As far a trauma and life support in the field, ER or Anesthesia?

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keeping-it-real

keeping-it-real

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would an ER doc or Anesthesiologist be better at keeping you alive/sustained if you were to experience some type of trauma out in the field (i.e. fall rock climbing, get hit by a car, shock, etc.)

i guess my question is "which is more practical in 'civilian' life?"

try and keep it unbiased if you could as i know this is the ER subforum. thanks.
 
Personally, I think it would depend on the particular physician in question, not on their particular specialty.
 
Haha, how funny. "Try to keep it unbiased as this is an EM subforum?" Give me a break!

As far as I know, anesthesiologists aren't routinely trained in advanced trauma life support. I'm sure they would be better at managing your airway, but other than that, they aren't really trained on initial workups and stabilization. Most are trained on stabilizing critical care patients in the units, but not on initial workups.

As Steve pointed out, it's also highly dependent on the physician in question.
 
Most anesthesiologists are damn good at maintaining BP's and such and securing airways, but as was said, initial workups are not their forte'.

As for "initial workups", remember this is in the field, and most docs in general are not the most astute at working in the field because of their lack of experience in it. Personally I think you'd be much better served by having a competent paramedic (or EMT-I) taking care of you. There have been actually studies done showing that trauma patients who are transported by services utilizing physicians in the prehospital setting have LOWER survival rates than those attended only by EMT's and paramedics. The study I read discussing this attributed it to the fact that docs are more likely to spend more time in the field attempting to "stabilize" the patient prior to transport.
 
What you really need is an DrNP(EM)/CRNA who is also a midwife just in case you're prgenant. 😉
 
Yep, I agree. The best physician to deal with a trauma patient in the field is a paramedic.

If you want to know why having docs in the field is a bad idea, just as Prince William about his mom.

BTW, I think EMS physicians in the field is a wonderful idea. They just aren't out there taking care of patients, they're running the system and evaluating/training the paramedics.

Take care,
Jeff <- not even a little bit biased 🙂
 
< Personally I think you'd be much better served by having a competent paramedic (or EMT-I) taking care of you. >

Good call. I would add that if we're talking about REALLY out in the field, more than 30 to 45 away from the right equipment and drugs, I would want an EMT or Paramedic with "W" (wilderness) certification watching my sorry just-fell-off-a-rockface butt.
 
physicians aside, which program would give you better opportunity for this type of training? i'm really not looking to get flamed, it was an honest question. i also posted this in anesthesia subforum for more of an unbiased view.

i'm talking stitches, splints, airway, basically everything that could potentially go wrong in an outdoor/family situation. thanks.
 
Nobody's flaming you. You asked our opinions and we gave them.

As for "outdoor/family situations", how often do you need airway management in a "family" situation? Seriously, even a Basic EMT can manage airway. You don't need an MD for that.

By the way, there's no such things as an unbiased view. Everyone is biased to a degree. It just matters whether or not you hold the same opinion that they do. 👍
 
ISU_Steve said:
Nobody's flaming you. You asked our opinions and we gave them.

As for "outdoor/family situations", how often do you need airway management in a "family" situation? Seriously, even a Basic EMT can manage airway. You don't need an MD for that.

By the way, there's no such things as an unbiased view. Everyone is biased to a degree. It just matters whether or not you hold the same opinion that they do. 👍
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you are right, not really flamed... but i guess not being taken very seriously

i think i am ignorant as to what anesthesia critical care actually entails... is this limited to drugs/airway?
 
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You're being taken seriously. It's just that the question you asked has no real answer. As we said, outside of a hospital there are not doctors that take care of this (at least not in most parts of the US). So, that's why you think we're not taking you seriously.
 
You're generally going to find this type of training (wilderness medicine) more in EM than in anesthesia. That said any physician who put the time into learning it could handle most of these types of things no matter what their field of specialty.
 
Given the limited resources in the field and assuming your physician in the field knows at least some EMT basic level stuff the answer is going to be whomever has the cell phone with the best coverage
 
I think the person who can intubate you on the first try, decompress your chest with a needle, stop/control major external bleeding, start two large-bore IVs with two liters of saline, and get your ass to an ED with a surgeon the fastest would be the best to manage you in the field. Anything beyond that is ultimately a waste of time if it isn't done in route.

Blood products would be nice but impractical.

I hope you aren't basing your career choice on the answers to this question.
 
Jeff698 said:
Yep, I agree. The best physician to deal with a trauma patient in the field is a paramedic.

If you want to know why having docs in the field is a bad idea, just as Prince William about his mom.

BTW, I think EMS physicians in the field is a wonderful idea. They just aren't out there taking care of patients, they're running the system and evaluating/training the paramedics.

Take care,
Jeff <- not even a little bit biased 🙂
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Physicians in the field aren't a bad idea. Princess Di is an extreme example of a messed up system. Having physicians in the field is not a bad idea. In the case of France, it's their philosophy of stabilizing patients in the field prior to transport that caused Di's problems/death.

