vehicle damage paramedics observed could have indicated patients with internal injuries."
Apparently he did not read the literature that states that the particular mechanism of injury (MOI) trauma criteria that Maryland relies upon so heavily you would have thought Moses carried it down Mt. Sinai on a tablet of stone-including the criterion he is trying to cite here- has been found to not be reliable or predictive of serious injuries in otherwise stable trauma patients.
"Some state lawmakers also have been critical of the program, saying the way Maryland's emergency workers are taught to evaluate potential internal injuries results in "overtriage" and many unnecessary airlifts. "
That is putting it extremely mildly. Over half of the flights turned out to not be necessary and even that is an underestimate of the problem given the proximity of many of these patients to trauma centers by ground transportation. Maryland is probably one of the most densely packed states when it comes to the presence of registered trauma centers, both Level I and Level II. The difference between the two is for all intents and purposes for the immediate stabilization of trauma patients is minimal enough to make either an equally acceptable destination for all but a minority of patients.
Dr. Bass and his colleague, Dr. Thomas Scalea (a man whom I previously held in regard reserved for only a select few, and still consider to be a very intelligent man and a very talented surgeon) continue to argue that the endangering the lives of many and adding excessive costs to the treatment of thousands of trauma patients is a worthwhile practice because it may save a handful of people. Keep in mind, the cost to the residents of Maryland for the operation of the State Police helicopters annually- something on the order of $12-14 million depending upon which source you rely upon- is enough to provide preventative care to most, if not every child in the state. Such an action would save far more lives and I can't recall the last time I heard of a health care worker dying because of an accident during administration of childhood vaccination.
Now, this coming out of the mouth of Dr. Scalea astounded me. He is probably one of the most intelligent people in trauma care- albeit one who has downed a bit too much of the Cowley Kool-aid over the years, but we all have our little quirks from those who trained us in our respective professions- so to hear him brush aside a wealth of literature was shocking and depressing. I expected such bullshit from Dr. Bass, who has made a profession out of maintaining the status quo- because a sea change would likely cost him his beloved position of near God-like authority.
The triage discrepancy came to light late last week in about 16 minutes of taped communications between responders and dispatchers released by Bass's agency. The initial Category D assessment was first reported by the Baltimore Sun.
To give my non-medical readers some scale, if you trip and scrape your knees and palms on the streets of Baltimore and someone overreacts and calls an ambulance, you would be a Category D trauma patient. Does anyone else still think this flight was in any way, shape or form defensible?
Keeping in mind that comment about my dedication to personal accountability, the thing I can not begin to understand is how- given his lies, his posturing and all of the other examples of his disdain for quality improvement- this man, this physician, this otherwise intelligent man (I've met him in person before, albeit briefly....he is not stupid by the definition most commonly cited) can be allowed to be allowed to continue to occupy a position that is penultimately responsible for the quality improvement of emergency medicine in the prehospital environment in Maryland.
More importantly, and somewhat more emphatically, how does one justify leaving Dr. Bass- with what seems to be his blatant and persistent disregard for the safety of those in his charge and their patients- maintain himself in a position where he is in many ways, the person who should be leading the charge to assure the safety of EMS providers in Maryland? The best answer I can give at this time- short of simply attributing it to either the apathy of those who are above him in the state government food chain or some form of political corruption- is that he has done thus far an above par job of bullshitting his superiors which is a laudable skill in situations where it is not getting people killed. Let us hope he comes to his senses soon or is forced to at least keep his opinions regarding aeromedical operations to himself and his dwindling group of supporters. If he does not learn, let us hope he finds himself seeking a new employer before we are burying more of our colleagues. Perhaps his attempt at a whitewash with this little panel of his will backfire....who knows how this will end, but I sincerely hope that we do not have to have another year like this one to achieve the needed changes.
At least, there should be a state investigation of his dealings, given the power he wields and the fraud, waste and abuse of government funds by his office on personal sacred cow projects with no merit. Any state department head whose operating budget can not be justified by the best evidence available would be called to account for his actions, why not the state medical director? I honestly don't believe he is doing this to be malevolent or just to be an ass (other than having a chip on his shoulder, he seemed like a nice enough guy), I think he is acting in what he deems to be the best interests of EMS in the State of Maryland, but as the saying goes, the road to hell is paved with the best of intentions. In medicine, personal opinions and disproven notions have no place in anywhere but the history books. It is my sincere hope that Dr. Bass and his colleagues learn this lesson soon. Otherwise someone (the Governor? The state legislature?) may have to forcibly remove him from office in order to change the marching cadence of Maryland EMS from
"It puts the patient in the helicopter, or it gets the hose again", as one of the brightest bloggers commenting on EMS today (Rogue Medic) so eloquently stated.
