RE: Corpus Christi newspaper reports on EMS response to Cheney ...

February 17, 2006

Let's get down to the nitty gritty. Unless we were there, we really have no

business speculating about what we would have done about transport

priorities.

It all comes down to good clinical judgment, which I know my good friend

Henry has, and which I hope to hell I have.

As I have said on many occasions with regard to lawsuits, every case turns

upon its own unique set of facts. So it is with medicine.

Generally speaking, I'm against flying patients. I have done it, however,

when the patient was off in the boonies on some ranch with a femur fracture and

the bumpy ride in the truck would have probably exacerbated the injury and

outweighed the risk of air transport.

What's important is not whether you or I would have done with Poor Harry,

it's whether or not we understand fully the implications of what we do and that

we use good clinical judgment in making these decisions.

Some seem to feel that helicopters possess some magic curative powers. They

don't. They are a useful tool under the right circumstances, but each of

such circumstances must be determined by good clinical judgment.

And, BTW, using good clinical judgment is the best way to keep the lawyers

away.

Gene.

>

> In a message dated 2/17/2006 8:30:18 A.M. Central Standard Time,

> hbarber@... writes:

>

> Dr. B, Gene and others that people look up to, if

> we keep going down this path younger medics that read your post may

> interpret that helicopters have no place in EMS and should not be used.

>

> I'll let them defend or not their own comments but I've never once heard

> anyone on this list that is among those you mention advocate that there is

> NO

> PLACE just mis-use and or really over use of same.

>

> Louis N. Molino, Sr., CET

> FF/NREMT-B/FSI/EMSI

> LNMolino@...

> (Office)

> (Office Fax)

> (Cell Phone)

>

> " A Texan with a Jersey Attitude "

> " Great minds discuss ideas; Average minds discuss events; Small minds

> discuss people. "

> Eleanor Roosevelt

>

> The comments contained in this E-mail are the opinions of the author and

> the

> author alone. I in no way ever intend to speak for any person or

> organization that I am in any way whatsoever involved or associated with

> unless I

> specifically state that I am doing so. Further this E-mail is intended only

> for its

> stated recipient and may contain private and or confidential materials

> retransmission is strictly prohibited unless placed in the public domain by

> the

> original author.

>

February 17, 2006

Let's get down to the nitty gritty. Unless we were there, we really have no

business speculating about what we would have done about transport

priorities.

It all comes down to good clinical judgment, which I know my good friend

Henry has, and which I hope to hell I have.

As I have said on many occasions with regard to lawsuits, every case turns

upon its own unique set of facts. So it is with medicine.

Generally speaking, I'm against flying patients. I have done it, however,

when the patient was off in the boonies on some ranch with a femur fracture and

the bumpy ride in the truck would have probably exacerbated the injury and

outweighed the risk of air transport.

What's important is not whether you or I would have done with Poor Harry,

it's whether or not we understand fully the implications of what we do and that

we use good clinical judgment in making these decisions.

Some seem to feel that helicopters possess some magic curative powers. They

don't. They are a useful tool under the right circumstances, but each of

such circumstances must be determined by good clinical judgment.

And, BTW, using good clinical judgment is the best way to keep the lawyers

away.

Gene.

>

> In a message dated 2/17/2006 8:30:18 A.M. Central Standard Time,

> hbarber@... writes:

>

> Dr. B, Gene and others that people look up to, if

> we keep going down this path younger medics that read your post may

> interpret that helicopters have no place in EMS and should not be used.

>

> I'll let them defend or not their own comments but I've never once heard

> anyone on this list that is among those you mention advocate that there is

> NO

> PLACE just mis-use and or really over use of same.

>

> Louis N. Molino, Sr., CET

> FF/NREMT-B/FSI/EMSI

> LNMolino@...

> (Office)

> (Office Fax)

> (Cell Phone)

>

> " A Texan with a Jersey Attitude "

> " Great minds discuss ideas; Average minds discuss events; Small minds

> discuss people. "

> Eleanor Roosevelt

>

> The comments contained in this E-mail are the opinions of the author and

> the

> author alone. I in no way ever intend to speak for any person or

> organization that I am in any way whatsoever involved or associated with

> unless I

> specifically state that I am doing so. Further this E-mail is intended only

> for its

> stated recipient and may contain private and or confidential materials

> retransmission is strictly prohibited unless placed in the public domain by

> the

> original author.

>

February 17, 2006

Gene Gandy wrote, “And, BTW, using good clinical judgment is the best way to

keep the lawyers

away.”

