Medevac Decision Making - was in Somers MVA photo thread

[DR104 141]

Apparently the ambulance was a Westchester EMS Alpha Unit coming from Mt Kisco because Somers had to go Mutual Aid.

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Why did they go Mutual Aid? How many ambulances does Somers have? Are they a Vac or are they part of the FD?

[JM15 386]

Why does anyone go mutual aid? We didn't have a full crew for our ambulance. It was a late night/early morning call on a workday. That is no excuse for not covering calls but it happens to every volunteer organization on here. I was on scene and 45 Medic 2 made the right decision in calling for Stat Flight. The patient had multiple head injuries and was combative with an unstable airway. Everyone on scene did a great job and did everything quickly and efficiently. I am sure that this kid is still alive because of this. Thanks to the crew of WEMS Alpha 9 I believe for the help. Somers FD has 3 ambulances which are part of the fire department.

[Guest alsfirefighter]

I'm still not understanding a few things here when the unstable airway gets mentioned. What does that have to do with utilizing air resources? ALS providers are trained to deal with unstable airways...now with that said, I do understand sometimes that the narcs we carry doesn't always facilitate the process of taking control of it. But in all educational senses...rapid transport the closest appropriate facility is the correct protocol answer. With that also said..I being I know the provider, he is rock solid and made a clinical decision. And as I always say if I wanted to follow step by step directions from a book, I would have went to the culinary institute.

Secondly as it keeps coming up I'm intrigued. What was the etiology of the unstable airway?

I've mentioned this in a thread that I started in regard to not getting a bus in a timely manner for a stabbing vic. When VAC's don't get out for trauma's that is a eyebrow raiser to me. That used to be the y'all come call of the services. I'm hearing this more and more in the area.

[ckroll 101]

I still don't get it. No extrication means Somers to WMC is faster by bus than by bird and we still fly out patients. Yet every time this comes up no one come up with a reason why these people are still being flown. If it is true that everyone actually agrees that many of these flights are unnecessary, too many medics/chiefs/vac capts/etc read and comment on this board for nothing to have changed.

A couple of things.. I would guess that things have changed. These discussions help current decision makers and just as important, future decision makers, come up with a rationale for the decisions that they do, or will, make. One of the good aspects of these discussions is that when we need to make the decision in the field we have 10 or 15 seconds to make a call and endless time here in threads to play with it. I know I make better decisions having had the time to think about it after reading these threads.

When I saw we'd brought out the medevac topic again, my first thought was that it was one of two other calls that happened this week. I had the opportunity to talk to principals on both of them, and both sounded like very good decisions. Without question, air service has a place in EMS, even with otherwise short transport times. Critically injured patients may present a situation where there are NO good options and we have to pick the best of the bad ones, and in those situations having air service as one of the options is invaluable.

Think of air service as a treatment modality, which it is. Cost/benefit/risk is a vast topic, especially given the current health care issues. There is danger attached to helicopter use, just as there is with, say, surgery. The good needs to outweigh risk to the crew and patient, the price of the good needs to be compared to the options. Using up the resource needs to be balanced with the odds that someone else more deserving will go without. And let us not forget to pile on 'the price of a life'.... and the inevitable litigation that ensues if the outcome is poor. We cannot sit at the side of the road puzzling through this stuff. As providers we need to return to BLS that starts with GOOD CLINICAL JUDGMENT, [NYS emphasis, not mine]. Sometimes that decision, in the long fullness of time, will be shown to be correct or incorrect, but that in no way reflects on the judgment made in the heat of the moment.

If all indications are that there is significant injury and time, or airway, or smoothness of the ride, or the capabilities of the medic are ,in the judgment of the medic, worth the risk then it is a decision well made. If the injuries were so profound that I didn't think I could properly manage a patient by myself for the ground trip, then I hope I'd have the humility to call for added help, most likely air transport. If the patient were one pothole from permanent paralysis, I think I'd ask for a helicopter. If the patient was clenched, projectile vomiting and needed full immobilization, I'd call air.

What we can't do is simplify the arguments to 'Any chance is too much of a chance therefore it all goes by air.' or 'There's never a situation that can't be met by ground transport.' It's why I never tire of this thread. Nasty or nice, here and now is the absolute best place to have this discussion. Here is where we ask questions and build framework for our own decisions out in the field.

[NWFDMedic 58]

My take on this is that there was a request for a resource that the patient needed for the best possible patient care. It just happens to be that that resource came out of the sky. The medic on-scene noted that the patient had a possible head injury, was combative, and was likely not going to be able to have a secure airway by the means available to him. There is a resource available that can assist in securing that airway, so why not call them?