The second is summed up by the second clause of the professor's statement: I hold everyone to the same standards- extreme as they may be- that I hold myself to. If you are not at the top of your game, then please find the door or I will do the debate equivalent of tearing your heart out of your chest and taking a bite out of it like some form of evidence-based practice espousing latter day Aztec priest.
The final point one has to recognize about my personality is that I believe in absolute personal responsibility so far as it is possible. That is one of the reasons I am such a staunch and unyielding detractor of the current medical director of the Maryland Institute of Emergency Medical Services, Dr. Robert Bass. He is a perfect example of why Mark Twain famously stated that political appointees and politicians should be changed like diapers: often and for the same reason. Perhaps no state in the country has as flawed set of EMS operations as Maryland does. The rampant abuse of helicopter transport, the regressive "mother-may-I?" protocols and the Mafia-like grasp MIEMSS exacts upon the state's prehospital care providers have done nothing to further the delivery of state-of-the-art care, unless you believe that medical care has not advanced since the death of R Adams Cowley (circa October 1991).
Last week, Dr. Bass further demonstrated his blatant disregard for the lives of the EMS personnel who practice under his authority, those of the patients those professionals are charged with tending to and the reputations of his state and all those associated with prehospital emergency care in it. I refer my readers to an article in the Washington Post (http://www.washingtonpost.com/wp-dyn/content/article/2008/11/01/AR2008110101884.html) in which he was paraphrased as stating:
"He said the flight was justified because the vehicle damage paramedics observed could have indicated patients with internal injuries."
Apparently he did not read the literature that states that the particular mechanism of injury (MOI) trauma criteria that Maryland relies upon so heavily you would have thought Moses carried it down Mt. Sinai on a tablet of stone-including the criterion he is trying to cite here- has been found to not be reliable or predictive of serious injuries in otherwise stable trauma patients.
"Some state lawmakers also have been critical of the program, saying the way Maryland's emergency workers are taught to evaluate potential internal injuries results in "overtriage" and many unnecessary airlifts. "
That is putting it extremely mildly. Over half of the flights turned out to not be necessary and even that is an underestimate of the problem given the proximity of many of these patients to trauma centers by ground transportation. Maryland is probably one of the most densely packed states when it comes to the presence of registered trauma centers, both Level I and Level II. The difference between the two is for all intents and purposes for the immediate stabilization of trauma patients is minimal enough to make either an equally acceptable destination for all but a minority of patients.
Dr. Bass and his colleague, Dr. Thomas Scalea (a man whom I previously held in regard reserved for only a select few, and still consider to be a very intelligent man and a very talented surgeon) continue to argue that the endangering the lives of many and adding excessive costs to the treatment of thousands of trauma patients is a worthwhile practice because it may save a handful of people. Keep in mind, the cost to the residents of Maryland for the operation of the State Police helicopters annually- something on the order of $12-14 million depending upon which source you rely upon- is enough to provide preventative care to most, if not every child in the state. Such an action would save far more lives and I can't recall the last time I heard of a health care worker dying because of an accident during administration of childhood vaccination.
Now, this coming out of the mouth of Dr. Scalea astounded me. He is probably one of the most intelligent people in trauma care- albeit one who has downed a bit too much of the Cowley Kool-aid over the years, but we all have our little quirks from those who trained us in our respective professions- so to hear him brush aside a wealth of literature was shocking and depressing. I expected such bullshit from Dr. Bass, who has made a profession out of maintaining the status quo- because a sea change would likely cost him his beloved position of near God-like authority.
The triage discrepancy came to light late last week in about 16 minutes of taped communications between responders and dispatchers released by Bass's agency. The initial Category D assessment was first reported by the Baltimore Sun.
To give my non-medical readers some scale, if you trip and scrape your knees and palms on the streets of Baltimore and someone overreacts and calls an ambulance, you would be a Category D trauma patient. Does anyone else still think this flight was in any way, shape or form defensible?
The tapes also revealed an exchange between a state police helicopter dispatcher and pilot Stephen J. Bunker that suggested at least a perception among Maryland State Police that they are often called to transport accident victims from the Waldorf area. In the tape, Bunker asked where he was being deployed and the dispatcher responded, "Waldorf, where else?" Bass said. Bunker died in the crash.
"The comment was that they would not frequently drive," Bass said. "We heard that, went back and looked at it, and found nothing to substantiate the comment." He said an analysis of requested rescue flights by county and population showed that Eastern Shore counties request airlifts more often.