Also, garlic and crucifixes.

_____

From: [mailto: ] On

Behalf Of wegandy1938@...

Sent: Friday, February 17, 2006 5:59 PM

To: LNMolino@...;

Subject: Re: Corpus Christi newspaper reports on EMS response

to Cheney ...

Let's get down to the nitty gritty. Unless we were there, we really have

no

business speculating about what we would have done about transport

priorities.

It all comes down to good clinical judgment, which I know my good friend

Henry has, and which I hope to hell I have.

As I have said on many occasions with regard to lawsuits, every case turns

upon its own unique set of facts. So it is with medicine.

Generally speaking, I'm against flying patients. I have done it, however,

when the patient was off in the boonies on some ranch with a femur fracture

and

the bumpy ride in the truck would have probably exacerbated the injury and

outweighed the risk of air transport.

What's important is not whether you or I would have done with Poor Harry,

it's whether or not we understand fully the implications of what we do and

that

we use good clinical judgment in making these decisions.

Some seem to feel that helicopters possess some magic curative powers.

They

don't. They are a useful tool under the right circumstances, but each of

such circumstances must be determined by good clinical judgment.

And, BTW, using good clinical judgment is the best way to keep the lawyers

away.

Gene.

>

> In a message dated 2/17/2006 8:30:18 A.M. Central Standard Time,

> hbarber@... writes:

>

> Dr. B, Gene and others that people look up to, if

> we keep going down this path younger medics that read your post may

> interpret that helicopters have no place in EMS and should not be used.

>

> I'll let them defend or not their own comments but I've never once heard

> anyone on this list that is among those you mention advocate that there is

> NO

> PLACE just mis-use and or really over use of same.

>

> Louis N. Molino, Sr., CET

> FF/NREMT-B/FSI/EMSI

> LNMolino@...

> (Office)

> (Office Fax)

> (Cell Phone)

>

> " A Texan with a Jersey Attitude "

> " Great minds discuss ideas; Average minds discuss events; Small minds

> discuss people. "

> Eleanor Roosevelt

>

> The comments contained in this E-mail are the opinions of the author and

> the

> author alone. I in no way ever intend to speak for any person or

> organization that I am in any way whatsoever involved or associated with

> unless I

> specifically state that I am doing so. Further this E-mail is intended

only

> for its

> stated recipient and may contain private and or confidential materials

> retransmission is strictly prohibited unless placed in the public domain

by

> the

> original author.

>

February 17, 2006

Gene Gandy wrote, “And, BTW, using good clinical judgment is the best way to

keep the lawyers

away.”

Also, garlic and crucifixes.

_____

From: [mailto: ] On

Behalf Of wegandy1938@...

Sent: Friday, February 17, 2006 5:59 PM

To: LNMolino@...;

Subject: Re: Corpus Christi newspaper reports on EMS response

to Cheney ...

Let's get down to the nitty gritty. Unless we were there, we really have

no

business speculating about what we would have done about transport

priorities.

It all comes down to good clinical judgment, which I know my good friend

Henry has, and which I hope to hell I have.

As I have said on many occasions with regard to lawsuits, every case turns

upon its own unique set of facts. So it is with medicine.

Generally speaking, I'm against flying patients. I have done it, however,

when the patient was off in the boonies on some ranch with a femur fracture

and

the bumpy ride in the truck would have probably exacerbated the injury and

outweighed the risk of air transport.

What's important is not whether you or I would have done with Poor Harry,

it's whether or not we understand fully the implications of what we do and

that

we use good clinical judgment in making these decisions.

Some seem to feel that helicopters possess some magic curative powers.

They

don't. They are a useful tool under the right circumstances, but each of

such circumstances must be determined by good clinical judgment.

And, BTW, using good clinical judgment is the best way to keep the lawyers

away.

Gene.

>

> In a message dated 2/17/2006 8:30:18 A.M. Central Standard Time,

> hbarber@... writes:

>

> Dr. B, Gene and others that people look up to, if

> we keep going down this path younger medics that read your post may

> interpret that helicopters have no place in EMS and should not be used.

>

> I'll let them defend or not their own comments but I've never once heard

> anyone on this list that is among those you mention advocate that there is

> NO

> PLACE just mis-use and or really over use of same.

>

> Louis N. Molino, Sr., CET

> FF/NREMT-B/FSI/EMSI

> LNMolino@...