Many agencies use physicians in the field. Virgin HEMS (London Air Ambulance), Berlin Germany EMS, etc. Those agencies realize the importance of quick transport and do not have worse outcomes than paramedics.

A blanket statement that physicians in the field cause worse mortality is a jump to a conclusion that is a little far fetched. It is highly system dependent. Some systems might have worse outcomes, but others may have improved outcomes (take a look at London's use of flight docs from HEMS in the field).
 
I still maintain that in our country, with the economics the way they are, having physicians routinely available in the field and on the ground for the clinical management of trauma patients is a bad idea.

If you have a system where physicians are effectively managing trauma patients on the ground in the field, then you are essentially WAY overpaying a paramedic. Clearly this does not hold for air systems, nor for medical patients, nor for transfers. But that's not how I interpreted the OP's question. BTW, I don't say this as a way of demeaning physicians. I say it because I feel US paramedics are well trained for the job they do.

As I said, putting us out there for other reasons is a great idea. In fact, its the reason I went to medical school.

Take care,
Jeff
 
Oh, I forgot to add this. All EM residents are supposed to cover EMS in their training. I guess you could make the case that EM training would better prepare you as a result for the type of situation you describe.

Honestly, though, I don't think it makes a difference if you're talking about going out playing with your buddies in the wilderness and someone gets hurt.

Take care,
Jeff
 
Jeff698 said:
Honestly, though, I don't think it makes a difference if you're talking about going out playing with your buddies in the wilderness and someone gets hurt.
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Right, a well trained GP, internist, or even dermatologist can handle someone getting hurt outside the hospital if he/she is a good physician.

I support physicians in the field in the US on helicopters. In fact, I think we should have more physician-based flight services (personal preference, no data to back this up, n=1, p=1 also). Physician response teams in the field are a good idea, but staffing every ambulance in the field with a physician is not.

At any rate, how did we get off topic? We were discussing which is better: an EP or an anesthesiologist. Oddly enough, the OP pointed out that we should be unbiased in our answers since we are EP's. He didn't point this out for the anesthesiologists in the anesthesiology forum. Perhaps he's already made his mind subconsciously.
 
Couple of points:
1- EDinOH, about the large bore IV's and 2 liters of saline....would you like me to put you in touch with Dr. Ken Mattox so he can give you a lesson in permissive hypotension in trauma pts?

2- Aeromedical transport is of no proven benefit in 99% of cases, so why risk killing a doctor for no likely benefit?
 
Permissive hypotension is news to me. I'm pretty sure they don't teach that in ATLS.
 
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2- Aeromedical transport is of no proven benefit in 99% of cases, so why risk killing a doctor for no likely benefit?[/QUOTE]

----

This is not accurate. One of the largest studies regarding HEMS (16,000 helicopter vs. 6500 ground ALS -- Braithwaite 1998, Journal of Trauma) noted a survival likelihood for HEMS transports 2.1-2.6x that of ALS transports, for ISS scores 16-60 (midrange severity). Obviously if you transport ankle sprains or decapitated patients (the extremes) you're not going to see any benefit one way or the other.

empractice.net has a good review of the literature on this. Also note that head injured patients benefit substantially from HEMS, and not necessarily from the transport time alone. Look at a study by Wang (2004 Annals of Emerg Med) comparing prehospital intubation by ground paramedics vs. air crews. (4 fold mortality increase and worse functional outcomes) Also note the study in San Diego where ground medics were letting patients desat significantly on intubation attempts. Bottom line is that helicopter crews, whether they contain medics, docs or nurses are better at taking care of sick patients. Why? Well, maybe because air crews routinely see very sick patients on most of their transports. Maybe because they have more experience -- I'm not sure.
 
Endo, EMPractice's aeromedical transport article was pretty good. For those who are not familiar, if you are an EMRA member, you can access EMPractice for free. Just email them requesting your customer number.

ISU_Steve, "permissive hypotension" is practiced at most places now. Even Mattox himself doesn't practice it to the fullest extent, however. It's really sad that it took more than 15 years before his research took hold. Ken is a great guy, unless you're one of his residents (I hear he's brutal to them).
 
He's been brutal to me during online mailing list discussions and I've only had the pleasure (or displeasure depending on how you look at it) of meeting him one time face to face. I can't imagine having him as my attending- although if you lived through it, you'd be one competent surgeon.

The problem I have with aeromedical transport is not with the treatment rendered necessarily, but rather with the dispatch criteria- ground crews and dispatchers tend to overtriage and call for the helicopter when it is not needed. This is especially a problem in places where the helicopter crews go out and "educate" the responders (normally volunteer rescue squads and fire departments whose members do not tend to be the most up to speed on research) about when to call for the helicopter- i.e., whenever they feel like it, because each flight means money for the company running the flight op.
 
