These will soon be commonplace.

[Guest guest]

,

I share your frustration with the studies. However, they DO reflect real

world experiences. You seem to be saying that you base your opinions on

anecdotal evidence, meaning, what you have observed. We all have observed

things

that seem to go against the evidence.

For example, I have had patients recover (for a short time) from asystole in

spite of all the odds, but my anecdotal experience doesn't contradict the

evidence that patients in asystole seldom survive. I have never had one walk

out

of the hospital intact two weeks later. The evidence also shows that.

You say that " air medical does make a difference " yet you offer nothing but

anecdotal experience. You are assuming that since the patient was airevaced

and survived, that it was the air evac that made the difference. I don't think

you can prove that to be the case. In fact, your patient may have survived

just as well if s/he had not been air evaced. Now, we have discussed stroke

window, and so forth, and I'm not in any way saying that there are NOT times

when

air is good, but there's no research evidence to prove that it made a

difference. Anecdotal, yes, but reseach, no.

Does that mean you should never use air? Of course not. But to allege that

it " does make a difference " is to make an assumption based upon anecdotal

information, not research. It's used much too much when it isn't warranted.

You want research that measures ALL services that use air evac. That ain't

gonna happen, as you well know. Research takes representative samples and

extrapolates the findings to wider applications. I don't know of ANY research

study that has ever encompassed ALL providers of whatever level. Studies are,

by

necessity, limited in scope, and few studies are so definitive that no

further research is necessary. It is a standard comment in most meta analyses

that

more research is necessary before definite conclusions can be drawn.

Now, here's where I do agree with you. Your comments about education are

right on target except for one. Being college based is no guarantee of quality

in education.

I worked in a college based program for years, but in the end, the college

destroyed the program because it determined that the program didn't make enough

profit. So it imposed limitations that made it impossible to carry on a

quality program. There are great college based programs and lousy college based

programs. Just being college based is no guarantee of quality in education.

OTOH, there ARE some privately run, and some hospital based programs that are

state of the art. Please don't assume that excellence depends upon college

affiliation. It does not.

ANY program ought to teach, at a minimum, the basics of medical science,

patient assessment, and a myriad of other subjects that will enable the medic to

have a global view of emergency medicine and all the tools to implement sound,

critically thought out, patient care. You are right about this.

Many programs around the country do not do this, but they are not confined to

non-college programs. The main reason that education programs fail is the

hourly limitations imposed by fire chiefs and private EMS management. They want

a body with a patch as soon as possible, and they are not usually either

aware of quality issues nor interested in them.

A good program is a good program, and whether it be independent, hospital

based, service based, or college based, it ought to be judged by the same

principles.

National accreditation is nice to have, but in no way does it equate to

quality in a program. There's no study that proves that. Some of the worst

programs in the state have been accredited for a long time, and some of the best

have never been nationally accredited.

National accreditation is a process that helps a program assess itself and

meet certain goals, but the mere fact that a program is accredited bears little

relationship to its success in instruction. In fact, accreditation does not

place much emphasis on assesment of results. It is more oriented to the

bureaucratic aspects of a program. Believe me, accreditation has little

correlation

with success in instruction.

You correctly mention that EMS education programs ought to be regulated.

Unfortunately, under the present structure of the DSHS, it is impossible for the

staff of the EMS Office to adequately regulate education programs around the

state. There is simply not enough staff to go around.

This is why we need an independent EMS Commission, reporting directly to the

Governor, and not under the structure of another mega-agency which can dilute

the effectiveness of regulatory staff simply through the normal attrition of

personnel and budgetary limitations on staff, together with total fragmentation

of the mission that EMS regulators ought to be able to do.

We need better education, but the answer to that is NOT to require all

programs to be college based, because not all colleges do a good job with it.

I'm biased. I used to be with a college based program, and at one time I was

an advocate of college based programs. But now I teach for an independent

program, and an online college, and I must say that I think these programs do a

better job than many college based programs. Your mileage may differ, but

this is what I think.

Bottom line: Education rules. But it must be quality education. All EMS

practice, including use of air evac, depends upon knowledge, experience,

critical thinking, and judgment. We all want medics who are capable of critical

thinking, who are knowledgeable of the basic facts of medical practice, anatomy

and physiology, possess the ability to think critically and exercise independent

judgment while working under the license of a medical control physician.