> (Office)

> (Office Fax)

> (Cell Phone)

>

> " A Texan with a Jersey Attitude "

> " Great minds discuss ideas; Average minds discuss events; Small minds

> discuss people. "

> Eleanor Roosevelt

>

> The comments contained in this E-mail are the opinions of the author and

> the

> author alone. I in no way ever intend to speak for any person or

> organization that I am in any way whatsoever involved or associated with

> unless I

> specifically state that I am doing so. Further this E-mail is intended

only

> for its

> stated recipient and may contain private and or confidential materials

> retransmission is strictly prohibited unless placed in the public domain

by

> the

> original author.

>

February 17, 2006

Flying a Pt. does not and should not have anything to do with how good you think

your skills are as a medic except one (assessment). If you have the ability to

recognize the cause of the concern whether it be medical or trauma and how

serious it is and know what you local hospital can handle. Time is precious and

does not need to be wasted at a facility that can not provide proper care. My

local hospital is a level four and can provide very little care for Pt's who

require advanced surgical intervention.

" Bledsoe, DO " wrote: Gene Gandy wrote, “And,

BTW, using good clinical judgment is the best way to

keep the lawyers

away.”

Also, garlic and crucifixes.

_____

From: [mailto: ] On

Behalf Of wegandy1938@...

Sent: Friday, February 17, 2006 5:59 PM

To: LNMolino@...;

Subject: Re: Corpus Christi newspaper reports on EMS response

to Cheney ...

Let's get down to the nitty gritty. Unless we were there, we really have

no

business speculating about what we would have done about transport

priorities.

It all comes down to good clinical judgment, which I know my good friend

Henry has, and which I hope to hell I have.

As I have said on many occasions with regard to lawsuits, every case turns

upon its own unique set of facts. So it is with medicine.

Generally speaking, I'm against flying patients. I have done it, however,

when the patient was off in the boonies on some ranch with a femur fracture

and

the bumpy ride in the truck would have probably exacerbated the injury and

outweighed the risk of air transport.

What's important is not whether you or I would have done with Poor Harry,

it's whether or not we understand fully the implications of what we do and

that

we use good clinical judgment in making these decisions.

Some seem to feel that helicopters possess some magic curative powers.

They

don't. They are a useful tool under the right circumstances, but each of

such circumstances must be determined by good clinical judgment.

And, BTW, using good clinical judgment is the best way to keep the lawyers

away.

Gene.

>

> In a message dated 2/17/2006 8:30:18 A.M. Central Standard Time,

> hbarber@... writes:

>

> Dr. B, Gene and others that people look up to, if

> we keep going down this path younger medics that read your post may

> interpret that helicopters have no place in EMS and should not be used.

>

> I'll let them defend or not their own comments but I've never once heard

> anyone on this list that is among those you mention advocate that there is

> NO

> PLACE just mis-use and or really over use of same.

>

> Louis N. Molino, Sr., CET

> FF/NREMT-B/FSI/EMSI

> LNMolino@...

> (Office)

> (Office Fax)

> (Cell Phone)

>

> " A Texan with a Jersey Attitude "

> " Great minds discuss ideas; Average minds discuss events; Small minds

> discuss people. "

> Eleanor Roosevelt

>

> The comments contained in this E-mail are the opinions of the author and

> the

> author alone. I in no way ever intend to speak for any person or

> organization that I am in any way whatsoever involved or associated with

> unless I

> specifically state that I am doing so. Further this E-mail is intended

only

> for its

> stated recipient and may contain private and or confidential materials

> retransmission is strictly prohibited unless placed in the public domain

by

> the

> original author.

>

February 17, 2006

Flying a Pt. does not and should not have anything to do with how good you think

your skills are as a medic except one (assessment). If you have the ability to

recognize the cause of the concern whether it be medical or trauma and how

serious it is and know what you local hospital can handle. Time is precious and

does not need to be wasted at a facility that can not provide proper care. My

local hospital is a level four and can provide very little care for Pt's who

require advanced surgical intervention.

" Bledsoe, DO " wrote: Gene Gandy wrote, “And,

BTW, using good clinical judgment is the best way to

keep the lawyers

away.”

Also, garlic and crucifixes.

_____

From: [mailto: ] On

Behalf Of wegandy1938@...

Sent: Friday, February 17, 2006 5:59 PM

To: LNMolino@...;

Subject: Re: Corpus Christi newspaper reports on EMS response

to Cheney ...

