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Have We Set the Bar Too High? Bryan E. Bledsoe, DO, FACEP UNLV Bryan E. Bledsoe, DO, FACEP UNLV.

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Presentation on theme: "Have We Set the Bar Too High? Bryan E. Bledsoe, DO, FACEP UNLV Bryan E. Bledsoe, DO, FACEP UNLV."— Presentation transcript:

1 Have We Set the Bar Too High? Bryan E. Bledsoe, DO, FACEP UNLV Bryan E. Bledsoe, DO, FACEP UNLV

2 The EMS Image

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11 “You wanted to be a doctor, maybe you should have buckled down a little more in high school.”

12 The Problem

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14 The EMS Image

15 We Raise the Dead Researchers watched all 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 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.

16 We Raise the Dead 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.

17 We Raise the Dead 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.

18 We Raise the Dead 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.

19 We Raise the Dead 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.

20 We Raise the Dead No change in survival for the first group since the Crimean war.

21 We Raise the Dead

22 “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)

23 We Raise the Dead 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?

24 The EMS Image

25 Hospital will Save Them Most Australian paramedics have never done CPR in a moving ambulance.

26 Hospital will Save Them NAEMSP has had a position paper on field termination of out-of- hospital non-traumatic cardiac arrest since 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: NAEMSP has had a position paper on field termination of out-of- hospital non-traumatic cardiac arrest since 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:

27 Hospital will Save Them NAEMSP and the American College of Surgeons has had a position paper on the termination of traumatic cardiac arrest since 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: NAEMSP and the American College of Surgeons has had a position paper on the termination of traumatic cardiac arrest since 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:

28 Hospital will Save Them 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:

29 Hospital will Save Them 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:

30 Hospital will Save Them 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

31 Hospital will Save Them 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:

32 Hospital will Save Them 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: 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

33 Hospital will Save Them

34 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?

35 The “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

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

37 The “Golden Hour” exists. “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.

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

39 The “Golden Hour” exists 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.

40 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? 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?

41 Lights and Sirens Save Lives

42 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):

43 Lights and Sirens Save Lives 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

44 Lights and Sirens Save Lives 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):

45 Lights and Sirens Save Lives 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):

46 Lights and Sirens Save Lives

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

48 Lights and Sirens Save Lives This begs the question: “Why do we continue to endanger our employees and our patients by significantly overusing lights and sirens response? This begs the question: “Why do we continue to endanger our employees and our patients by significantly overusing lights and sirens response?

49 The EMS Image

50 7 Minutes, 59 Seconds (90%) Where is the safest place in America to have your cardiac arrest?

51 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

52 7 minutes, 59 seconds (90%) 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.

53 7 minutes, 59 seconds (90%) 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.

54 7 minutes, 59 seconds (90%) What does the science tell us?

55 7 minutes, 59 seconds (90%) 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.

56 7 minutes, 59 seconds (90%) How many EMS systems can guarantee a 4 minute response time?

57 7 minutes, 59 seconds (90%) 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.

58 7 minutes, 59 seconds (90%) “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

59 7 minutes, 59 seconds (90%) 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

60 7 minutes, 59 seconds (90%) 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

61 7 minutes, 59 seconds (90%) This begs the question: “Why do we continue to endanger our employees and our patients by setting artificial response times that have no correlation with patient outcomes? This begs the question: “Why do we continue to endanger our employees and our patients by setting artificial response times that have no correlation with patient outcomes?

62 7 minutes, 59 seconds (90%) This begs the question: “Why do we continue to endanger our employees and our patients by setting artificial response times that have no correlation with patient outcomes? This begs the question: “Why do we continue to endanger our employees and our patients by setting artificial response times that have no correlation with patient outcomes?

63 Helicopters Save Lives

64 Medical 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 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 Spending by Medicare has more than doubled to $103 million over the same period.

65 Medical Helicopters In FY 2001, the University of Michigan’s flight program “Survival Flight”: $6,000,000 operational costs $62,000,000 in inpatient revenues 28% of ICU days Helicopter patients were twice as likely to have commercial health insurance compared to regular patient profile.

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

67 Medical Helicopters

68 Medical Helicopter Accidents (Source: NTSB)

69 Medical Helicopter Accidents Source: NTSB

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

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

72 Occupational Deaths per 100,000 per Year All Workers 5 Farming26 Mining27 Air Medical Crew 74 US Source: Johns Hopkins University School of Public Health

73 Fatal Crashes per Million Flight Hours (2001) Source: AMPA, A Safety Review and Risk Assessment in Air Medical Transport (2002)

74 Medical Helicopter Accidents 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

75 Pressure 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

76 Medical Helicopters 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.

77 Medical Helicopters 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): year retrospective review of 947 consecutive trauma patients transported to the Santa Clara Valley trauma center. Blunt trauma: 911 Penetrating 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): year retrospective review of 947 consecutive trauma patients transported to the Santa Clara Valley trauma center. Blunt trauma: 911 Penetrating trauma: 36