Unfortunately, only a few medics meet that standard. Many who could choose

to leave EMS for nursing or medicine because of monetary considerations. How

can we keep the best medics in our profession? By making it a profession, and

as you say, making it education driven. But the folks who control EMS, the

fire chiefs and the private EMS managers, for the most part, do not have an

interest in this because it impacts their budgets and profits. That's too bad,

but it's fact.

GG.

In a message dated 4/21/06 10:16:59 Central Daylight Time, wjince@...

writes:

> Everyone on this list is concerned with numerous research studies that have

> been done but few to none have mentioned real world experiences. I know

> what I have seen and that is the air medical does indeed make a difference.

> What I have gathered from these numerous studies is that the system has been

> used too much by some providers. This does increase the risk overall in the

> statistical sense; however I do not believe that all services and their use

> of air medical is shown in any of these studies. I know some medics who

> would fly anything and others who don't fly anything. All I have said is

> that air medical has a useful legitimate place in EMS when utilized

> correctly. Those studies that have been posted are not the end all of this

> discussion. They all say further research is necessary. A major issue in

> this field is education and credibility. As long as we allow anyone with a

> building to teach EMS and not an accredited college institution teach the

> new medics then we will never move forward. I believe that education is the

> main reason that these studies are showing so much negativity. Numerous

> programs do not teach new medics how to assess a patient properly and

> thoroughly. When someone is going via air medical transport then It should

> be a necessary situation based on the patients condition, not solely based

> on the mechanism of injury. All the posts I have seen on this list in the

> past about regulation and governance of our industry have left out education

> for the most part. Why not start with regulations that govern who can

> educate the next group of medics? We have progressed from the era of

> workforce education and are now truly a profession so why not require our

> members to be educated like any other professional group?

>

> Ince

>

> " He who dares, wins! "

>

>

[Guest guest]

In a message dated 21-Apr-06 18:24:09 Central Daylight Time, N5XNU@...

writes:

I've run across paramedics that would

fly a patient because the unit would be out of service for an hour or so if

they didn't fly. Again, that doesn't make sense.

sometimes it might...IF the patient appears to be more than the local

facility can handle, *AND* it will take a sole remaining unit in the local area

out

of service for an extended period of time, THEN it makes sense to seek a

means of transport outside of local assets.

ck

S. Krin, DO FAAFP

[Guest guest]

I agree with Chuck. If you only have one active truck and to get your

patient 150 miles to the cathlab, then helo is justified.

In our conversations on this, we have all taken certain positions based upon

our central feelings, but all of us recognize that there are exceptions to any

rule, based upon the specific facts of the situation.

What most of us have been trying to say is that protocols for this and that

are just guidelines and can be subject to deviation, as needed.

The bottom line is that there is no substitute for judgment and critical

thinking, based upon the situation that you're faced with.

What must not happen is blind adherence to a written protocol without

consideration of the dynamics of every call.

You've got to know when to fold em, and know when to hold em.

GG

In a message dated 4/23/06 23:04:06 Central Daylight Time, krin135@...

writes:

> Subj:Re: These will soon be commonplace.

> Date:4/23/06 23:04:06 Central Daylight Time

> From:krin135@...

> Reply-to:texasems-l

> To:texasems-l

> Sent from the Internet

>

>

>

>

> In a message dated 21-Apr-06 18:24:09 Central Daylight Time, N5XNU@...

> writes:

>

> I've run across paramedics that would

> fly a patient because the unit would be out of service for an hour or so

> if

> they didn't fly. Again, that doesn't make sense.

>

>

> sometimes it might...IF the patient appears to be more than the local

> facility can handle, *AND* it will take a sole remaining unit in the local

> area out

> of service for an extended period of time, THEN it makes sense to seek a

> means of transport outside of local assets.

>

> ck

>

> S. Krin, DO FAAFP

>

>

>

>

[Guest guest]

In a message dated 24-Apr-06 07:17:58 Central Daylight Time,

bbledsoe@... writes:

Just because you only have one truck available, you are going to use a

modality that is quite expensive and considerably more dangerous? Just as

with the use of lights and sirens, the choice to use a helicopter should be

based solely on the patient's condition or perhaps unique ingress or egress

issues. Thus is the need for mutual aid programs. This is akin to running

with lights and siren just because the system is busy. It exposes the

patient to unnecessary risks. It would be hard to defend to a jury if there

were many similarities to the South Carolina case.