I am lucky enough to work for an agency that has several adjuncts above and beyond the protocols such as RSI and CPAP. I have been called mutual aid to other ALS services to assist with an RSI or a CPAP application because we had the resource, it was available, and it assisted in the best patient outcome. I know if it were my family member, I'd want to know that the paramedic on scene did whatever was in his best judgment to perform the best life-sustaining measures for the patient. If the paramedic felt that getting an RSI medic to the scene via air was better overall for patient outcome than trying to run to the closest facility with a BLS airway or to make the 20 minute ride to the Medical Center with the same, then good for him for requesting it.

The agency's QA/QI program is responsible for the retrospective review based on the medic's paperwork and potentially a personal interview. The EMTBravo QA/QI committee often seems to work on generalization and assumption more than fact.

[helicopper 1,050]

My take on this is that there was a request for a resource that the patient needed for the best possible patient care. It just happens to be that that resource came out of the sky. The medic on-scene noted that the patient had a possible head injury, was combative, and was likely not going to be able to have a secure airway by the means available to him. There is a resource available that can assist in securing that airway, so why not call them?

I am lucky enough to work for an agency that has several adjuncts above and beyond the protocols such as RSI and CPAP. I have been called mutual aid to other ALS services to assist with an RSI or a CPAP application because we had the resource, it was available, and it assisted in the best patient outcome. I know if it were my family member, I'd want to know that the paramedic on scene did whatever was in his best judgment to perform the best life-sustaining measures for the patient. If the paramedic felt that getting an RSI medic to the scene via air was better overall for patient outcome than trying to run to the closest facility with a BLS airway or to make the 20 minute ride to the Medical Center with the same, then good for him for requesting it.

The agency's QA/QI program is responsible for the retrospective review based on the medic's paperwork and potentially a personal interview. The EMTBravo QA/QI committee often seems to work on generalization and assumption more than fact.

Why only your agency? Why can't medics in all agencies provide this service; the efficacy is well documented, the trials should certainly have produced data supporting it so why is it just two agencies in our region?

As for the QA/QI programs, my question is do they review the appropriateness of medevac decisions? Do they specifically address this aspect of EMS? As has been said, air ambulances are far more costly and far more dangerous than calling you from the next town over for RSI when needed so I'd like to know if our QI programs provide any feedback on these cases?

Some of the people you're calling the EMTBravo QA/QI committee are among the best and the brightest in EMS; they are instructors and field providers with a wealth of hands-on experience. To say that they are not qualified to discuss an issue such as this and do so intelligently and based upon science is downright insulting.

[NWFDMedic 58]

Why only your agency? Why can't medics in all agencies provide this service; the efficacy is well documented, the trials should certainly have produced data supporting it so why is it just two agencies in our region?

As for the QA/QI programs, my question is do they review the appropriateness of medevac decisions? Do they specifically address this aspect of EMS? As has been said, air ambulances are far more costly and far more dangerous than calling you from the next town over for RSI when needed so I'd like to know if our QI programs provide any feedback on these cases?

Some of the people you're calling the EMTBravo QA/QI committee are among the best and the brightest in EMS; they are instructors and field providers with a wealth of hands-on experience. To say that they are not qualified to discuss an issue such as this and do so intelligently and based upon science is downright insulting.

I don't know the answer to why only 2 agencies in Westchester. The protocol for RSI was opened to any agency in the Hudson Valley Region where I work and only 2 agencies that I know of have chosen to be in the program.

I guess you would have to ask each particular agency whether the QA/QI appropriateness of medevac decisions. I know how my agency's program works and all flight calls are reviewed and the appropriateness of the decision is considered.

Finally, there is a difference between calling someone unqualified to discuss an issue and calling someone unqualified to discuss a case. I consider myself to have a pretty good knowledge base about EMS but I couldn't tell you a thing about a specific call in Somers nor would I be the one answering questions about it on this forum if I was involved. All the knowledge in the world without the proper information can lead to bad assumptions and decisions. Part of my job is to proactively question cases such as this at my agency (even before they get official QA/QI review) and I would never come to judgment without first asking even my newest medic what his/her reasoning was at the scene.

[ckroll 101]

.....

The agency's QA/QI program is responsible for the retrospective review based on the medic's paperwork and potentially a personal interview. The EMTBravo QA/QI committee often seems to work on generalization and assumption more than fact.

