have we set the bar too high? bryan e. bledsoe, do, facep unlv bryan e. bledsoe, do, facep unlv

Have We Set the Bar Too High?

Have We Set the Bar Too High?

Bryan E. Bledsoe, DO, FACEP

UNLV

Bryan E. Bledsoe, DO, FACEP

UNLV

The EMS ImageThe EMS Image


http://www.pasty.com/order.html


“You wanted to be a doctor, maybe you

should have buckled down a little more in

high school.”

The ProblemThe Problem

System PerformanceCustomer Satisfaction =

Customer Expectations

The ProblemThe Problem

Our customers have expectations we can

never meet!


WE RAISE THE

DEAD!

We Raise the DeadWe Raise the Dead

Researchers watched all 1994-1995 episodes of ER and Chicago Hope.

Watched 50 consecutive episodes of Rescue 911.

Findings:65% of cardiac arrests occurred in children, teenagers or young adults.

75% survived the initial arrest.

67% survived to discharge.

Researchers watched all 1994-1995 episodes of ER and Chicago Hope.

Watched 50 consecutive episodes of Rescue 911.

Findings:65% of cardiac arrests occurred in children, teenagers or young adults.

75% survived the initial arrest.

67% survived to discharge.

Diem SJ, Lantos JD, Tulsky JA: “Cardiopulmonary resuscitation on television. Miracles and misinformation.” New England Journal of Medicine. 133:1578–1582, 1996.


Los Angeles, CA:1-year study (1JUL00-1JUL01).

2,021 consecutive cardiac arrests.

1,700 met entry criteria as a primary cardiac event.

28% received bystander CPR.

Los Angeles, CA:1-year study (1JUL00-1JUL01).

2,021 consecutive cardiac arrests.

1,700 met entry criteria as a primary cardiac event.

28% received bystander CPR.


Results:1.4% survived neurologically intact.

6.1% survived from bystander-witnessed ventricular fibrillation.

2.1% survival with bystander CPR.

3.2% survival with witnessed arrest and bystander CPR.

1% survival without bystander CPR.

Results:1.4% survived neurologically intact.

6.1% survived from bystander-witnessed ventricular fibrillation.

2.1% survival with bystander CPR.

3.2% survival with witnessed arrest and bystander CPR.

1% survival without bystander CPR.

Eckstein M, Stratton SJ, Chan LS: “Cardiac Arrest Resuscitation in Los Angeles: CARE-LA.” Annals of Emergency Medicine. 45:504–509, 2005.


Mechanical CPR devices have not been shown to improve outcomes.

Some actually worsen CPR outcomes.

Tucson IRB stopped multi-center RCT

Yet, many FDs still spend hundreds of thousands of dollars on these.

Mechanical CPR devices have not been shown to improve outcomes.

Some actually worsen CPR outcomes.

Tucson IRB stopped multi-center RCT

Yet, many FDs still spend hundreds of thousands of dollars on these.


Civilian Trauma deaths occur in a trimodal distribution:

Death within minutes = 50%Neurologic and vascular injuries.

Death within hours = 30%Hypoxia and hypovolemia.

Death within days = 20%Sepsis, MODS and other complications.

Civilian Trauma deaths occur in a trimodal distribution:

Death within minutes = 50%Neurologic and vascular injuries.

Death within hours = 30%Hypoxia and hypovolemia.

Death within days = 20%Sepsis, MODS and other complications.

Trunkey DD: “Trauma.” Scientific American. 249:220–227, 1983.


No change in survival for the first group since the Crimean war.

No change in survival for the first group since the Crimean war.


Despite 30+ years of EMS, and the expenditure of billions of dollars, dead people remain dead.


“Insanity: Doing the same thing over and over and expecting a different result.”

John Dryden

The Spanish Friar (Act II, Scene 1)

“Insanity: Doing the same thing over and over and expecting a different result.”

John Dryden

The Spanish Friar (Act II, Scene 1)


This begs the question:Why do we put so much money and resources into cardiac arrest management when the out-of-hospital survival rate remains abysmally miniscule?

This begs the question:Why do we put so much money and resources into cardiac arrest management when the out-of-hospital survival rate remains abysmally miniscule?


IF We DON’T SAVE

THEM, THEHOSPITAL

WILL!

Hospital will Save ThemHospital will Save Them

Most Australian paramedics have never done CPR in a moving ambulance.

Most Australian paramedics have never done CPR in a moving ambulance.


NAEMSP has had a position paper on field termination of out-of-hospital non-traumatic cardiac arrest since 1999.

Bailey ED, Wydro GC, Cone DC.

Termination of Resuscitation in the Prehospital Setting for Adult Patients Suffering Nontraumatic Cardiac

Arrest. Prehosp Emerg Care. 2000;4:190-195

NAEMSP has had a position paper on field termination of out-of-hospital non-traumatic cardiac arrest since 1999.

Bailey ED, Wydro GC, Cone DC.

