miemssemblem.jpgThis letter is copied from the Maryland EMS Newsletter for October 2008.  It is a response from our state medical director to perceptions about Maryland’s aeromedical transport system, how often it is used, and the need for major overhaul to the service.

It follows the investigation into the recent crash of Maryland Trooper 2, a Maryland State Police medevac helicopter, causing the deaths of the pilot, flight paramedic/trooper, a ground EMS provider and one of two patients on board.

The words are his.  The italics and emphasis are my editorial additions.

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From Dr. Scalea . . .

(On October 10, 2008, Dr. Thomas Scalea, Physician-in-Chief at the R Adams Cowley Shock Trauma Center, sent the following letter to the Maryland EMS Community. It is reprinted here in its entirety.)

To My EMS Friends and Family:

The recent crash of a Maryland State Police Medevac helicopter reminds us of the constant risk faced by everyone who serves in the emergency medical response system. We mourn the loss of colleagues who devoted and ultimately sacrificed their lives for others. We also mourn a young accident victim whose life was cut tragically short, even as we work to speed the recovery of the second victim who survived the doomed flight.

In the aftermath of this, much has been said about Maryland’s medical emergency response system. Some critics have called into question the use

or overuse, as they suggest

of helicopter transports to trauma centers. Regrettably, what has been missing from this public dialogue is an informed and balanced medical perspective on appropriate triage and Medevac utilization.

I am writing to you to express my steadfast resolve to sustain the exceptional quality of Maryland’s prehospital trauma system, and to thank you for the contributions you make to the system’s success. It is no exaggeration to say Maryland is a model for the nation and the world.

  • Is our system perfect? No.
  • Can our system be improved? Yes.
  • Are all of us who work in trauma care committed to making it even better? Absolutely.

In the wake of this tragedy, I fear that some will seek to weaken our system, forgetting that the genius of Maryland’s trauma response system is its singular focus on doing what is best for the patient, not what is best for Shock Trauma, or Johns Hopkins, or the Medevac fleet.

Much has been made of the protocols that you and your colleagues use to make life-critical decisions about how best to respond to an injured patient’s condition. As you are well aware, the most current protocols were implemented in just the past year. As much as all of us would like certainty in every decision we make in life, you know first-hand that triage at a crash site cannot be perfect. While our shared goal is to send the right patient to the right place within the right amount of time, you must make quick decisions in the field, often under difficult conditions, and without the added benefit of sophisticated diagnostic technology.  When you call me on the radio to give your report, you are there with the patient; I am not. I must trust in your training and your judgment, and I do.

To critics of our system, I ask:

“What if the injured patient was your child or your loved one? Which risk would you rather we take: send too many to the trauma center within the recommended time limit, or send too few? Send too many, and we risk being accused of wasteful spending. Send too few, and we risk patients dying who would otherwise be saved.”

Critics note that nearly half of the patients sent to Maryland trauma centers by helicopter are discharged within 24 hours. That makes a great sound-bite, but like many sound-bites, it masks the truth. Trauma centers are designed to quickly and accurately determine which patients have sustained serious injury, and then utilize the needed resources to save lives. Typical Emergency Departments (EDs) are not equipped to do the same.

“National trauma standards suggest that over-triage is not only to be expected, it is absolutely necessary to avoid needless loss of life.”

The American College of Surgeons’ recommended rate of over-triage is up to 50%, a range consistent with our experience in Maryland. In making triage decisions, we must err on the side of the patient.

What then about the protocol known as “mechanism only,” which involves triaging patients to trauma centers based only on the circumstance of the crash. You know as well as I the possibility of unseen internal injuries. On countless occasions, I have treated trauma victims whose outward appearance and alertness belied the severity of their injuries. I have seen patients who gave every appearance of being “okay” suddenly deteriorate — a situation only a trauma center is prepared to treat. Some suggest that these suspected cases should be sent first to the nearest ED, where their injuries, or lack thereof, can be documented. Time, however, is the enemy of trauma care. The time it would take to make a definitive trauma diagnosis in a typical ED setting, and then arrange for transport by helicopter or ambulance, is time the patient often cannot afford.

Those of us who work in trauma care must be determined that this recent tragedy will have some positive outcome. We will embrace whatever lessons we can learn. We welcome an objective review of how our system in Maryland applies national standards of field triage and medevac utilization. We have a responsibility to assure the public that our policies and protocols are grounded in good science and good medicine. Nonetheless, I reject the notion that it is acceptable to let people die to save money.

The public needs to know that the system is working, that it is safe, and that it remains the best in the nation. In defending the quality of our system against those who would seek to diminish it, I know I speak for all trauma physicians in Maryland. I have received many emails and calls from EMS providers throughout the state who share this same concern. Most important, I know I speak for the tens of thousands of patients, and their families, whose lives have been shattered by injury, and whose recovery would not have been possible without Maryland’s vaunted trauma response system.

God bless you for the work you do everyday. Please join me in keeping this issue at the forefront when it is debated and decisions are made.

Thomas M. Scalea, MD, FACS
Physician-in-Chief
R Adams Cowley Shock Trauma Center

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I’ll be following up on this in a future episode but I think two salient points are outlined in bold above.  I’ll reiterate them here, too.

“Send too many, and we risk being accused of wasteful spending. Send too few, and we risk patients dying who would otherwise be saved.”

“National trauma standards suggest that over-triage is not only to be expected, it is absolutely necessary to avoid needless loss of life.”

I’ve been vocal calling for the institution of safer transportation rules regarding flying in questionable weather.  I stand behind that call.

What I don’t want to see is the budget watchdogs who don’t understand the nature of the problem, and those private medevac services interested in taking over a public service so they can make money off it, using their considerable resources trying to break a system that has saved thousands of lives.

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