Excellent points. What QA/QI is almost never based on is patient injuries/outcome. In 20 years doing this I've gotten feedback [other than what I read in the newspaper] maybe a couple dozen times. The agency that I work for that is hospital based is pretty good about it, but other agencies have no handy feedback capability. What with the push to make records electronically accessible, should there not be an effort to get existing information back to providers? Even lab rats get a treat for pushing the right buttons. How do we get better at this if we don't get timely information about our decisions? Can you imagine if doctors treated patients but weren't given access to information about whether or not it was the right thing to do?

That 'the EMTBravo QA/QI committee' works on generalizations is how it should be. There really shouldn't be detailed discussion of specific facts of a call on an open forum. Such discussions should not happen outside the primary care givers. Ergo, assumptions about will be made. Thank goodness that out in the field we never have to make assumptions, as all the facts are readily available.

[NWFDMedic 58]

Excellent points. What QA/QI is almost never based on is patient injuries/outcome. In 20 years doing this I've gotten feedback [other than what I read in the newspaper] maybe a couple dozen times. The agency that I work for that is hospital based is pretty good about it, but other agencies have no handy feedback capability. What with the push to make records electronically accessible, should there not be an effort to get existing information back to providers? Even lab rats get a treat for pushing the right buttons. How do we get better at this if we don't get timely information about our decisions? Can you imagine if doctors treated patients but weren't given access to information about whether or not it was the right thing to do?

Funny you should mention that actually. It's definitely difficult for commercial or municipal services to get information about patient outcome. The nice feeling we get is when the patient gets to the ER alive or alive and improved. Sometimes the ER doc might tell us how the patient progressed until they went to the floor, but rarely do we hear how the patient made out in the long run and whether our care helped or hindered the outcome. That's always been one of the questions about intubation in general.

We had an in-service yesterday for our new electronic PCR's that we will soon be implementing. A couple of the data fields that they have involve patient outcome, even to the point of discharge. While we obviously cannot get this information in most instances, I wonder if this is a precursor to better national data reporting.

[TSull 33]

I find this to be an interesting topic. I have had discussions in my department about the number of times that a helicopter gets called, used and why. Especially on the eastern side of our response area (which includes Rt 22, 684, 84) the time that it takes to extricate, package, and move a patient to a landing zone, have the bird land, have the flight crew do their assessment, and more then a few times, have to bring the bird back up to full power to take off is time wasted that could have been used to transport the patient to a Level II Trauma Center less then 10 miles away. I understand that it is the paramedic's call but I believe that some of the medics get tunnel vision that they can only take a trauma patient to WMC and that the only way to get the patient there is via helicopter. When Keltie's Resturant blew up, I was on the first ambulance on scene. As soon as the firemen pulled the first victim out, he was in our bus, the medic jumped in, and we rolled. The medic did all his work enroute (assessment, IV, tube, ekg). That patient was in the operating room 47 minutes from the time he was pulled out of the rubble. That is just one example of how the system worked well.

What is the difference between a Level I Trauma Center and a Level II Trauma Center other then the Level I having a burn unit?

[Goose 188]

Why only your agency? Why can't medics in all agencies provide this service; the efficacy is well documented, the trials should certainly have produced data supporting it so why is it just two agencies in our region?

As for the QA/QI programs, my question is do they review the appropriateness of medevac decisions? Do they specifically address this aspect of EMS? As has been said, air ambulances are far more costly and far more dangerous than calling you from the next town over for RSI when needed so I'd like to know if our QI programs provide any feedback on these cases?

Some of the people you're calling the EMTBravo QA/QI committee are among the best and the brightest in EMS; they are instructors and field providers with a wealth of hands-on experience. To say that they are not qualified to discuss an issue such as this and do so intelligently and based upon science is downright insulting.

I always found this ironic when i worked up in the hudson valley region. Years of hard evidence and probably cubic yards worth of paperwork that proves that CPAP works yet they still needed to conduct their own study. And then they touted it in the news paper as some new fangeled god send....when the reality was they were years behind the eight ball.

I guess it all boils down to the type of doctors and committee members sitting on the REMAC.

Generally speaking it's hard not to stop and think about medvacs. I can't tell you how many individuals i've run into that love to bang their chests and exclaim "when in doubt we fly em' out!"