How about a county-by-county breakdown? If they really looked into this (note: I have my doubts), it should not be a problem to put that data out there. This sounds remarkably like a further dismissal of the concerns of anyone who does not bow down and pray at the altar of the Church of St. Robert of Miemms. Anyone who questions his opinions, his papal bulls, or the other longheld beliefs- regardless of the evidence against them- is simply wrong and to be dismissed or deemed not even worthy of a response. It is cheaper just to ignore the problem, than to actually teach the EMTs and medics the correct knowledge and to equip them to use it.Keeping in mind that comment about my dedication to personal accountability, the thing I can not begin to understand is how- given his lies, his posturing and all of the other examples of his disdain for quality improvement- this man, this physician, this otherwise intelligent man (I've met him in person before, albeit briefly....he is not stupid by the definition most commonly cited) can be allowed to be allowed to continue to occupy a position that is penultimately responsible for the quality improvement of emergency medicine in the prehospital environment in Maryland.
More importantly, and somewhat more emphatically, how does one justify leaving Dr. Bass- with what seems to be his blatant and persistent disregard for the safety of those in his charge and their patients- maintain himself in a position where he is in many ways, the person who should be leading the charge to assure the safety of EMS providers in Maryland? The best answer I can give at this time- short of simply attributing it to either the apathy of those who are above him in the state government food chain or some form of political corruption- is that he has done thus far an above par job of bullshitting his superiors which is a laudable skill in situations where it is not getting people killed. Let us hope he comes to his senses soon or is forced to at least keep his opinions regarding aeromedical operations to himself and his dwindling group of supporters. If he does not learn, let us hope he finds himself seeking a new employer before we are burying more of our colleagues. Perhaps his attempt at a whitewash with this little panel of his will backfire....who knows how this will end, but I sincerely hope that we do not have to have another year like this one to achieve the needed changes.
At least, there should be a state investigation of his dealings, given the power he wields and the fraud, waste and abuse of government funds by his office on personal sacred cow projects with no merit. Any state department head whose operating budget can not be justified by the best evidence available would be called to account for his actions, why not the state medical director? I honestly don't believe he is doing this to be malevolent or just to be an ass (other than having a chip on his shoulder, he seemed like a nice enough guy), I think he is acting in what he deems to be the best interests of EMS in the State of Maryland, but as the saying goes, the road to hell is paved with the best of intentions. In medicine, personal opinions and disproven notions have no place in anywhere but the history books. It is my sincere hope that Dr. Bass and his colleagues learn this lesson soon. Otherwise someone (the Governor? The state legislature?) may have to forcibly remove him from office in order to change the marching cadence of Maryland EMS from
"It puts the patient in the helicopter, or it gets the hose again", as one of the brightest bloggers commenting on EMS today (Rogue Medic) so eloquently stated.
Friday, October 24, 2008
Touching Base and Pissing People Off at the Same Time
It has been quite a while since I last posted, and for that I do apologize to anyone who had been expecting more frequent postings. Hopefully the next year will have a little more free time to allow me to keep up with this blog.
The past year has seen my research and the related matters grow exponentially. The database project now has data for 1071 cases, with another several hundred expected by the end of the year. The amount of time this project has consumed has been astronomical but it is still a worthy cause to spend my time at (to paraphrase Teddy Roosevelt's Citizenship in a Republic). To the outside observer, this is the boring side of my work, so I will let what has already been said regarding it suffice for now.
The part of the project, or to be more precise, the sideline of it that has attracted the most attention, hate mail, nasty phone calls and the occasional loogie has been my involvement with the debate over the utility of the widespread use of helicopters for the transport of critically ill and injured persons. The problem arises because of two factors:
-An appalling death toll of pilots, paramedics, EMTs and patients over the past few years and especially this year
-The misguided belief amongst the public and a portion of the medical community (from doctors down to the newest first responder) that helicopters speed the patient to a trauma center faster than a ground ambulance. Those who hold this faith- and that's what it really is, something akin to the belief in a particular deity because of the lack of evidence to support their stance- will vehemently accuse the other side of a bias and ignore the evidence they bring to the table whilst refusing to support their own stance with anything more than hyperbole. The best description of how many of them handle being confronted is to ask the reader to picture a young girl who doesn't want to hear what her friend is telling her so she sticks her fingers in her ears and walks away going "Lalalalalalalalalaala! I can't hear you! Lalalalalalalalala".
The problem with the aeromedical advocates' demand that the critics of the excessive use of helicopters prove that helicopters are not effective (beyond the fact that it has already been proven to the satisfaction of many) is that this is contrary to how science works. I'll use the example of someone who believes in Sasquatch (aka Bigfoot). If they want to prove the creature exists (which it may or may not...I don't dismiss it out of hand, but I have yet to see anything I as a scientifically minded person would consider conclusive), the burden of proof is on them to provide the evidence demanded by the rest of the scientific community.