78 Medical Helicopters Mean ISS = 8.9 Deaths in ED = 15 Discharged from ED = 312 (33.5%) Hospitalized = 620 ISS ≤ 9 = 339 (54.7%) ISS ≥ 16 = 148 (23.9%) Emergency surgery = 84 (8.9%) Mean ISS = 8.9 Deaths in ED = 15 Discharged from ED = 312 (33.5%) Hospitalized = 620 ISS ≤ 9 = 339 (54.7%) ISS ≥ 16 = 148 (23.9%) Emergency surgery = 84 (8.9%)

79 Medical Helicopters 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.

80 Medical Helicopters 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: Retrospective review of 189 pediatric trauma patients (<15) transported by helicopter from the scene in LA. Median age: 5 years RTS > 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: Retrospective review of 189 pediatric trauma patients (<15) transported by helicopter from the scene in LA. Median age: 5 years RTS > 7 = 82% ISS < 15 = 83% Admitted to ICU = 18% Discharged from ED = 33%

81 Medical Helicopters 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.

82 Medical Helicopters 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):140-4 Data for 162,730 Pennsylvania trauma patients obtained from state trauma registry. Patients treated at 28 accredited trauma centers 15,938 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):140-4 Data for 162,730 Pennsylvania trauma patients obtained from state trauma registry. Patients treated at 28 accredited trauma centers 15,938 patients were transported from the scene by helicopters. 6,273 patients were transported by ALS ground ambulance.

83 Medical Helicopters Patients transported by helicopter: Significantly younger Males More seriously injured Had 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 younger Males More seriously injured Had 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.

84 Medical Helicopters Cocanour CS, Fischer RP, Ursie CM. Are scene flights for penetrating trauma justified? J Trauma. 1997;43(1): consecutive victims of non-cranial penetrating trauma transported by helicopter from the scene. Average RTS = 10.6 Dead 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): consecutive victims of non-cranial penetrating trauma transported by helicopter from the scene. Average RTS = 10.6 Dead 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.

85 Medical Helicopters 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): Data obtained from NC trauma registry from on trauma patients and compared: 1,346 transported by air 17,144 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): Data obtained from NC trauma registry from on trauma patients and compared: 1,346 transported by air 17,144 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.

86 Helicopters Moront ML, Gotschall CS, Eichelberger MR. Helicopter transport of injured children: system effectiveness and triage criteria. J Pediatr Surg. 1996;31(8): ,861 children transported by local EMS 1,460 arrived by helicopter 2,896 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): ,861 children transported by local EMS 1,460 arrived by helicopter 2,896 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.

87 Helicopters Wills VL, Eno L, Walker C, et al. Use of an ambulance-based helicopter retrieval service. Aust N Z J Surg. 2000;70(7): trauma patients arrived by helicopter during study year. 122 male 57 female Severity of injuries: ISS < 9 = 67.6% ISS ≥ 16 = 17.9% 12 (6.7%) discharged from the ED 46 (25.7%) discharged within 48 hours. Results: 17.3% of patients were felt to have benefited from helicopter transport 81.0% of patients were felt to have no benefit from helicopter transport 1.7% 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): trauma patients arrived by helicopter during study year. 122 male 57 female Severity of injuries: ISS < 9 = 67.6% ISS ≥ 16 = 17.9% 12 (6.7%) discharged from the ED 46 (25.7%) discharged within 48 hours. Results: 17.3% of patients were felt to have benefited from helicopter transport 81.0% of patients were felt to have no benefit from helicopter transport 1.7% of patients were felt to have been harmed from helicopter transport

88 Medical Helicopters 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:

89 Medical Helicopters Considerations: Severe injury: ISS > 15 TS < 12 RTS ≤ 11 Weighted RTS ≥ 4 Triss P s < 0.90 Non-life-threatening injuries: Patients not in above criteria Patients who refuse ED treatment Patients discharged from ED Patients not admitted to ICU Considerations: Severe injury: ISS > 15 TS < 12 RTS ≤ 11 Weighted RTS ≥ 4 Triss P s < 0.90 Non-life-threatening injuries: Patients not in above criteria Patients who refuse ED treatment Patients discharged from ED Patients not admitted to ICU

90 Medical Helicopters 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, 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

91 Medical Helicopters 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]

92 Medical Helicopters RTS > 11: Insufficient data TRISS P s > 0.90: N = 6,328 TRISS P s > 0.90 = 4,414 TRISS P s > 0.90 = 69.3% [99% CI: 58.5 to 80.2] RTS > 11: Insufficient data TRISS P s > 0.90: N = 6,328 TRISS P s > 0.90 = 4,414 TRISS P s > 0.90 = 69.3% [99% CI: 58.5 to 80.2]

93 Medical Helicopters 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

94 Medical Helicopters Patients discharged < 24 hours: N = 1,850 Discharged < 24 hours = 446 Discharged < 24 hours = 25.8% [99% CI: to 52.63] Patients discharged < 24 hours: N = 1,850 Discharged < 24 hours = 446 Discharged < 24 hours = 25.8% [99% CI: to 52.63]

95 Helicopters Save Lives 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.

96 Helicopters Save Lives “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

97 Medical Helicopters 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?

98 Summary 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.

99 Summary 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.


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