Edited July 17, 2009 by Goose

[ny10570 745]

Maybe its my ignorance since my only experience with RSI is my OR rotations as a medic student and my surgery last year, but what about a combative pt with an unstable airway specifically requires RSI? I agree its a great tool to have, but 20mg of Etomidate with a Versed back does a great job of taking the fight out of a patient and keeping them out of the fight. I am not trying to, nor have I ever been about dumping on a crew's decisions. I'm just curious to know the reasoning. Sometimes after a call we look back and realize that was excessive or maybe we should have done x,y,z. Either way we need to be critical of all of our decisions. It is only through discussion and frankly argument that we progress.

[medic25 0]

Maybe its my ignorance since my only experience with RSI is my OR rotations as a medic student and my surgery last year, but what about a combative pt with an unstable airway specifically requires RSI? I agree its a great tool to have, but 20mg of Etomidate with a Versed back does a great job of taking the fight out of a patient and keeping them out of the fight.

Most of the literature on "medication-assisted intubation" without a paralytic shows no improvement/worse outcomes for patients. All too often you give the etomidate/versed and snow them, knock out their respiratory drive, but they still have a clenched jaw. Now you've got a patient not breathing who's jaw you still can't open.

Most of the literature on prehospital RSI is also not showing patient benefit. Unless you've got a system with a limited number of providers getting frequent intubations and a true CQI and education system, the patients are doing worse. This might be achievable working with a flight service, but doesn't hold true for the majority fo the ground EMS systems in this country.

[ckroll 101]

Most of the literature on "medication-assisted intubation" without a paralytic shows no improvement/worse outcomes for patients. All too often you give the etomidate/versed and snow them, knock out their respiratory drive, but they still have a clenched jaw. Now you've got a patient not breathing who's jaw you still can't open.

Most of the literature on prehospital RSI is also not showing patient benefit. Unless you've got a system with a limited number of providers getting frequent intubations and a true CQI and education system, the patients are doing worse. This might be achievable working with a flight service, but doesn't hold true for the majority fo the ground EMS systems in this country.

And the thread is officially hijacked......Westchester protocols now have etomidate for all medics and above the medical control line at that ?

[helicopper 1,050]

Funny you should mention that actually. It's definitely difficult for commercial or municipal services to get information about patient outcome. The nice feeling we get is when the patient gets to the ER alive or alive and improved. Sometimes the ER doc might tell us how the patient progressed until they went to the floor, but rarely do we hear how the patient made out in the long run and whether our care helped or hindered the outcome. That's always been one of the questions about intubation in general.

We had an in-service yesterday for our new electronic PCR's that we will soon be implementing. A couple of the data fields that they have involve patient outcome, even to the point of discharge. While we obviously cannot get this information in most instances, I wonder if this is a precursor to better national data reporting.

That's sad. The QA/QI program should provide follow-up on patient outcome, admission diagnosis, outcome, etc. How else do we know that things are working the way that they should or that we're making the correct clinical judgements?

Most of the literature on "medication-assisted intubation" without a paralytic shows no improvement/worse outcomes for patients. All too often you give the etomidate/versed and snow them, knock out their respiratory drive, but they still have a clenched jaw. Now you've got a patient not breathing who's jaw you still can't open.

Most of the literature on prehospital RSI is also not showing patient benefit. Unless you've got a system with a limited number of providers getting frequent intubations and a true CQI and education system, the patients are doing worse. This might be achievable working with a flight service, but doesn't hold true for the majority fo the ground EMS systems in this country.

Interesting data on the medication assisted intubation. Got any links to the studies or papers? This may be another great example of misinformation becoming fact in the field because the QA/QI and training programs aren't countering bad information with good information. This may show the notion that calling for a helicopter to deliver advanced airway management isn't the best course... The plot thickens!

So, good BLS management of an airway in a trauma patient may be preferable to aggressive ALS interventions - what is that pesky concept they try beating into paramedics from day one of training??? What is that again? Oh yeah, BLS before ALS!!!

I find this to be an interesting topic. I have had discussions in my department about the number of times that a helicopter gets called, used and why. Especially on the eastern side of our response area (which includes Rt 22, 684, 84) the time that it takes to extricate, package, and move a patient to a landing zone, have the bird land, have the flight crew do their assessment, and more then a few times, have to bring the bird back up to full power to take off is time wasted that could have been used to transport the patient to a Level II Trauma Center less then 10 miles away. I understand that it is the paramedic's call but I believe that some of the medics get tunnel vision that they can only take a trauma patient to WMC and that the only way to get the patient there is via helicopter. When Keltie's Resturant blew up, I was on the first ambulance on scene. As soon as the firemen pulled the first victim out, he was in our bus, the medic jumped in, and we rolled. The medic did all his work enroute (assessment, IV, tube, ekg). That patient was in the operating room 47 minutes from the time he was pulled out of the rubble. That is just one example of how the system worked well.

