Have We Set the Bar Too High? Bryan E. Bledsoe, DO, FACEP UNLV Bryan E. Bledsoe, DO, FACEP UNLV.
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Transcript of 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
The EMS ImageThe EMS Image
The EMS ImageThe EMS Image
The EMS ImageThe EMS Image
The EMS ImageThe EMS Image
The EMS ImageThe EMS Image
The EMS ImageThe EMS Image
The EMS ImageThe EMS Image
The EMS ImageThe EMS Image
The EMS ImageThe EMS Image
“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!
The EMS ImageThe EMS Image
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.
We Raise the DeadWe 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.
We Raise the DeadWe 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.
We Raise the DeadWe 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.
We Raise the DeadWe 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.
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.
We Raise the DeadWe Raise the Dead
No change in survival for the first group since the Crimean war.
No change in survival for the first group since the Crimean war.
We Raise the DeadWe Raise the Dead
Despite 30+ years of EMS, and the expenditure of billions of dollars, dead people remain dead.
We Raise the DeadWe Raise the 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)
We Raise the DeadWe 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?
The EMS ImageThe EMS Image
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.
Hospital will Save ThemHospital will Save Them
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
Hospital will Save ThemHospital will Save Them
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
Hospital will Save ThemHospital 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;9:276-281
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
Hospital will Save ThemHospital 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;270:1433- 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
Hospital will Save ThemHospital 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
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
Hospital will Save ThemHospital 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;9:181- 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
Hospital will Save ThemHospital 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;12:56-61
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
Hospital will Save ThemHospital will Save Them
Hospital will Save ThemHospital will Save Them
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 “Golden Hour” existsThe “Golden Hour” exists
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.
The “Golden Hour” existsThe “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.”
Nobody wants to talk about the false notion of a “Golden Hour” because it so shakes the roots of EMS and trauma care.”
The “Golden Hour” existsThe “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.
The “Golden Hour” existsThe “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?
Lights and Sirens Save LivesLights and Sirens Save Lives
LIGHTS & SIRENS SAVE LIVES
Lights and Sirens Save LivesLights and 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
Lights and Sirens Save LivesLights 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
Lights and Sirens Save LivesLights 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):223-227
Lights and Sirens Save LivesLights 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):226-229
Lights and Sirens Save LivesLights and Sirens Save Lives
Lights and Sirens Save LivesLights and Sirens Save Lives
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.
Lights and Sirens Save LivesLights 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?
The EMS ImageThe EMS Image
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
7 minutes, 59 seconds (90%)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.
7 minutes, 59 seconds (90%)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.
7 minutes, 59 seconds (90%)7 minutes, 59 seconds (90%)
What does the science tell us?What does the science tell us?
Response times less than 4 minutes are highly
correlated with increased survival.
7 minutes, 59 seconds (90%)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.
7 minutes, 59 seconds (90%)7 minutes, 59 seconds (90%)
How many EMS systems can guarantee a 4 minute response time?
How many EMS systems can guarantee a 4 minute response time?
7 minutes, 59 seconds (90%)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.
7 minutes, 59 seconds (90%)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.”
“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
7 minutes, 59 seconds (90%)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
7 minutes, 59 seconds (90%)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
7 minutes, 59 seconds (90%)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?
7 minutes, 59 seconds (90%)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?
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.
Medical HelicoptersMedical Helicopters
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.
Medical HelicoptersMedical Helicopters
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)
Medical Helicopter AccidentsMedical Helicopter Accidents
0
2
4
6
8
10
12
14
16
18
1993 1995 1997 1999 2001 2003 2005 2007
Fatalities
Injuries
Source: NTSB
Medical Helicopter AccidentsMedical Helicopter Accidents
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
Medical Helicopter AccidentsMedical Helicopter Accidents
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)
Medical Helicopter AccidentsMedical 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
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
Medical Helicopters 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.
Medical HelicoptersMedical 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):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
Medical Helicopters Medical Helicopters
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%)
Medical HelicoptersMedical 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.
Medical HelicoptersMedical 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;53:340-344.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%
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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.
Medical HelicoptersMedical 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):140-4Data 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.
Medical HelicoptersMedical Helicopters
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.
Medical HelicoptersMedical Helicopters
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.
Medical HelicoptersMedical 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):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
Medical HelicoptersMedical 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;60:1256-1266
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
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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
Medical HelicoptersMedical 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: 37,350
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
Medical HelicoptersMedical 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]
Medical HelicoptersMedical Helicopters
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]
Medical HelicoptersMedical Helicopters
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
Medical HelicoptersMedical Helicopters
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]
Helicopters Save LivesHelicopters 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.
Helicopters Save LivesHelicopters 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
Medical HelicoptersMedical 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?
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.