ISU Steve,

Would you like for me to put you in touch with ATLS? I'm aware of the permissive hypotension you are referring to. The concept makes sense and I believe there are studies backing it (can't quote them for you.) As it stands now the standard approach to managing trauma related hypotension is a couple liters of saline challenge to augment intravascular volume before definitive surgical correction of hypovolemia and/or PRBCs. In the future the standard may be permissive hypotension to prevent loss of clot and further blood loss though fluid resuscitation or whatever other theories there may be, but for now I think it is hard for the lone ED physician in the middle of nowhere or even in the community to justify until it is incorporated into the standard practice. Some of our surgeons have embraced the concept more readily than others. I wouldn't be surprised to see it become more common in the near future.
 
I'm quite familiar with ATLS- I've set through two ATLS courses.

But it's just like ACLS, it's not a standard of care, but rather a clinical practice guideline- if you know better then you should be expected to do better. I'm not going to get in a pissing for distance contest with you over which of us is correct, but suffice to say I see where you are coming from and you're entitled to your opinion until such time as your burden of proof is met (which I suspect (correct me if I am wrong) will be the day after the ATLS standard is changed).
 
I didn't mean to start a flame war on permissive hypotension, it's just a term that's new to me although on review I find that it is something we do anyway without calling it "permissive hypotension."
 
southerndoc said:
Ken has never been brutal to me on trauma-l.
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He was only "brutal" (i.e. more than just short with me) once, in regards to a debate over needle thoracostomy in which I simply refused to back down. I now know better than to challenge him without exceedingly good evidence.
 
I've read some of Dr. Mattox's comments on the trauma list, he does get very short sometimes.
 
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Personally, and this is just my opinion, but Dr. Mattox tends to at least be a little more, uh, tolerant (for lack of a better word, because I don't feel "patient" would be the right word either) of new people (i.e. ignorance) than others on the trauma-l....example: Dr. Frykberg.
 
ISU_Steve said:
Personally, and this is just my opinion, but Dr. Mattox tends to at least be a little more, uh, tolerant (for lack of a better word, because I don't feel "patient" would be the right word either) of new people (i.e. ignorance) than others on the trauma-l....example: Dr. Frykberg.
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Are you refering to the snake bite discussion (for lack of a better term)?
 
Ah, someone else remembers it!
 
Practical in civilian life???? what does this mean? do you mean walking down the street minding your own?

If you have ever stopped at an accident, you will realize that no one is really 'better suited.'. unless you ahppen to be carrying around an intubation box, iv tubing, iv set up and fluids.


Maybe maybe if you do a wilderness medicine fellowship and happen to carry all these random things with you.

You could maybe crich someone but they taught Father McKayhee (sp?) over the cb how to do it.

So in the civilian world? what does it matter? people do bls.

In EM, one of the most valuable thing you can do is call EMS and keep other people from doing harm.
 
roja said:
....

In EM, one of the most valuable thing you can do is call EMS and keep other people from doing harm.
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Absolutely! I can recall countless instances in which forks, chalkboard erasers, and other objects were shoved into a siezing patient's mouth in an effort to respect the airway. Conversely, I have personally witnessed someone having a grand-mal seizure buried in their dinner plate, gurgling through spaghetti sauce simply because a bystander was screaming, "Dont move her neck! Don't move her neck!" People, even physicians, tend to underestimate the challenge of geography. No amount of schooling prepares you to start iv's in a ditch, intubate people who have wedged their arrested bodies beside a toilet, or extricate a 550 lb chf-er from his bedroom. The practice of, "paramedicine" is much like emergency medicine in that it depands a healthy respect for chaos and improvisation. Paramedics routinely work with less than optimal equipment and face sub-optimal conditions for the rendering of ALS level care. This alone makes them uniquely suitable for out-of-hospital resuscitation. I still have flashbacks about Ben Hill Griffin stadium (UFlorida) on hot gator game days......
 
pushinepi2 said:
I still have flashbacks about Ben Hill Griffin stadium (UFlorida) on hot gator game days......
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Wow. I thought it was just me. I still have thoughts of codes run at Kyle Field (Texas A&M). Fun stuff.

Take care,
Jeff
 
Jeff698 said:
Wow. I thought it was just me. I still have thoughts of codes run at Kyle Field (Texas A&M). Fun stuff.

Take care,
Jeff
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I used to provide EMS at a horse racing track that raced trotters (the ones with the carts). Usually boring but the twice that the horses wrecked it looked like a scene from Ben Hur. Nothing like performing for a crowd.

As for flashbacks... my first full code as a provisional paramedic was in a church in the middle of Sunday Morning Mass. Not fun...

- H
 
roja said:
You could maybe crich someone but they taught Father McKayhee (sp?) over the cb how to do it.

QUOTE]

Wait... I thought it was Radar. Better brush up on my MASH if I'm going to be using it to answer the "Why do you want to go into emergency medicine" question in interviews. 😉
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NotChoCheez! said:
roja said:
You could maybe crich someone but they taught Father McKayhee (sp?) over the cb how to do it.

QUOTE]

Wait... I thought it was Radar. Better brush up on my MASH if I'm going to be using it to answer the "Why do you want to go into emergency medicine" question in interviews. 😉
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Radar was there, Father M did the cutting. He snuck on the ride with Radar against Col. Potter's wishes because a patient had told him that he "didn't have the right to talk about the war" because he'd never seen combat.