Termination of Resuscitation in the Prehospital Setting for Adult Patients Suffering Nontraumatic Cardiac

Arrest. Prehosp Emerg Care. 2000;4:190-195


NAEMSP and the American College of Surgeons has had a position paper on the termination of traumatic cardiac arrest since 2002.

Hopson LR, Hirsh E, Delgado J,

Dormier RM, McSwain NE, Krohmer J. Guidelines for Withholding or

Termination of Resuscitation in Prehospital Traumatic

Cardiopulmonary Arrest. Prehosp Emerg Care. 2003;7:141-146

NAEMSP and the American College of Surgeons has had a position paper on the termination of traumatic cardiac arrest since 2002.

Hopson LR, Hirsh E, Delgado J,

Dormier RM, McSwain NE, Krohmer J. Guidelines for Withholding or

Termination of Resuscitation in Prehospital Traumatic

Cardiopulmonary Arrest. Prehosp Emerg Care. 2003;7:141-146


336 prospective and 135 retrospective cases of OOHCA.

12 patients survived to discharge (none met criteria for field TOR).

63 patients survived to admission, 4 were eligible for TOR.

None of these 4 survived to discharge.

336 prospective and 135 retrospective cases of OOHCA.

12 patients survived to discharge (none met criteria for field TOR).

63 patients survived to admission, 4 were eligible for TOR.

None of these 4 survived to discharge.

Conclusion: Protocol 100% specific for lack of survival from OOHCA.

Cone CD, Bailey ED, Spackman

AB. The Safety of Field Termination-of- Resuscitation Protocol. Prehosp

Emerg Care. 2005;9:276-281

Conclusion: Protocol 100% specific for lack of survival from OOHCA.

Cone CD, Bailey ED, Spackman

AB. The Safety of Field Termination-of- Resuscitation Protocol. Prehosp

Emerg Care. 2005;9:276-281


1,068 victims of OOHCA treated by Memphis FD.

310 (29%) had ROSC prior to transport.

Admitted: 69%

Discharged alive: 26.5%

758 (71%) never regained a pulse and were transported with CPR underway.

Admitted: 7.0%

Discharged alive: 0.4%††-All had moderate-severe CNS

disability.

1,068 victims of OOHCA treated by Memphis FD.

310 (29%) had ROSC prior to transport.

Admitted: 69%

Discharged alive: 26.5%

758 (71%) never regained a pulse and were transported with CPR underway.

Admitted: 7.0%

Discharged alive: 0.4%††-All had moderate-severe CNS

disability.

“Rapid transport of adults who fail to respond to an adequate trial of prehospital ACLS does not result in meaningful rates of survival.”

Kellerman AL, Hackman BB, Somes G. Predicting the Outcome of

Unsuccessful Prehospial Advanced Life Support. JAMA. 1993;270:1433- 1436

“Rapid transport of adults who fail to respond to an adequate trial of prehospital ACLS does not result in meaningful rates of survival.”

Kellerman AL, Hackman BB, Somes G. Predicting the Outcome of

Unsuccessful Prehospial Advanced Life Support. JAMA. 1993;270:1433- 1436


189 pediatric patients with OOHCA studied:

39 (20.6%) received BLS only

150 (79.4%) received ALS.

5 (2.6%) survived to discharge.

No significant improvement in survival in those who received ALS.

189 pediatric patients with OOHCA studied:

39 (20.6%) received BLS only

150 (79.4%) received ALS.

5 (2.6%) survived to discharge.

No significant improvement in survival in those who received ALS.

Those likely to survive had a sinus rhythm and received fewer doses of epinephrine in the ED.

ALS does not improve survival in pediatric OOHCA.

Pitetti R, Glustein JZ, Bhende MS. Prehospital Care and Outcome of Pediatric Out-of-Hospital Cardiac Arrest. Prehosp Emerg Care.

2002;6:283-90

Those likely to survive had a sinus rhythm and received fewer doses of epinephrine in the ED.

ALS does not improve survival in pediatric OOHCA.

Pitetti R, Glustein JZ, Bhende MS. Prehospital Care and Outcome of Pediatric Out-of-Hospital Cardiac Arrest. Prehosp Emerg Care.

2002;6:283-90


LA and Orange County (CA) SIDS study:

114 SIDS patients

6 (5%) had ROSC

0 (0%) survived

50 (44%) received lights and siren transport.

LA and Orange County (CA) SIDS study:

114 SIDS patients

6 (5%) had ROSC

0 (0%) survived

50 (44%) received lights and siren transport.

“Given that there were no survivors, new prehospital policies are needed governing the use of lights and sirens, resuscitation decisions including termination of resuscitation.”

Smith MP, Kaji A, Young KD, Gausche-Hill M. Presentation

and Survival of Apparent Prehospital Sudden Infant Death Syndrome. Prehosp Emerg Care.

