October 8, 2008

Panel to Review Medevac Guidelines

By EARL KELLY Staff Writer

BALTIMORE - A national panel will review the protocols Maryland uses to determine which patients are taken from accident scenes to trauma centers, state officials said Monday.

Also, starting as soon as the state can get the process in place, paramedics must begin consulting a trauma center physician before sending a patient to a trauma center.

The new requirements apply in cases where patients don't show signs of serious injury, officials said.

"Let's be clear, ladies and gentlemen, emergency triage is not a precise science," Dr. Thomas M. Scalea, physician-in-chief at Maryland Shock Trauma Center in Baltimore, said at the hospital. "These are complicated issues."

"We are determined this tragedy will have some positive outcomes. We welcome a national review."

The review comes after the fatal crash Sept. 27 of a state police medevac helicopter that killed all three crew members and one patient, and seriously injured another.

Maryland is the only place where state police provide a centralized, statewide medevac system. No one from the agency spoke at Monday's media briefing. The two patients involved in the crash were being transported from a car accident to a trauma hospital. They had Priority 2 non-life threatening injuries, officials said.

Dr. Robert Bass, executive director of the Maryland Institute for Emergency Medical Services Systems, said the national panel of experts will review the triage protocols Maryland paramedics use in the field.

The protocols were updated just a year ago following a two-year review, Dr. Bass said, and are based on the model designed by the American College of Surgeons. Yet, about 50 percent of patients transported by state police helicopters are treated and released within 24 hours.

Dr. Scalea, a strong defender of existing protocols, said anyone who uses this statistic as a yardstick for determining that patients are being taken to trauma centers unnecessarily is guilty of "unsophisticated" thinking.

"Saying 50 percent of patients walk out within 24 hours is a great sound bite, but masks the truth," Dr. Scalea said.

The American College of Surgeons has established that it is permissible to have between 25 percent and 50 percent of patients admitted to trauma centers but whose injuries prove minor, Dr. Scalea said.

"What's the better risk, sending too many patients to the trauma center ... or sending too few," Dr. Scalea said.

The panel of experts will be assembled as soon as schedules will permit, Dr. Bass said.

The review will focus on "mechanism of injury cases," a category where patients display no sign of serious injury but are transported to trauma centers, often by Maryland State Police helicopter.

"We are trying to pull in people who are national experts," Dr. Bass said. "We want middle-of-the road folks" who don't have a strong position on the issues to be covered.

Del. Bob Costa, R-Deale, a career paramedic, said this morning that he is skeptical that Dr. Bass and Dr. Scalea will select medical experts who disagree with existing standards.

"It's just a matter of whether they will let enough people come in on both sides." Mr. Costa said.

"I hope they will have some EMS field personnel on this panel. They have to look at the whole perspective, and I hope they would have some local community-based emergency medicine physicians (from local hospitals) on it; if they are going to have a panel of just elitist trauma physicians on there, nothing is going to change."

One national expert who said he does not expect to be invited is Dr. Clayton H. Shatney, who worked with the Maryland trauma system's founder, Dr. R Adams Cowley.

Dr. Shatney, who established trauma centers in Florida and California, has long disagreed with the widespread use of helicopters in trauma care.

Helicopters are expensive to purchase and maintain, and dangerousto operate, he said, and have little or no benefit over ground transportation.

"The helicopter industry has done a PR program for the past 20 years," he said. "They have sold our trauma centers and John Q. Public on helicopters."

Dr. Shatney said the "mechanism of injury" standard for selecting patients for trauma care is outdated, especially as they apply to car accidents.

Under existing protocols, patients in car accidents qualify for trauma care if there has been an intrusion into the passenger compartment of 12 inches on the driver's side or 18 inches in any area.

"The standards were developed in the 1970s and 1980s, but today all the cars are built like race cars," Dr. Shatney said. "The cars are made to collapse to protect the passengers, so all this mechanism of injury stuff is specious."

As for the new requirement that field paramedics must consult a trauma physician before sending a patient to a trauma center, Dr. Bass said the conversation will take only about "60 to 90 seconds."

"It is to enable them to take a momentary pause during a chaotic and stressful incident," Dr. Bass said. "This requirement will remain in place until further notice and until its impact is reviewed and analyzed."

Mr. Costa disagreed and said it could take several minutes just to get a doctor at a trauma center to come to the phone.

"I can understand the concept of why they want to do it because they want to manage the scene a little bit better," Mr. Costa said, "but they ought to let the paramedic use his discretion."

The key to reforming the system, Mr. Costa said, is rewrite the protocols for determining which patients are sent to trauma centers.

Dr. Bass and Dr. Scalea emphasized in announcing the review panel and the new procedures for field paramedics, that paramedics involved in transporting patients aboard the ill-fated helicopter on Sept. 27 complied fully with existing state requirements.

Scott Wells, father of Jordan Wells, 18, and the survivor of the helicopter crash, appeared briefly at the news conference.

Ms. Wells was being transported by helicopter with bruises and pain from a car accident in Waldorf shortly before midnight on Sept. 27 when the helicopter crashed in Prince George's County, possibly in a weather-related incident.

"Her mother and I are extremely grateful for the paramedics and pilot who came out that night," Mr. Wells said. "I am not going to say it hasn't been a nightmare."

Dr. Scalea said Miss Wells, who is in critical but stable condition at the trauma center in Baltimore, "has a long rehabilitation ahead of her ... It is a 12-month process."

State police grounded its remaining 11 helicopters following the crash, but said this morning that two bases are operational, one outside Baltimore and the other in St. Mary's County. The National Park Service is staffing the base in Frederick.

The major issue in grounding the fleet, said state police spokesman Greg Shipley, is testing the glide scope equipment. Preliminary results indicate that this equipment, which helps pilots land in bad weather, may have malfunctioned in the helicopter that crashed.

Mr. Shipley said state police hope to have two more hangars operational by Thursday.

The crash remains under investigation by the National Transportation Safety Board.--- {Corrections:} {Status:}

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