Yep, that's me, certified "M*A*S*H" and "Emergency" geek. Hey, given all of the cool stuff you learn on those shows, I think a couch potato beats both EM and anesthesiology in the "real world"! :laugh:

- H
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FoughtFyr said:
Yep, that's me, certified "M*A*S*H" and "Emergency" geek.
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Honesty check...how many times did you practice arcing the caps on the bristojets, Johnnie n' Roy style?

My wife caught me mid-arc on film once. I was so embarrased at the time but I get a kick outta looking at that picture now. Of course, most of the kick is seeing how young I was 17 years ago with that pristine new red paramedic patch on my shoulder. 🙂

Take care,
Jeff
 
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Jeff698 said:
Honesty check...how many times did you practice arcing the caps on the bristojets, Johnnie n' Roy style?

My wife caught me mid-arc on film once. I was so embarrased at the time but I get a kick outta looking at that picture now. Of course, most of the kick is seeing how young I was 17 years ago with that pristine new red paramedic patch on my shoulder. 🙂

Take care,
Jeff
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Still do it at least once during every ACLS class when I show the code cart drugs and how to set things up. Haven't done it on the scene for a while...

- H
 
Or I could explain it to you since i have written published journal articles on the topic.

As for Air Medical not being supported in 99% of case. There is absolutely no research to back this up. There is research, however, to prove it DOES make a difference in patient outcomes.

As far as physicians on helicopters, well all research on pt outcomes shows only one team to have the best outcomes of doc-rn, doc-emt-p, rn-rn, emt-p emt-p, rn emt-p. Its the last one RN EMT-P. Look it up.

ISU_Steve said:
Couple of points:
1- EDinOH, about the large bore IV's and 2 liters of saline....would you like me to put you in touch with Dr. Ken Mattox so he can give you a lesson in permissive hypotension in trauma pts?

2- Aeromedical transport is of no proven benefit in 99% of cases, so why risk killing a doctor for no likely benefit?
Click to expand...
 
pushinepi2 said:
Conversely, I have personally witnessed someone having a grand-mal seizure buried in their dinner plate, gurgling through spaghetti sauce simply because a bystander was screaming, "Dont move her neck! Don't move her neck!"
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I have also been completely surprised at the inginuity that some people resort to in order prevent someone from "swallowing their tongue". You would be amazed at the dental damage and oral lacerations a well intentioned spoon can cause. I made this issue part of my ad hoc public education campaign.

Your message reminded me of an incident that I responded to as a medic on a QRV with a basic squad in my county. We were extracting a patient from a car in a rollover incident. The patient was not trapped or seriously injured but the car was upside down in a ditch. As we were transferring her to a long spine board I was holding c-spine. Suddenly, out of nowhere, a brand spankin' new EMT (by the way, one of the few on the team I had not worked with for years) starts screaming at me at the top of her lungs "DON"T PULL HER BY HER HEAD! DON'T PULL HER BY HER HEAD!" I was mortified. Countless bystanders nearby looked at me with disbelief, seemingly glad that she had stopped me before I could do any serious damage. It was one of the few times I have been speechless...

But, if I could have legally flogged her...
 
Mike MacKinnon said:
Or I could explain it to you since i have written published journal articles on the topic.

As for Air Medical not being supported in 99% of case. There is absolutely no research to back this up. There is research, however, to prove it DOES make a difference in patient outcomes.

As far as physicians on helicopters, well all research on pt outcomes shows only one team to have the best outcomes of doc-rn, doc-emt-p, rn-rn, emt-p emt-p, rn emt-p. Its the last one RN EMT-P. Look it up.
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Welcome to SDN. Sources, please.
 
Apollyon said:
Welcome to SDN. Sources, please.
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I have to agree with Apollyon. I do not doubt the aeromedical services are a benefit occasionally. But, from my experience, they are largely glorified transport services. And, before you start flaming me, I have been involved in EMS for 14 years and have good friends that both work on and manage aeromedical services. I have no doubt that the crews are highly trained. But part of the reason for feeling this way is the fact that aeromedical transport services are widely publicized in order to increase run volume for profit. They are in essence, a large PR mechanism for the hospital. When they do training for fire departments or EMS services, they are quick to point out that they can be called for ANYTHING (regarding trauma). I just do not feel this is supported.


Most ground transport services are capable of managing a vast majority of these calls, as well as interfacility transports, with equal outcomes. In a few select cases I have witnessed, I would argue better outcome. Perhaps the choppers are justified for multisystem trauma where a level one trauma center is far away, or for very complicated cardiac patients, but otherwise they are an unnecessay expense.

My system did not utilize these services unless there was a prolonged extrication and they could be on scene by before or immediately after we got them out, otherwise we loaded and transported.

This message is not meant to diminish anyone that works for aeromedical services, but I do feel that this is the perception of many in prehospital medicine as well as some that work for air transport services.
 