2005;9:181- 185

“Given that there were no survivors, new prehospital policies are needed governing the use of lights and sirens, resuscitation decisions including termination of resuscitation.”

Smith MP, Kaji A, Young KD, Gausche-Hill M. Presentation

and Survival of Apparent Prehospital Sudden Infant Death Syndrome. Prehosp Emerg Care.

2005;9:181- 185


235 OOHCA patients:131 (56%) met criteria for TOR.

All expired at the hospital.

No mitigating reasons found to justify transport.

TOR protocols are not being followed.

O’Brian E, Hendricks D, Cone CD. Field Termination of Resuscitation: Analysis of a Newly-Implemented Protocol. Prehosp Emerg Care. 2008;12:56-61

235 OOHCA patients:131 (56%) met criteria for TOR.

All expired at the hospital.

No mitigating reasons found to justify transport.

TOR protocols are not being followed.

O’Brian E, Hendricks D, Cone CD. Field Termination of Resuscitation: Analysis of a Newly-Implemented Protocol. Prehosp Emerg Care. 2008;12:56-61


This begs the question:Why do we put our resources and personnel at risk in transporting CPR cases when the results are always futile?

This begs the question:Why do we put our resources and personnel at risk in transporting CPR cases when the results are always futile?

The “Golden Hour” existsThe “Golden Hour” exists

“Patients must arrive at a trauma center within one hour of their injury in order to have their best chance of survival.”

R. Adams Cowley, MD

“Patients must arrive at a trauma center within one hour of their injury in order to have their best chance of survival.”

R. Adams Cowley, MD


The concept of the “Golden Hour” was developed to promote the newly-opened University of Maryland “Shock Trauma” center.

The concept of the “Golden Hour” was developed to promote the newly-opened University of Maryland “Shock Trauma” center.

The “Golden Hour” exists.The “Golden Hour” exists.

“This article discusses a detailed literature and historical records search for support of the ‘Golden Hour’ concept. None is identified.”

“This article discusses a detailed literature and historical records search for support of the ‘Golden Hour’ concept. None is identified.” Lerner ED, Moscatti RM: “The Golden

Hour: Scientific Fact or Medical ‘Urban Legend’?” Academic Emergency Medicine. 8:758–760, 2001.


Nobody wants to talk about the false notion of a “Golden Hour” because it so shakes the roots of EMS and trauma care.”

Nobody wants to talk about the false notion of a “Golden Hour” because it so shakes the roots of EMS and trauma care.”


Our old trauma practices may have been harming more patients than it was helping.

Large volume crystalloids.

Endotracheal intubation.

Our old trauma practices may have been harming more patients than it was helping.

Large volume crystalloids.

Endotracheal intubation.


This begs the question:Why are we putting our personnel and patients at risk to meet the constraints of the ‘Golden Hour’ when there is no evidence that the ‘Golden Hour’ exists?

This begs the question:Why are we putting our personnel and patients at risk to meet the constraints of the ‘Golden Hour’ when there is no evidence that the ‘Golden Hour’ exists?

Lights and Sirens Save LivesLights and Sirens Save Lives

LIGHTS & SIRENS SAVE LIVES


In a North Carolina, Hunt and colleagues found only a 43.5 second mean time savings with lights and siren compared to transport without lights and siren.

In a North Carolina, Hunt and colleagues found only a 43.5 second mean time savings with lights and siren compared to transport without lights and siren.

Hunt RC, Brown LH, Cabinum TW et al. Is ambulance transport time with lights and siren faster than that without? Annals of Emergency Medicine. 1995;25(4):507-511


Upper New York (Syracuse) study.

“L&S reduce ambulance response times by an average of 1 minute, 46 seconds. Although statistically significant, this time saving is likely to be clinically relevant in only a very few cases.”

Upper New York (Syracuse) study.

“L&S reduce ambulance response times by an average of 1 minute, 46 seconds. Although statistically significant, this time saving is likely to be clinically relevant in only a very few cases.”

Brown LH, Whitney CL, Hunt RC, et al. Do warning lights and sirens reduce ambulance response times? Prehospital Emergency Care. 2000;4(1):70-74


Pediatrics?“In our preliminary study, inappropriate use of L&S in the transport of pediatric patients in stable condition is common.”

Pediatrics?“In our preliminary study, inappropriate use of L&S in the transport of pediatric patients in stable condition is common.”

Lacher ME, Bauscher JC. Lights and sirens in pediatric 911 transports. Are they being misused? Annals of Emergency Medicine. 1997;29(2):223-227


A 1994 study evaluated patient outcomes when an EMS agency used a medical protocol directing the use of lights and siren.

They found, “No adverse outcomes were identified as related to non-L&S transport.”

A 1994 study evaluated patient outcomes when an EMS agency used a medical protocol directing the use of lights and siren.

They found, “No adverse outcomes were identified as related to non-L&S transport.”