This standard is widely accepted: the person(s) making the outlandish, excessively expensive, or hazardous claim has to prove that their stance is the correct one. However, the aeromedical community has taken a page from the ranks of "ufologists" (aka crackpots who believe in aliens) and claimed that more or less there is some sort of bias against their precious stance and that there is evidence to support their claim (which no one seems to be able to produce in amounts even resembling statistical significance) and that the vast volume of literature out there criticizing the abuse of helicopters is simply the product of what has all but been called a vast conspiracy against them.
Now, my take on this- as someone primarily interested in not letting people get killed in aircraft crashes if it can be avoided and as someone who worked in EMS for several years and has lost three people he knew or worked with (two I knew well, one I had met on a couple of occasions) this year alone in crashes- is that helicopters DO have their place in emergency and critical care medicine. They honestly belong in situations where it actually is more feasible for the time delays associated with calling for the helicopter is less than the ground transport time of the local ambulance service. They should not be used for the convenience of the ground providers, they should not be used to obviate the need to further educate the local EMS providers and they certainly should not be launched on the basis of disproven and misguided "mechanism of injury" standards.
The air ambulance operations need to adopt and, more importantly, abide by standards regarding weather conditions under which flights are permissible. Likewise, all flights should be flown with two pilots, with both having access to full instrument panels and otherwise equipped with the features deemed necessary by the NTSB, etc such as terrain awareness and warning systems, night vision, etc. Conducting flights without such restrictions and equipment is tantamount to reckless endangerment of flight crews and can not be tolerated.
The past year has seen my research and the related matters grow exponentially. The database project now has data for 1071 cases, with another several hundred expected by the end of the year. The amount of time this project has consumed has been astronomical but it is still a worthy cause to spend my time at (to paraphrase Teddy Roosevelt's Citizenship in a Republic). To the outside observer, this is the boring side of my work, so I will let what has already been said regarding it suffice for now.
The part of the project, or to be more precise, the sideline of it that has attracted the most attention, hate mail, nasty phone calls and the occasional loogie has been my involvement with the debate over the utility of the widespread use of helicopters for the transport of critically ill and injured persons. The problem arises because of two factors:
-An appalling death toll of pilots, paramedics, EMTs and patients over the past few years and especially this year
-The misguided belief amongst the public and a portion of the medical community (from doctors down to the newest first responder) that helicopters speed the patient to a trauma center faster than a ground ambulance. Those who hold this faith- and that's what it really is, something akin to the belief in a particular deity because of the lack of evidence to support their stance- will vehemently accuse the other side of a bias and ignore the evidence they bring to the table whilst refusing to support their own stance with anything more than hyperbole. The best description of how many of them handle being confronted is to ask the reader to picture a young girl who doesn't want to hear what her friend is telling her so she sticks her fingers in her ears and walks away going "Lalalalalalalalalaala! I can't hear you! Lalalalalalalalala".
The problem with the aeromedical advocates' demand that the critics of the excessive use of helicopters prove that helicopters are not effective (beyond the fact that it has already been proven to the satisfaction of many) is that this is contrary to how science works. I'll use the example of someone who believes in Sasquatch (aka Bigfoot). If they want to prove the creature exists (which it may or may not...I don't dismiss it out of hand, but I have yet to see anything I as a scientifically minded person would consider conclusive), the burden of proof is on them to provide the evidence demanded by the rest of the scientific community.
This standard is widely accepted: the person(s) making the outlandish, excessively expensive, or hazardous claim has to prove that their stance is the correct one. However, the aeromedical community has taken a page from the ranks of "ufologists" (aka crackpots who believe in aliens) and claimed that more or less there is some sort of bias against their precious stance and that there is evidence to support their claim (which no one seems to be able to produce in amounts even resembling statistical significance) and that the vast volume of literature out there criticizing the abuse of helicopters is simply the product of what has all but been called a vast conspiracy against them.
Now, my take on this- as someone primarily interested in not letting people get killed in aircraft crashes if it can be avoided and as someone who worked in EMS for several years and has lost three people he knew or worked with (two I knew well, one I had met on a couple of occasions) this year alone in crashes- is that helicopters DO have their place in emergency and critical care medicine. They honestly belong in situations where it actually is more feasible for the time delays associated with calling for the helicopter is less than the ground transport time of the local ambulance service. They should not be used for the convenience of the ground providers, they should not be used to obviate the need to further educate the local EMS providers and they certainly should not be launched on the basis of disproven and misguided "mechanism of injury" standards.
The air ambulance operations need to adopt and, more importantly, abide by standards regarding weather conditions under which flights are permissible. Likewise, all flights should be flown with two pilots, with both having access to full instrument panels and otherwise equipped with the features deemed necessary by the NTSB, etc such as terrain awareness and warning systems, night vision, etc. Conducting flights without such restrictions and equipment is tantamount to reckless endangerment of flight crews and can not be tolerated.
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