Hello

Actually the artcile about how outcomes are changed was posted earlier. My article is entitled permissive hypotension in uncontrolled blunt or penetrating trauma and is in Air Medical Journal MArch-April edition 2005.

here are a few more:
An Analysis of an Air-Ambulance Program for Children.
Journal of Pediatric Orthopedics. 19(2):240-246, March/April 1999.
Letts, Merv M.D., F.R.C.S.C.; McCaffrey, Michael B.Sc.; Pang, Elizabeth B.Sc.; Lalonde, Francois M.D., F.R.C.S.C.

THE EVOLVING ROLE OF HELICOPTER EMERGENCY MEDICAL SERVICES IN THE TRANSFER OF STROKE PATIENTS TO SPECIALIZED CENTERS

Stephen H. Thomas A1, Christine Kociszewski A1, Lee H. Schwamm A1, Suzanne K. Wedel A1

# Air Medical Physician Association: Air Medical Physician Handbook. Blumen IJ, Rodenberg H, eds. 1996.
# Baxt WG, Moody P: The impact of a rotorcraft aeromedical emergency care service on trauma mortality. JAMA 1983 Jun 10; 249(22): 3047-51[Medline].
# Black RE, Mayer T, Walker ML, et al: Special report. Air transport of pediatric emergency cases. N Engl J Med 1982 Dec 2; 307(23): 1465-8[Medline].
# Bruhn JD, Williams KA, Aghababian R: True costs of air medical vs. ground ambulance systems. Air Med J 1993 Aug; 12(8): 262-8[Medline].
# Grines CL, Westerhausen DR, Grines LL, Grines LL: A randomized trial of transfer for primary angioplasty versus on-site thrombolysis in patients with high-risk myocardial infarction. J Amer Coll Cardiol 2002; 39: 1713-1719.
# Mann NC, Pinkney KA, Price DD: Injury mortality following the loss of air medical support for rural interhospital transport. Acad Emerg Med 2002; 9: 694-698.
# Suominen P, Silfvast T, Korpela R, Erosuo J: Pediatric prehospital care provided by a physician-staffed emergency medical helicopter unit in Finland. Pediatr Emerg Care 1996 Jun; 12(3): 169-72[Medline].
# Thomas SH, Cheema F, Wedel SK: Helicopter EMS trauma transport: Annotated review of selected outcomes-related literature. Prehosp Emerg Care 2002; 6: 359-371.
# Thomas SH, Cheema F, Cumming M: Nontrauma helicopter EMS transport: Annotated review of selected outcomes-related literature. Prehosp Emerg Care 2002; 6: 242-255.
# Thomas SH: Helicopter EMS transport literature: Annotated review of articles published 2000-2003. Prehosp Emerg Care 2004; 8: 322-333.
# Thomson DP, Thomas SH: Guidelines for air medical dispatch. Prehosp Emerg Care 2003 Apr-Jun; 7(2): 265-71[Medline].

Air Transport: Preparing a patient for transfer.
AJN, American Journal of Nursing. 104(12):49-53, December 2004.
Bird, Mark RN, CCRN, EMT-P; Stover-Wall, Tracey BSN, CCRN, CFRN, CEN

Association of Air Medical Services (AAMS): Rotorcraft Standards. Adopted at 6th

American College of Surgeons Committee on Trauma: Appendix D to Hospital Resources Document. Critical Care Air Ambulance Service. Approved June 8, 1986

Emergency Care Services and Trauma Mortality: A Multicenter Study. Ann Emerg Med; 1985; 14:859-864.

Cleveland HC, Miller JA: An Air Emergency Service: The Extension of the

Emergency Department. Top Emerq Med; 1979; 1:47 54.

Commission on Accreditation of Medical Transport Systems (CAMTS); Accreditation

Standards of CAMTS, Fourth Edition, October 1999

Kyes FN: National Flight Nurses Association: Liaison Committee Flight Programs

Data Report. Unpublished Raw Data: 1984.

Neel SH: Helicopter Evacuation in Korea. USAF Med J ; 1955: 6:691-702.

Neel SH: Army Aeromedical Evacuation Procedures in Vietnam. JAMA ; 1968;

204:99-103.

Rau W: 2000 Medical Crew Survey. AIRMED; Sept/Oct 2000; Vol. 6, No. 5; 17-22

Scheib BT, Foust J, Mueller W, et al: MAST: Military Assistance to Safety and

Traffic, A Decade of Service. JEMS; November, 1983; 38-45.

Shea, D: The Role of Nurses and Paramedics on EMS Rotorcraft. Trauma Quarterly;

May, 1985; 1:33-37.

U.S. Department of Health, Education and Welfare: Essentials and Guidelines for

the Education and Training of the Emergency Medical Technician - Paramedic .

Washington, D.C. U.S Department of Health, Education and Welfare, 1999.

U.S. Department of Transportation: National training course: Emergency Medical

Technician - Paramedic . (Module I and Course Guide). National Highway Traffic

Safety Administration. Washington, D.C.: U.S. Government Printing Office, 1999.