Kupas DF, Dula DJ, Pino BJ. Patient outcome using medical protocol to limit “lights and siren transport. Prehosp Diast Med. 1994:9(4):226-229


In any endeavor you must weigh the benefits and the risks.

With lights and siren transport, the “clinical benefits” do not outweigh the risks for the vast majority of patients.


This begs the question:“Why do we continue to endanger our

employees and our patients by significantly overusing lights and sirens response?


employees and our patients by significantly overusing lights and sirens response?


IF WE CAN GET THERE

IN 7 MINUTES, 59 SECONDS,

YOU’LL LIVE!

7 Minutes, 59 Seconds (90%)7 Minutes, 59 Seconds (90%)

Where is the safest place in America to have your cardiac arrest?

Where is the safest place in America to have your cardiac arrest?

7 minutes, 59 seconds (90%)7 minutes, 59 seconds (90%)

The time it takes to travel between two points is determined by speed.

Speed can be affected by:

Traffic

Road conditions

Vehicle conditions

Operator experience

The time it takes to travel between two points is determined by speed.

Speed can be affected by:

Traffic

Road conditions

Vehicle conditions

Operator experience


EMS “visionaries” have set 8 minutes (7 minutes, 59 seconds [90% of the time]) as the goal for an EMS response.

This time interval was based purely on rational conjecture and not a shred of science.

EMS “visionaries” have set 8 minutes (7 minutes, 59 seconds [90% of the time]) as the goal for an EMS response.

This time interval was based purely on rational conjecture and not a shred of science.


Various strategies have been proposed to decrease travel times.

It is impossible, with any degree of accuracy, to predict when and where an EMS call will occur.

Various strategies have been proposed to decrease travel times.

It is impossible, with any degree of accuracy, to predict when and where an EMS call will occur.


What does the science tell us?What does the science tell us?

Response times less than 4 minutes are highly

correlated with increased survival.


OPALS study:9,273 patients treated

4.2% survival

6.2 minute defibrillation response time.

“There was a steep decrease in the first 5 minutes of the survival curve, beyond which the slope gradually leveled off. Controlling for known covariates, the decrement in the odds of survival with increasing response interval was 0.77 per minute (95% confidence interval 0.74 to 0.83).”

OPALS study:9,273 patients treated

4.2% survival

6.2 minute defibrillation response time.

“There was a steep decrease in the first 5 minutes of the survival curve, beyond which the slope gradually leveled off. Controlling for known covariates, the decrement in the odds of survival with increasing response interval was 0.77 per minute (95% confidence interval 0.74 to 0.83).”

De Maio VJ, Stiell IG, Wells GA, Spaite DW; Ontario Prehospital Advanced Life Support Study Group: “Optimal defibrillation response intervals for maximum out-of-hospital cardiac arrest survival rates.” Annals of Emergency Medicine. 42(2):242–250, 2003.


How many EMS systems can guarantee a 4 minute response time?

How many EMS systems can guarantee a 4 minute response time?


A paramedic response time of 8 minutes was not associated with improved survival to hospital discharge.

A response time of 4 minutes did improve survival in patients with moderate to high risk of mortality.

A paramedic response time of 8 minutes was not associated with improved survival to hospital discharge.

A response time of 4 minutes did improve survival in patients with moderate to high risk of mortality.

Pons PT, Markovchick VJ: “Eight minutes or less: Does the ambulance response time guideline impact trauma patient outcome?” Journal of Emergency Medicine. 23(1):43–48, 2002.


“Our data are most consistent with the inference that neither the mortality or frequency of critical procedural interventions performed in the field vary substantially based upon this pre-specified (10 min, 59 sec) ALS response time.”

“Our data are most consistent with the inference that neither the mortality or frequency of critical procedural interventions performed in the field vary substantially based upon this pre-specified (10 min, 59 sec) ALS response time.” Blackwell TH, Kline J, Willis J, et al. Lack

of association between prehospital response times and patient outcomes. Prehospital Emergency Care. 2007;11(1):115


Pennsylvania Study:

“Although response times were differentiated by location, they were not necessarily predictive of survival. Factors other than response time such as patient population or resuscitation skill could influence survival from cardiac arrest occurring in diverse prehospital service areas.”

Pennsylvania Study:

“Although response times were differentiated by location, they were not necessarily predictive of survival. Factors other than response time such as patient population or resuscitation skill could influence survival from cardiac arrest occurring in diverse prehospital service areas.” Vukmir RM, Sodium Bicarbonate Study

Group. The influence of urban, suburban, or rural locale on survival from refractory cardiac arrest. American Journal of Emergency Medicine. 2004;22(2):90-93


UK Study:

“Overall, there is little evidence in the data that faster response times have led to better outcomes.”

“The number of patients who might benefit from a fast response is actually very small and the benefit in this small group is being ‘lost’ in the larger group who do not need fast response.”

UK Study:

“Overall, there is little evidence in the data that faster response times have led to better outcomes.”