What is the difference between a Level I Trauma Center and a Level II Trauma Center other then the Level I having a burn unit?

There are more differences between Level 1 and 2 trauma centers and I don't think all level 1 trauma centers have burn units - those are separate and distinct specialties.

As for your comments on your experience - I agree that if you have to use a remote landing area that requires extrication and packaging, then transport to the LZ, assessment and treatment by the flight crew, transfer to the aircraft, start-up and take-off, it may be more expeditious to load the patient at the scene and go straight to the nearest appropriate facility (whether local hospital, Level 2 Trauma Center, or Level 1).

I'm so glad there are still medics out there who do their work enroute. It used to make me crazy sitting on a scene for 20 minutes when we could have been moving. I know it's not always appropriate or possible but 90% of what we do can be done on the go.

This thread has taken a few different turns but I don't think it's been hijacked. It has been a lively and interesting conversation (except for khas of course ) about EMS issues.

[Bnechis 3,961]

Why does anyone go mutual aid? We didn't have a full crew for our ambulance.

In most 100% tax supported systems the only reason is because you've run out of ambulances. Do the taxpayers know that you cant always staff the vehicles you asked them to pay for?

It was a late night/early morning call on a workday. That is no excuse for not covering calls but it happens to every volunteer organization on here.

Then they need to take their responsability more seriously and come up with a solution. Just because it happens to others does not mean its ok. I think we call that the bridge effect...you know if everyone else jumped of a bridge would you.

Somers FD has 3 ambulances which are part of the fire department.

How many can they staff?

[ja3kfd 34]

Guys I would like to say one thing on here it takes longer than 20 minutes, to get WMC, from Somers well at least Purdys I can attest to it with Jimmy and hot responses from my house all the way there.

[JM15 386]

Of course Bnechis you know exactly what is going on in N.Westchester VAC's?

[ny10570 745]

Most of the literature on "medication-assisted intubation" without a paralytic shows no improvement/worse outcomes for patients. All too often you give the etomidate/versed and snow them, knock out their respiratory drive, but they still have a clenched jaw.

I've seen plenty of research showing etomidate to be better than ketamine, versed, valium, etc and RSI is better than etomidate. They suggest more training and better QA/QI for paralytics because of associated risks with paralyzing someone. Etomidate is a sedative hypnotic, not an analgesic and its benefits are because it does not suppress respiratory or cardiac function. While there may be a brief period of apnea, there is no lasting respiratory depression. This applies only to when Etomidate is the lone induction agent. Once intubation is successful a benzo can be used to maintain sedation. When Etomidate is used in conjunction with a benzo the respiratory and cardiovascular depressant affects can be potentiated. The incidence of trismus or myoclonis is between 1 and 4% depending upon the study you read. If the clenched jaw is a result of a medical or structural issue (ie nerve damage, head trauma) then Etomidate will likely have no affect on that issue. If its a result of an anxious pt trying to maintain their airway or prevent you sticking that laryngoscope blade in their gullet then Etomidate could be just the thing you need.

[Bnechis 3,961]

Of course Bnechis you know exactly what is going on in N.Westchester VAC's?

What I know is people here keep commenting on how some agencies cant meet there commitments. How many VAC's are 100% tax supported? My comment was if you are, then you need to step up to the plate and resolve the issue, even if not, you need to step up to the plate, but if tax supported you cant use the excuse that you cant afford it.

[Guest alsfirefighter]

Of course Bnechis you know exactly what is going on in N.Westchester VAC's?

Not for nothing brother...its not exactly rocket science to know who is having problems out there...and who won't admit it or are riding on dumb luck. I can say Barry is well versed in EMS in the county and has been for some time. Providers all talk..particularly ALS providers in ALSFR systems who have to rely on these agencies for transport.

[Goose 188]

Not for nothing brother...its not exactly rocket science to know who is having problems out there...and who won't admit it or are riding on dumb luck. I can say Barry is well versed in EMS in the county and has been for some time. Providers all talk..particularly ALS providers in ALSFR systems who have to rely on these agencies for transport.

I would just like to quarterback this by saying it is a well known reality that response times are a problem county wide, particularly in the northern parts of the county. I've heard this consistently from ALS providers & firefighters who have/do work in the area and VAC leadership themselves. It's not like this is some sort of military secret...i'm sure DES is aware of it, but naturally have no authority to mitigate.

Edited July 19, 2009 by Goose