Approved by the Board of Directors of the Emergency Nurses Association, July 27,

1986, and by the Board of Directors of the Air & Surface Transport Nurses

Association, July 29, 1986

There are the references. I have more.


Apollyon said:
Welcome to SDN. Sources, please.
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Mike MacKinnon said:
Hello


Neel SH: Helicopter Evacuation in Korea. USAF Med J ; 1955: 6:691-702.

Neel SH: Army Aeromedical Evacuation Procedures in Vietnam. JAMA ; 1968;

204:99-103.

Scheib BT, Foust J, Mueller W, et al: MAST: Military Assistance to Safety and

Traffic, A Decade of Service. JEMS; November, 1983; 38-45.

Shea, D: The Role of Nurses and Paramedics on EMS Rotorcraft. Trauma Quarterly;

May, 1985; 1:33-37.

.
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I appreciate your attempt at references. However, it appeared more as if you were trying to throw a large list of useless junk at the group rather than a well thought out list of studies. One of these papers is 50 years old, others are over 20 to 30. If you want to prove a point please do it, but please do not waste everyones time with this approach.
 
Mike MacKinnon said:
Actually the artcile about how outcomes are changed was posted earlier. My article is entitled permissive hypotension in uncontrolled blunt or penetrating trauma and is in Air Medical Journal MArch-April edition 2005.
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It seems "I reject your reality and substitute it with my own!" may be a good tagline for you 😛

Now, when you post sources here it is generally helpful to link to an abstract and comment on the article itself. Some of you articles don't actually support the position you are advocating. For example, the link posted regarding permissive hypotension leads to an editorial by Dr. Maddox. In the bibliography prepared for that discussion, the following study is included: http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=12045644&query_hl=1 which concluded:
"Titration of initial fluid therapy to a lower than normal SBP during active hemorrhage did not affect mortality in this study. Reasons for the decreased overall mortality and the lack of differentiation between groups likely include improvements in diagnostic and therapeutic technology, the heterogeneous nature of human traumatic injuries, and the imprecision of SBP as a marker for tissue oxygen delivery"​

A Cochrane review (available here: http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=12917926&query_hl=4) also doesn't seem to support the idea.
"CONCLUSIONS: We found no evidence from randomised controlled trials for or against early or larger volume of intravenous fluid administration in uncontrolled haemorrhage. There is continuing uncertainty about the best fluid administration strategy in bleeding trauma patients. Further randomised controlled trials are needed to establish the most effective fluid resuscitation strategy."​
The gestalt being this is not really a "decided" matter yet. There are still significant questions, however, the closest thing to a nationalized standard of care, ATLS, still recommends volume resusitation.

Let's start to see what else we have here...

Mike MacKinnon said:
here are a few more:
An Analysis of an Air-Ambulance Program for Children.
Journal of Pediatric Orthopedics. 19(2):240-246, March/April 1999.
Letts, Merv M.D., F.R.C.S.C.; McCaffrey, Michael B.Sc.; Pang, Elizabeth B.Sc.; Lalonde, Francois M.D., F.R.C.S.C.
Click to expand...

The abstract is here: http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=10088697&query_hl=6

While the authors concluded :"The air-ambulance program for children in the Ottawa-Carleton Eastern Ontario areas, was found to be safe, effective, and allowed earlier specialized medical care to be provided.", they did no outcomes based measures. They merely denoted that their protocols seemed to provide a good screening tool for who "needed" to be flown. They also demonstrated that there were no untoward safety events (read accidents) involving crew injury. While this is laudable, the rules for EMS flight in Canada are markedly different than in the U.S. Canadian authorities require dual pilot, IFR, twin engine aircraft, and NVGs. The same are not required in the U.S. and thus conclusions regarding safety may not be generalizable. Lastly, the authors to concede (in the text)
"The second question regards urban versus rural use. Schiller et al. and Fischer et al. have come to the conclusion that there is no advantage to the use of the helicopter in an urban area with trained paramedics, given the high cost and potential hazards involved in urban helicopter landings. It would seem, therefore, that the patients to be chosen for AMS must be carefully selected, and its use limited to rural areas if it is to maximize cost and medical effectiveness"​

Mike MacKinnon said:
THE EVOLVING ROLE OF HELICOPTER EMERGENCY MEDICAL SERVICES IN THE TRANSFER OF STROKE PATIENTS TO SPECIALIZED CENTERS

Stephen H. Thomas A1, Christine Kociszewski A1, Lee H. Schwamm A1, Suzanne K. Wedel A1
Click to expand...