“The number of patients who might benefit from a fast response is actually very small and the benefit in this small group is being ‘lost’ in the larger group who do not need fast response.”

Turner J, O’Keefe C, Dixon S, Warren K, Nicholl J: The Costs and Benefits of Changing Ambulance Response Time Performance Standards. Medical Care Research Unit School of Health and Related Research, University of Sheffield. 2006



employees and our patients by setting artificial response times that have no correlation with patient outcomes?


employees and our patients by setting artificial response times that have no correlation with patient outcomes?

Helicopters Save LivesHelicopters Save Lives

1998 1999 2000 2001 2002 2003 2004 2005 20060

100200300400500600700800900

1000

US Medical Helicopters

Medical HelicoptersMedical Helicopters

In 2002, Medicare increased the rates for medical helicopter transport.Price for airlift ranges from $5,000 to $10,000, 5 to 10 times that of a ground ambulance. Helicopters in the US have doubled from a decade ago; and with more of them scrambling for business, specialists say that emergency personnel are feeling more pressure to use them. In 2004, the number of flights paid for by Medicare alone was 58 percent higher than in 2001. Spending by Medicare has more than doubled to $103 million over the same period.

In 2002, Medicare increased the rates for medical helicopter transport.Price for airlift ranges from $5,000 to $10,000, 5 to 10 times that of a ground ambulance. Helicopters in the US have doubled from a decade ago; and with more of them scrambling for business, specialists say that emergency personnel are feeling more pressure to use them. In 2004, the number of flights paid for by Medicare alone was 58 percent higher than in 2001. Spending by Medicare has more than doubled to $103 million over the same period.


In FY 2001, the University of Michigan’s flight program “Survival Flight”:

$6,000,000 operational costs$62,000,000 in inpatient revenues28% of ICU daysHelicopter patients were twice as likely to have commercial health insurance compared to regular patient profile.

In FY 2001, the University of Michigan’s flight program “Survival Flight”:

$6,000,000 operational costs$62,000,000 in inpatient revenues28% of ICU daysHelicopter patients were twice as likely to have commercial health insurance compared to regular patient profile.


Bledsoe BE, Smith MG. Medical Helicopter Accidents in the United States: A 10-Year Review. Journal of Trauma/. 2004;56:1325-1329

Bledsoe BE, Smith MG. Medical Helicopter Accidents in the United States: A 10-Year Review. Journal of Trauma/. 2004;56:1325-1329

Medical Helicopters Medical Helicopters

Medical Helicopter AccidentsMedical Helicopter Accidents

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

0

5

10

15

20

25

3 4

8

24

910

15

12

16

2119 19

15

11Accidents

1993-2007 (Source: NTSB)


0

2

4

6

8

10

12

14

16

18

1993 1995 1997 1999 2001 2003 2005 2007

Fatalities

Injuries

Source: NTSB


1993-2002

0123456789

10

12AM

2AM

4AM

6AM

8AM

10AM

12PM

2PM

4PM

6PM

8PM

10PM

Accidents

Source: NTSB & Bledsoe BE and Smith MG. Medical Helicopter Accidents in the United States: A 10-Year Review. J Trauma. 2004;56:1225-1229


Accidents by Cause

61%

26%

11%2%

Pilot ErrorMechanical FailureUndeterminedOther

Source: NTSB & Bledsoe BE and Smith MG. Medical Helicopter Accidents in the United States: A 10-Year Review. J Trauma. 2004;56:1225-1229

Occupational Deaths per 100,000 per YearOccupational Deaths per 100,000 per Year

All Workers 5

Farming 26

Mining 27

Air Medical Crew 74

US 1995-2001

Source: Johns Hopkins University School of Public Health

Fatal Crashes per Million Flight Hours (2001)Fatal Crashes per Million Flight Hours (2001)

1

6

12 12

19

0

2

4

6

8

10

12

14

16

18

20

Airline

Commuter

Ground Ambulance

All Helicopters

Medical Helicopters

Source: AMPA, A Safety Review and Risk Assessment in Air Medical Transport (2002)


Weather a factor in one-fourth of all crashes.

Source: AMPA. A Safety Review and Risk Assessment in Air Medical Transport, 2002

Weather a factor in one-fourth of all crashes.

Source: AMPA. A Safety Review and Risk Assessment in Air Medical Transport, 2002

Pressure on PilotsPressure on Pilots

Undue pressure from:Management

Dispatch

Flight Crews

Pressure to:Speed response or lift-off times

Launch/continue in marginal weather

Fly when fatigued or ill

Undue pressure from:Management

Dispatch

Flight Crews

Pressure to:Speed response or lift-off times

Launch/continue in marginal weather

Fly when fatigued or ill

EMS Line Pilot Survey, 2001


Initial studies in the 1980s showed that trauma patients have better outcomes when transported by helicopter.

Today, other than speed, helicopters offer little additional care than provided by ground ambulances.

Initial studies in the 1980s showed that trauma patients have better outcomes when transported by helicopter.