Let's get down to the nitty gritty. Unless we were there, we really have

no

business speculating about what we would have done about transport

priorities.

It all comes down to good clinical judgment, which I know my good friend

Henry has, and which I hope to hell I have.

As I have said on many occasions with regard to lawsuits, every case turns

upon its own unique set of facts. So it is with medicine.

Generally speaking, I'm against flying patients. I have done it, however,

when the patient was off in the boonies on some ranch with a femur fracture

and

the bumpy ride in the truck would have probably exacerbated the injury and

outweighed the risk of air transport.

What's important is not whether you or I would have done with Poor Harry,

it's whether or not we understand fully the implications of what we do and

that

we use good clinical judgment in making these decisions.

Some seem to feel that helicopters possess some magic curative powers.

They

don't. They are a useful tool under the right circumstances, but each of

such circumstances must be determined by good clinical judgment.

And, BTW, using good clinical judgment is the best way to keep the lawyers

away.

Gene.

>

> In a message dated 2/17/2006 8:30:18 A.M. Central Standard Time,

> hbarber@... writes:

>

> Dr. B, Gene and others that people look up to, if

> we keep going down this path younger medics that read your post may

> interpret that helicopters have no place in EMS and should not be used.

>

> I'll let them defend or not their own comments but I've never once heard

> anyone on this list that is among those you mention advocate that there is

> NO

> PLACE just mis-use and or really over use of same.

>

> Louis N. Molino, Sr., CET

> FF/NREMT-B/FSI/EMSI

> LNMolino@...

> (Office)

> (Office Fax)

> (Cell Phone)

>

> " A Texan with a Jersey Attitude "

> " Great minds discuss ideas; Average minds discuss events; Small minds

> discuss people. "

> Eleanor Roosevelt

>

> The comments contained in this E-mail are the opinions of the author and

> the

> author alone. I in no way ever intend to speak for any person or

> organization that I am in any way whatsoever involved or associated with

> unless I

> specifically state that I am doing so. Further this E-mail is intended

only

> for its

> stated recipient and may contain private and or confidential materials

> retransmission is strictly prohibited unless placed in the public domain

by

> the

> original author.

>

February 17, 2006

Ben wrote, " Time is precious and does not need to be wasted at a facility

that can not provide proper care. My local hospital is a level four and can

provide very little care for Pt's who require advanced surgical

intervention. "

First, how much time is precious? The Golden hour is a myth.

Second, what is " advanced surgical intervention? "

Third, what " advanced surgical intervention " is time-sensitive?

Sometimes, what seems intuitive does not prove to be so:

------------------------------------

Med Care. 2001 Jul;39(7):643-53.

Mortality among seriously injured patients treated in remote rural trauma

centers before and after implementation of a statewide trauma system.

Clay Mann N, Mullins RJ, Hedges JR, Rowland D, Arthur M, Zechnich AD.

Department of Emergency Medicine, Univeristy of Utah, School of Medicine,

Salt Lake City 84108-9161, USA. clay.mann@...

BACKGROUND: Injury mortality in rural regions remains high with little

evidence that trauma system implementation has benefited rural populations.

OBJECTIVE: To evaluate risk-adjusted mortality in remote regions of Oregon

before and after implementation of a statewide trauma system. RESEARCH

DESIGN: A retrospective cohort study assessing injury mortality through 30

days after hospital discharge. SETTING: Nine rural Oregon hospitals serving

counties with populations <18 persons per square mile. SUBJECTS: Severely

injured patients presenting to four level-3 and five level-4 trauma

hospitals 3 years before and 3 years after trauma system implementation.

MEASURES: Interhospital transfer, hospital death, and demise within 30 days

following hospital discharge. RESULTS: A total of 940 patients were

analyzed. After trauma system implementation, patients presenting to level-4

hospitals were more likely transferred to level-2 facilities (P <0.001).

Interhospital transfer times from level-3 hospitals lengthened significantly

after system implementation (P <0.001). Overall mortality rates were higher

in the postsystem period (8.3%) than the presystem period (6.7%), but not

significantly. Controlling for covariates, no additional benefit to

risk-adjusted mortality was associated with trauma system implementation.

Additional deaths, occurring after trauma system implementation, included

head-injured patients transferred from rural hospitals to nonlevel-1 trauma

center hospitals. CONCLUSIONS: Increased injury survival after Oregon trauma

system implementation, demonstrated in urban and statewide analyses, was not

confirmed in remote regions of the state. Efforts to improve trauma systems

in rural areas should focus on the processes of care for head-injured

patients transferred to higher designation trauma centers

----------------------------------------------

J Trauma. 2003 Sep;55(3):444-9.