Which is worse? say the patient NEEDS definitive care NOT available in the

local facility...you already have two of your three rigs on the road taking

other patients to different distant facilities (so you didn't even have the

option of adding a second medic and loading two into one truck)...you have ONE

truck left to cover a 30 mile radius from your hospital.

You got lucky and found a stroke in evolution 30 minutes after it occurred,

but your CT scanner is down so you can not confirm lack of bleeding...and the

patient is young (50s male) and was walking, talking and potty trained (and

making a 6 figure salary yesterday) and needs to go to the stroke center 3

hours away by ground...in his home town (he was visiting his aged parents in

your small town)...he is now drooling from the right side of his mouth, aphasic

and can't move his right arm, but has decent reflexes in his right leg and

can lift his knee abet weakly...He has a significant bruit in his LEFT

carotid...you have no vascular imaging capability because it's the weekend and

you're are depending on TeleRad, and your covering surgeon will not consider

hacking the carotid without a decent angiogram.

by the time the ground CCU team from the receiving hospital gets there, a

mutual aid team can arrive or even one of your own trucks gets back into

effective range), you will be beyond the window for effective treatment, much

less

after he spends another three hours on the road.

His young wife and six kids, ranging from 6 to 18 are looking at you

expectantly...

Now if you are talking about a simple 'return haul' transport, I'll agree

that the patient could wait until one of the ground units can cover and the

first truck can leave....but there is a place for a unit that can make a rapid

transition 'door to door'...and yes, while I have exaggerated facets of this

case, we had a similar case when I was down in Western Louisiana last year.

Due to weather, we were unable to send the patient to the best facility

available (in Shreveport, where the guy was an executive) but sent him to

andria

instead (much closer to us, and they did a decent job, but it was very tough

on the family for the two weeks until he was stable enough to transfer back

to Shreveport for the rest of his rehab)...

What if that had happened in North Central Texas, and the guy had to go to

Wichita Falls instead of Fort Worth/Dallas or Amarillo?

ck

S. Krin, DO FAAFP

[Guest guest]

I agree. There are no absolutes. The crew on the ground has to look at all

of the variables and make the decision to fly or not fly based on what's

best for the patient.

Kirk

EMT-B

[Guest guest]

Just because you only have one truck available, you are going to use a

modality that is quite expensive and considerably more dangerous? Just as

with the use of lights and sirens, the choice to use a helicopter should be

based solely on the patient's condition or perhaps unique ingress or egress

issues. Thus is the need for mutual aid programs. This is akin to running

with lights and siren just because the system is busy. It exposes the

patient to unnecessary risks. It would be hard to defend to a jury if there

were many similarities to the South Carolina case.

Re: These will soon be commonplace.

I agree with Chuck. If you only have one active truck and to get your

patient 150 miles to the cathlab, then helo is justified.

In our conversations on this, we have all taken certain positions based upon

our central feelings, but all of us recognize that there are exceptions to

any

rule, based upon the specific facts of the situation.

What most of us have been trying to say is that protocols for this and that

are just guidelines and can be subject to deviation, as needed.

The bottom line is that there is no substitute for judgment and critical

thinking, based upon the situation that you're faced with.

What must not happen is blind adherence to a written protocol without

consideration of the dynamics of every call.

You've got to know when to fold em, and know when to hold em.

GG

In a message dated 4/23/06 23:04:06 Central Daylight Time, krin135@...

writes:

> Subj:Re: These will soon be commonplace.

> Date:4/23/06 23:04:06 Central Daylight Time

> From:krin135@...

> Reply-to:texasems-l

> To:texasems-l

> Sent from the Internet

>

>

>

>

> In a message dated 21-Apr-06 18:24:09 Central Daylight Time, N5XNU@...

> writes:

>

> I've run across paramedics that would

> fly a patient because the unit would be out of service for an hour or so

> if

> they didn't fly. Again, that doesn't make sense.

>

>

> sometimes it might...IF the patient appears to be more than the local

> facility can handle, *AND* it will take a sole remaining unit in the local

> area out

> of service for an extended period of time, THEN it makes sense to seek a

> means of transport outside of local assets.

>

> ck

>

> S. Krin, DO FAAFP

>

>

>

>