Today, other than speed, helicopters offer little additional care than provided by ground ambulances.


Shatney CH, Homan SJ, Sherek JP, et al. The utility of helicopter transport of trauma patients from the injury scene in an urban trauma system. J Trauma. 2002;53(5):817-2210-year retrospective review of 947 consecutive trauma patients transported to the Santa Clara Valley trauma center.

Blunt trauma: 911Penetrating trauma: 36

Shatney CH, Homan SJ, Sherek JP, et al. The utility of helicopter transport of trauma patients from the injury scene in an urban trauma system. J Trauma. 2002;53(5):817-2210-year retrospective review of 947 consecutive trauma patients transported to the Santa Clara Valley trauma center.

Blunt trauma: 911Penetrating trauma: 36


Mean ISS = 8.9Deaths in ED = 15Discharged from ED = 312 (33.5%)Hospitalized = 620

ISS ≤ 9 = 339 (54.7%)ISS ≥ 16 = 148 (23.9%)Emergency surgery = 84 (8.9%)

Mean ISS = 8.9Deaths in ED = 15Discharged from ED = 312 (33.5%)Hospitalized = 620

ISS ≤ 9 = 339 (54.7%)ISS ≥ 16 = 148 (23.9%)Emergency surgery = 84 (8.9%)


Only 17 patients (1.8%) underwent surgery for immediately life-threatening injuries.Helicopter arrival faster = 54.7%Helicopter arrival slower = 45.3%Only 22.4% of the study population were possibly helped by helicopter transport.CONCLUSION: The helicopter is used excessively for scene transport of trauma victims in our metropolitan trauma system. New criteria should be developed for helicopter deployment in the urban trauma environment.

Only 17 patients (1.8%) underwent surgery for immediately life-threatening injuries.Helicopter arrival faster = 54.7%Helicopter arrival slower = 45.3%Only 22.4% of the study population were possibly helped by helicopter transport.CONCLUSION: The helicopter is used excessively for scene transport of trauma victims in our metropolitan trauma system. New criteria should be developed for helicopter deployment in the urban trauma environment.


Eckstein M, Jantos T, Kelly N, et al. Helicopter transport of pediatric trauma patients in an urban emergency medical services system: a critical analysis. J Trauma, 2002;53:340-344.Retrospective review of 189 pediatric trauma patients (<15) transported by helicopter from the scene in LA. Median age: 5 yearsRTS > 7 = 82%ISS < 15 = 83%Admitted to ICU = 18%Discharged from ED = 33%

Eckstein M, Jantos T, Kelly N, et al. Helicopter transport of pediatric trauma patients in an urban emergency medical services system: a critical analysis. J Trauma, 2002;53:340-344.Retrospective review of 189 pediatric trauma patients (<15) transported by helicopter from the scene in LA. Median age: 5 yearsRTS > 7 = 82%ISS < 15 = 83%Admitted to ICU = 18%Discharged from ED = 33%


CONCLUSION: The majority of pediatric trauma patients transported by helicopter in our study sustained minor injuries. A revised policy to better identify pediatric patients who might benefit from helicopter transport appears to be warranted.

CONCLUSION: The majority of pediatric trauma patients transported by helicopter in our study sustained minor injuries. A revised policy to better identify pediatric patients who might benefit from helicopter transport appears to be warranted.


Braithwaite CE, Roski M, McDowell R, et al. A critical analysis of on-scene helicopter transport on survival in a statewide trauma system. J Trauma. 1998;45(1):140-4Data for 162,730 Pennsylvania trauma patients obtained from state trauma registry.

Patients treated at 28 accredited trauma centers15,938 patients were transported from the scene by helicopters.6,273 patients were transported by ALS ground ambulance.

Braithwaite CE, Roski M, McDowell R, et al. A critical analysis of on-scene helicopter transport on survival in a statewide trauma system. J Trauma. 1998;45(1):140-4Data for 162,730 Pennsylvania trauma patients obtained from state trauma registry.

Patients treated at 28 accredited trauma centers15,938 patients were transported from the scene by helicopters.6,273 patients were transported by ALS ground ambulance.


Patients transported by helicopter:Significantly youngerMalesMore seriously injuredHad lower blood pressure

Helicopter patients:ISS <15 = 55%

Logistical regression analysis revealed that when adjusted for other risk factors, transportation by helicopter did not affect the estimated odds of survival.CONCLUSION: A reappraisal of the cost-effectiveness of helicopter triage and transport criteria, when access to ground ALS squads is available, may be warranted.

Patients transported by helicopter:Significantly youngerMalesMore seriously injuredHad lower blood pressure

Helicopter patients:ISS <15 = 55%

Logistical regression analysis revealed that when adjusted for other risk factors, transportation by helicopter did not affect the estimated odds of survival.CONCLUSION: A reappraisal of the cost-effectiveness of helicopter triage and transport criteria, when access to ground ALS squads is available, may be warranted.