The effect of interfacility transfer on outcome in an urban trauma system.

Nathens AB, Maier RV, Brundage SI, Jurkovich GJ, Grossman DC.

Division of General and Trauma Surgery, Harborview Medical Center, and

Department of Surgery, University of Washington, Seattle, 98104-2499, USA.

anathens@...

BACKGROUND: Transporting all trauma patients to regional trauma centers is

inefficient; however, the bypass of nearer, nondesignated hospitals in

deference to regional trauma centers decreases mortality in the severely

injured. One approach to improving efficiency is to allow the initial

assessment of selected patients at lower level (Level III/IV) designated

centers. We set out to evaluate whether patients initially assessed at these

centers and then transferred to a Level I facility were adversely affected

by delays to definitive care. METHODS: This is a retrospective cohort study

in which the primary exposure being evaluated is initial assessment at a

Level III or IV trauma center before transport to a Level I center in an

urban setting. The outcomes in this transfer cohort were compared with

outcomes in patients transported directly from the scene to a Level I center

(direct cohort). The outcomes of interest were mortality, length of stay,

and hospital charges. Multivariate analyses were used to adjust for

differences in baseline characteristics across these two cohorts. RESULTS:

Crude length of stay was comparable, whereas mortality was lower and charges

were 40% higher in the transfer cohort (n = 281) compared with the direct

cohort (n = 4,439). After adjusting for confounders, mortality and length of

stay were similar and total charges were significantly greater in the

transferred patients. CONCLUSION: Interfacility transfers in a mature urban

trauma system do not appear to impact on clinical outcome. However, transfer

patients use significantly greater resources as measured by hospital

charges. This effect is likely because of the nature of their injuries or,

alternatively, delays in reaching definitive care.

------------------------------------

J Trauma. 2004 Jan;56(1):89-93.

Effective use of the air ambulance for pediatric trauma.

Larson JT, Dietrich AM, Abdessalam SF, Werman HA.

Department of Pediatrics, College of Medicine and Public Health, Ohio State

University, Columbus, 43205, USA. larsonj@...

BACKGROUND: The purpose of this study was to compare outcomes of pediatric

trauma patients transported by helicopter from the injury scene (IS group)

to a trauma center and those transported by air after hospital stabilization

(HS group). METHODS: A retrospective analysis of pediatric trauma patients

(<19 years of age) transported by air ambulance and admitted to a pediatric

trauma center was conducted. Outcomes compared were mortality and length of

stay. Patients were subdivided into minor (Injury Severity Score [iSS] < 15)

and major (ISS > 15) trauma. TRISS analysis was performed to verify the

overall quality of the care. RESULTS: Eight hundred forty-two HS and 379 IS

patients were included. The mean age, median ISS, and distribution of

penetrating and blunt injuries did not differ significantly between the

groups. The overall death rate was significantly lower for the interfacility

transfer patients (HS group, 5.5%; IS group, 8.7%; p < 0.05). Mean intensive

care unit (ICU) and hospital length of stay did not differ significantly. HS

patients with major trauma had significantly less mortality (HS group,

15.5%; IS group, 26.7%; p < 0.05) and shorter mean ICU stays (HS group,

118.3 hours; IS group, 149.1 hours; p < 0.05) than IS major trauma patients.

No differences were seen in patients with minor trauma. TRISS analysis

showed improved survival for all patients compared with Major Trauma Outcome

Study norms. CONCLUSION: Retrospective analysis was not able to demonstrate

any benefit to direct transport from the scene to a trauma center. Hospital

stabilization before transfer by air ambulance may improve survival and

shorten ICU stays for patients with major trauma.

----------------------------------------------

Granted, trauma centers improve outcomes. The jury is out on whether one

should go to Level III or IV first and then transferred or to a Level I or

II first. It is not as cut and dried as everybody thinks.

February 18, 2006

Well one thing that I have learned in my limited experience as a paramedic is

that everyone has a opinion and for every study that promotes a particular way

to treat there is another study that directs you toward a different path. Is one

hospital as good as another? who knows but I always call ahead to see who is

working if I need medical care for myself or love one. But many of the ideals

presented on this site has made me think a little harder each time I have a

decision to make including when to fly and when not to.

" Bledsoe, DO " wrote: Ben wrote, " Time is

precious and does not need to be wasted at a facility