Abstract here: http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=11962569&query_hl=8

"RESULTS: There were 192 total transports, 76 (40%) pre-thrombolysis era and 116 (60%) thrombolysis era. Thrombolysis era patients were more likely (p < 0.0001) to have time of symptom onset documented, and also had significantly (p = 0.0003) shorter time intervals between referring and receiving hospital arrival. The shorter time intervals were due in part to decreased time lapse between referring hospital arrival and that hospital's request for helicopter transport; thrombolysis era patients were 2.5 times more likely than pre-thrombolysis era patients to have HEMS activation within three hours of community hospital arrival. CONCLUSIONS: Helicopter EMS transport is playing an increasing role in interfacility transfer of patients with ischemic stroke. Earlier HEMS activation is associated with decreased time lapse between referral and receiving hospital arrival."​

Once again, the article is a nice decscription but does not include outcomes. So how can it be determined if the helicopter actually made a difference. I will grant you that this demonstrates a higher likelihood of getting the CVA patient to a tertiary center more quickly if a helicopter is used, but does that actually translate to improved patient outcome?

Mike MacKinnon said:
# Air Medical Physician Association: Air Medical Physician Handbook. Blumen IJ, Rodenberg H, eds. 1996.
Click to expand...

I think we all agree there are textbooks on aeromedical transport

Mike MacKinnon said:
# Baxt WG, Moody P: The impact of a rotorcraft aeromedical emergency care service on trauma mortality. JAMA 1983 Jun 10; 249(22): 3047-51[Medline].
Click to expand...
Abstract: http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=6854826&query_hl=10

Now this paper seems to support your argument.
"The mortality of 150 consecutive trauma patients treated at the site of injury and transported to a trauma center by standard land prehospital care services was compared with that of 150 consecutive trauma patients treated at the site of injury and transported to the same trauma center by a rotorcraft aeromedical service staffed by a physician and nurse. A statistical analysis designed to predict mortality based on injury severity revealed that the mortality of the land group was statistically no different from that of a large index trauma patient population treated at a major trauma center. There was a 52% reduction in predicted mortality of the aeromedical group, which was highly significant."​

Except, look at the date. 1983. EMS was in its infancy. The "standard land prehospital care services" of 1983 are VERY different than those of today. Secondly, the article was based on a predicited model, not actual outcomes.

Mike MacKinnon said:
# Black RE, Mayer T, Walker ML, et al: Special report. Air transport of pediatric emergency cases. N Engl J Med 1982 Dec 2; 307(23): 1465-8[Medline].
Click to expand...

I could not find this article's abstract (or text) online. It is impossible for me to comment beyond again questioning the date of publication.

Mike MacKinnon said:
# Bruhn JD, Williams KA, Aghababian R: True costs of air medical vs. ground ambulance systems. Air Med J 1993 Aug; 12(8): 262-8[Medline].
Click to expand...

Abstract: http://www.ncbi.nlm.nih.gov/entrez/...&dopt=Abstract&list_uids=10127870&query_hl=17

"The model is based on a less than 30-minute response time to the patient, similar medical team staffing and equal service area. The annual budgetary cost of the replacement ground network is $3,804,000 while the helicopter ambulance costs are $1,686,500 (based on 1991 dollars). The cost per patient transported is $4,475 for the ground system and $2,811 for the helicopter system. The comparison finds that the commonly held notion that condemns helicopters as an excessively expensive technology for patient transport is incorrect."​

O.k., this is an interesting point. In some areas ground ALS EMS is distant. To create a ground based system that has "similar medical team staffing and equal service area" to a helicopter service would be very expensive. But does that matter? Let me give you an example, a city could reduce the amount of fire related damage it suffers annually by placing a fully manned fire engine at every intersection. But the cost would be incredible. That is similar to what is suggested here. Yes, it would be very expensive to build a ground based system with the same capacity as a helicopter service. That doesn't answer the question of "is that cost warranted?"

to be continued...
 
...
Mike MacKinnon said:
# Grines CL, Westerhausen DR, Grines LL, Grines LL: A randomized trial of transfer for primary angioplasty versus on-site thrombolysis in patients with high-risk myocardial infarction. J Amer Coll Cardiol 2002; 39: 1713-1719.
Click to expand...

Abstract: http://www.ncbi.nlm.nih.gov/entrez/...&dopt=Abstract&list_uids=12039480&query_hl=19

Interesting choice to include. The paper did not reach statistical significance. "CONCLUSIONS: Patients with high-risk AMI at hospitals without a catheterization laboratory may have an improved outcome when transferred for primary PTCA versus on-site thrombolysis; however, this will require further study. The marked delay in the transfer process suggests a role for triaging patients directly to specialized heart-attack centers." The reason I question your inclusion of this paper in support of air medical transport is the finding "The time from arrival to treatment was delayed in the transfer group (155 vs. 51 min, p < 0.0001), largely due to the initiation of transfer (43 min) and transport time (26 min)." From this the authors concluded the preferred model was actually for EMS to triage the patients directly to the tertiary center in the first place, "we found that even in this study situation, the transfer process is slow, with long delays at each component. This suggests that there may be a role for obtaining ECGs in the field, transferring the patient directly from the home to a "heart-attack center" or even providing primary PTCA in smaller hospitals without on-site surgical capability."

Mike MacKinnon said:
# Mann NC, Pinkney KA, Price DD: Injury mortality following the loss of air medical support for rural interhospital transport. Acad Emerg Med 2002; 9: 694-698.
Click to expand...