Cocanour CS, Fischer RP, Ursie CM. Are scene flights for penetrating trauma justified? J Trauma. 1997;43(1):83-86122 consecutive victims of non-cranial penetrating trauma transported by helicopter from the scene.

Average RTS = 10.6Dead patients = 15.6%

Helicopter did not hasten arrival in for any of the 122 patients.Only 4.9% of patients required patient care interventions beyond those of ground ALS units.CONCLUSION: Scene flights in this metropolitan area for patients who suffered noncranial penetrating injuries demonstrated that these flights were not medically efficacious.

Cocanour CS, Fischer RP, Ursie CM. Are scene flights for penetrating trauma justified? J Trauma. 1997;43(1):83-86122 consecutive victims of non-cranial penetrating trauma transported by helicopter from the scene.

Average RTS = 10.6Dead patients = 15.6%

Helicopter did not hasten arrival in for any of the 122 patients.Only 4.9% of patients required patient care interventions beyond those of ground ALS units.CONCLUSION: Scene flights in this metropolitan area for patients who suffered noncranial penetrating injuries demonstrated that these flights were not medically efficacious.


Cunningham P, Rutledge R, Baker CC, Clancy TV. A comparison of the association of helicopter and ground ambulance transport with the outcome of injury in trauma patients transported from the scene. J Trauma 1997;43(6):940-946 Data obtained from NC trauma registry from 1987-1993 on trauma patients and compared:

1,346 transported by air17,144 transported by ground

CONCLUSION: The large majority of trauma patients transported by both helicopter and ground ambulance have low severity measures. Outcomes were not uniformly better among patients transported by helicopter. Only a very small subset of patients transported by helicopter appear to have any chance or improved survival.

Cunningham P, Rutledge R, Baker CC, Clancy TV. A comparison of the association of helicopter and ground ambulance transport with the outcome of injury in trauma patients transported from the scene. J Trauma 1997;43(6):940-946 Data obtained from NC trauma registry from 1987-1993 on trauma patients and compared:

1,346 transported by air17,144 transported by ground

CONCLUSION: The large majority of trauma patients transported by both helicopter and ground ambulance have low severity measures. Outcomes were not uniformly better among patients transported by helicopter. Only a very small subset of patients transported by helicopter appear to have any chance or improved survival.

HelicoptersHelicopters

Moront ML, Gotschall CS, Eichelberger MR. Helicopter transport of injured children: system effectiveness and triage criteria. J Pediatr Surg. 1996;31(8):1183-63,861 children transported by local EMS

1,460 arrived by helicopter2,896 arrived by ground

Helicopter transported patients:ISS <15 = 83%But survival rates for children transported by air were better than those transported by ground.

CONCLUSION: The authors conclude that (1) helicopter transport was associated with better survival rates among injured urban children; (2) pediatric helicopter triage criteria based on GSC and heart rate may improve helicopter utilization without compromising care; (3) current air triage practices result in overuse in approximately 85% of flights.

Moront ML, Gotschall CS, Eichelberger MR. Helicopter transport of injured children: system effectiveness and triage criteria. J Pediatr Surg. 1996;31(8):1183-63,861 children transported by local EMS

1,460 arrived by helicopter2,896 arrived by ground

Helicopter transported patients:ISS <15 = 83%But survival rates for children transported by air were better than those transported by ground.

CONCLUSION: The authors conclude that (1) helicopter transport was associated with better survival rates among injured urban children; (2) pediatric helicopter triage criteria based on GSC and heart rate may improve helicopter utilization without compromising care; (3) current air triage practices result in overuse in approximately 85% of flights.

HelicoptersHelicopters

Wills VL, Eno L, Walker C, et al. Use of an ambulance-based helicopter retrieval service. Aust N Z J Surg. 2000;70(7):506-510179 trauma patients arrived by helicopter during study year.

122 male57 female

Severity of injuries:ISS < 9 = 67.6%ISS ≥ 16 = 17.9%12 (6.7%) discharged from the ED46 (25.7%) discharged within 48 hours.

Results:17.3% of patients were felt to have benefited from helicopter transport81.0% of patients were felt to have no benefit from helicopter transport1.7% of patients were felt to have been harmed from helicopter transport

Wills VL, Eno L, Walker C, et al. Use of an ambulance-based helicopter retrieval service. Aust N Z J Surg. 2000;70(7):506-510179 trauma patients arrived by helicopter during study year.

122 male57 female

Severity of injuries:ISS < 9 = 67.6%ISS ≥ 16 = 17.9%12 (6.7%) discharged from the ED46 (25.7%) discharged within 48 hours.

Results:17.3% of patients were felt to have benefited from helicopter transport81.0% of patients were felt to have no benefit from helicopter transport1.7% of patients were felt to have been harmed from helicopter transport


Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MO. Helicopter scene transport of trauma patients: a meta-analysis. Journal of Trauma, Injury, Infection and Critical Care. 2006;60:1256-1266

Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MO. Helicopter scene transport of trauma patients: a meta-analysis. Journal of Trauma, Injury, Infection and Critical Care. 2006;60:1256-1266


Considerations:Severe injury:

ISS > 15TS < 12RTS ≤ 11Weighted RTS ≥ 4Triss Ps < 0.90

Non-life-threatening injuries:Patients not in above criteriaPatients who refuse ED treatmentPatients discharged from EDPatients not admitted to ICU

Considerations:Severe injury:

ISS > 15TS < 12RTS ≤ 11Weighted RTS ≥ 4Triss Ps < 0.90

Non-life-threatening injuries:Patients not in above criteriaPatients who refuse ED treatmentPatients discharged from EDPatients not admitted to ICU


48 papers met initial inclusion criteria.

26 papers rejected:Failure to stratify scores.

Failure to differentiate scene flights.

Failure to differentiate trauma flights.

22 papers accepted.

Span: 21 years

Cohort: 37,350

48 papers met initial inclusion criteria.

26 papers rejected:Failure to stratify scores.

Failure to differentiate scene flights.

Failure to differentiate trauma flights.

22 papers accepted.

Span: 21 years

Cohort: 37,350


ISS ≤ 15:N = 31,244

ISS ≤ 15 = 18,629

ISS ≤ 15 = 60.0% [99% CI: 54.5 to 64.8]

TS ≥ 13:N = 2,110

TS ≥ 13 = 1,296

TS ≥ 13 = 61.4% [99% CI: 58.5 to 80.2]

ISS ≤ 15:N = 31,244

ISS ≤ 15 = 18,629

ISS ≤ 15 = 60.0% [99% CI: 54.5 to 64.8]

TS ≥ 13:N = 2,110

TS ≥ 13 = 1,296

TS ≥ 13 = 61.4% [99% CI: 58.5 to 80.2]


RTS > 11:Insufficient data

TRISS Ps > 0.90:

N = 6,328

TRISS Ps > 0.90 = 4,414

TRISS Ps > 0.90 = 69.3% [99% CI: 58.5 to 80.2]

RTS > 11:Insufficient data

TRISS Ps > 0.90:

N = 6,328

TRISS Ps > 0.90 = 4,414

TRISS Ps > 0.90 = 69.3% [99% CI: 58.5 to 80.2]


54

56

58

60

62

64

66

68

70

ISS TS TRISS

Percentagewith minorinjuries

Source: Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MO. Helicopter

scene transport of trauma patients: a meta-analysis. Journal of Trauma.

N=37,350


Patients discharged < 24 hours:

N = 1,850

Discharged < 24 hours = 446

Discharged < 24 hours = 25.8% [99% CI: -0.90 to 52.63]

Patients discharged < 24 hours:

N = 1,850

Discharged < 24 hours = 446

Discharged < 24 hours = 25.8% [99% CI: -0.90 to 52.63]


No definitive body of data shows patient benefit from helicopter transport.

Yet, helicopters are on the increase—each transporting more and more patients.

No definitive body of data shows patient benefit from helicopter transport.

Yet, helicopters are on the increase—each transporting more and more patients.


“They brought the helicopter in. And Billy couldn't feel his legs.

Said he'd never walk again.

But Billy said he would and his mom and daddy prayed.

And the day we graduated, he stood up to say:

Unsinkable ships sink…”Nichols, J. The Impossible from Man with a Memory. 2000: Universal South

“They brought the helicopter in. And Billy couldn't feel his legs.

Said he'd never walk again.

But Billy said he would and his mom and daddy prayed.

And the day we graduated, he stood up to say:

Unsinkable ships sink…”Nichols, J. The Impossible from Man with a Memory. 2000: Universal South


This begs the question:“Why do we continue to endanger our patients

and employees on medical helicopters when only a very small percentage stand to benefit?

This begs the question:“Why do we continue to endanger our patients

and employees on medical helicopters when only a very small percentage stand to benefit?

SummarySummary

We would never buy a car with determining the benefit: risk ratio.

We routinely perform and promote considerably more dangerous EMS practices without considering the benefit: risk ratio.

We would never buy a car with determining the benefit: risk ratio.

We routinely perform and promote considerably more dangerous EMS practices without considering the benefit: risk ratio.

SummarySummary

Use TOR protocols.

Limit lights and siren responses and transports.

Use medical helicopters only when the patient has a significant chance of benefiting from transport.

Educate the public and PUBLIC OFFICIALS about the benefits and LIMITATIONS of EMS.

Use TOR protocols.

Limit lights and siren responses and transports.

Use medical helicopters only when the patient has a significant chance of benefiting from transport.

Educate the public and PUBLIC OFFICIALS about the benefits and LIMITATIONS of EMS.

have we set the bar too high? bryan e. bledsoe, do, facep unlv bryan e. bledsoe, do, facep unlv

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