Abstract: http://www.ncbi.nlm.nih.gov/entrez/...&dopt=Abstract&list_uids=12093709&query_hl=21

See now this is interesting. The paper you cite found "Injury mortality increased with loss of air transport for interfacility transfer in a rural area." Yet almost the exact same study was done at another center (abstract here: http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=11901324&query_hl=2) and found "Discontinuation of a hospital-based air ambulance service did not increase transport time or increase mortality for trauma patients."


Do you get the idea? It is nowhere near as simple as you make it. Now I am not going to go through the entirity of your list. I don't have that much time. I will leave you however with a few citations of my own that raise some questions of their own. BTW - I am not decided yet on aeromedical transport. I provide it and have a blast doing it, but much like permissive hypotension, I think the jury is still out on its effect on outcomes.

Two papers for aeromedical transport are here:
http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=10589149&query_hl=2

http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=10724739&query_hl=2

One that suggests there might be some utility, but concludes further research is needed to identify populations who benefit is here:
http://www.ncbi.nlm.nih.gov/entrez/...ed&dopt=Abstract&list_uids=9420109&query_hl=2

This one dealing with pediatric patients found that there was a benefit for patients who truly required, but also found that 85% of calls in their study did not require the resources of the aeromedical team:
http://www.ncbi.nlm.nih.gov/entrez/...ed&dopt=Abstract&list_uids=8863261&query_hl=2

- H
 
Oh i realise there are studies in the opposite direction. As we all know statistics can be, and are made to form whatever outcome the author wants.
What i can say is i have seen the difference made first hand both as a recieving facility and as a air medical provider.

I do not advocate Air Medical transport in large metropolitan areas. Clearly this provides no change in outcome and may even delay transport. Many of the studies done which oppose AM are focused on this type. The studies in favor of AM are done on long distance transport times and extremely sick patients. Clearly this is where there is a signifigant difference.

As far as permissive hypotension. I would suggest the jury isnt out anymore. In fact it is taught and used on a regular basis in the military and the statistics coming out of Afganistan and Iraq (which i reference in the article) support it 100%. Slowly, it is becomming common practice in areas where OR's arent easily avaliable. It will find its niche prehospital and in small ER's. Even ATLS in its new guidelines will be recognizing it. Afterall, we would never treat a hypotensive leaky triple A with fluids. It would be a disaster and the uncontrolled hemmorhage is no different.

In anycase, excellent discussion!

FoughtFyr said:
...


Abstract: http://www.ncbi.nlm.nih.gov/entrez/...&dopt=Abstract&list_uids=12039480&query_hl=19

Interesting choice to include. The paper did not reach statistical significance. "CONCLUSIONS: Patients with high-risk AMI at hospitals without a catheterization laboratory may have an improved outcome when transferred for primary PTCA versus on-site thrombolysis; however, this will require further study. The marked delay in the transfer process suggests a role for triaging patients directly to specialized heart-attack centers." The reason I question your inclusion of this paper in support of air medical transport is the finding "The time from arrival to treatment was delayed in the transfer group (155 vs. 51 min, p < 0.0001), largely due to the initiation of transfer (43 min) and transport time (26 min)." From this the authors concluded the preferred model was actually for EMS to triage the patients directly to the tertiary center in the first place, "we found that even in this study situation, the transfer process is slow, with long delays at each component. This suggests that there may be a role for obtaining ECGs in the field, transferring the patient directly from the home to a "heart-attack center" or even providing primary PTCA in smaller hospitals without on-site surgical capability."



Abstract: http://www.ncbi.nlm.nih.gov/entrez/...&dopt=Abstract&list_uids=12093709&query_hl=21

See now this is interesting. The paper you cite found "Injury mortality increased with loss of air transport for interfacility transfer in a rural area." Yet almost the exact same study was done at another center (abstract here: http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=11901324&query_hl=2) and found "Discontinuation of a hospital-based air ambulance service did not increase transport time or increase mortality for trauma patients."


Do you get the idea? It is nowhere near as simple as you make it. Now I am not going to go through the entirity of your list. I don't have that much time. I will leave you however with a few citations of my own that raise some questions of their own. BTW - I am not decided yet on aeromedical transport. I provide it and have a blast doing it, but much like permissive hypotension, I think the jury is still out on its effect on outcomes.

Two papers for aeromedical transport are here:
http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=10589149&query_hl=2

http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=10724739&query_hl=2

One that suggests there might be some utility, but concludes further research is needed to identify populations who benefit is here:
http://www.ncbi.nlm.nih.gov/entrez/...ed&dopt=Abstract&list_uids=9420109&query_hl=2

This one dealing with pediatric patients found that there was a benefit for patients who truly required, but also found that 85% of calls in their study did not require the resources of the aeromedical team:
http://www.ncbi.nlm.nih.gov/entrez/...ed&dopt=Abstract&list_uids=8863261&query_hl=2

- H
Click to expand...
 
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