Rogue Medic has been working on a series of posts concerning “research” in EMS. His most Recent post Whisky Tango Foxtrot Research relates to my post on spinal clearance in HEMS.
As usual not only did he get me thinking, but he pushed my dreams of being able to articulate my thoughts as proficiently as he just a little further away!
While he is focusing on the lack of an quality research in EMS, I am more focused soley on the validity of HEMS triage and the reality of safety in HEMS and Ground EMS. However, he did get me thinking with a few of his commets:
There is no good EMS research, if there is no good EMS in the study.
Assessment is the medical skill. Without that, nothing else matters.
Not much reason to believe that spinal clearance patients need to fly.
He couldn’t be more right with that one. So much time is spent in EMS doing Quality Assurance–but how much of that actually focusses on real tangible skills? Instead we focus on numbers–response time, scene time, out of service time, 12-lead scene time, etc, etc, etc. We aren’t assuring that our medics are capable of actually assessing a patient.
As a matter of fact, we are assuring that they don’t even get the chance to assess patients by taking the direction that protocols are to be followed in strict accordance, not as guidelines. Protocols can be a powerful tool. They provide a standard of care for patients with similar presentations. They do NOT assess the patient though.
A patient with chest pain needs little assessment based on most ALS protocols. IV, O2, Nitro, ASA, Morphine, 12-lead, transport.
Our “protocols” state any patient with substurnal chest pain, radiating arm pain, non-localized chest pain, un-specified epigastric pain, or a “HIGH LIKELYHOOD FOR CARDIAC ORIGIN” gets a full cardiac workup. While this one actually allows for some sort of assessment, it does not allow us to stop cardiac procedure for non-cardiac chest pain. Not that I do a full cardiac workup for trauma related chest pain–but my protocol says I should.
If I wasn’t the “thinking” type, I’d be putting a lot of patients through procedures that they didn’t need at all, and in some cases could actually be detrimental to their outcome.
The attempts to reach Quality Assurance in EMS are in vain. They lack any substance and many services are prime examples of this–HEMS included.
When a ground service calls for HEMS intervention, the HEMS service should demand a full report. Recently we were called to a high school football game for a 17yo male how spike his head into the ground. We were on standby at another game and the local VFD was on standby at that game.
We were called out, Code 1 but quickly upgraded to Code 3 when the VFD requested we try to request HEMS. Now in our area we rarely use HEMS. We can usually be at the receiving ED door before HEMS would get them there. Unless the patient needs a skillset that we absolutely cannot preform then there is no reason for us to delay transport. The VFD requesting HEMS got our blood pumping and as my partner drove in ways that make me cry at night, I was trying to hail the VFD over the radio.
Once I finally got through to them it became clear that the HEMS was more out of emotion than need. When we arrived to find mom and dad calm(dad is a volunteer EMT in a town about 40 miles away) I knew it was an overreaction common to these circumstances.
How often do we think that Emotion plays a major role in the usage of HEMS over practical assessment and triage?
Many might wonder why it is that I am ragging on HEMS so bad. So here is where I will end it:
- HEMS response times often delay the transport of the patient.
- ALS skills outside of what Ground EMS crews use are rarely utilized in HEMS
- HEMS is inherantly more dangerous. The use of HEMS should be limited to patients that will benefit from the extended skill set of HEMS providers or from the speed of HEMS(if HEMS is infact faster than ground EMS)
- HEMS usage inside city limits is rarely beneficial
- HEMS management by Hospitals could easily be seen as means of providing higher level income. Not only do they get to bill more for a HEMS services, but they will then have a patient that likely requires ICU or other Critical services(where SOME of the money lies(nothing is as profitable as outpatient surgery))
If we aren’t assuring that we have quality providers on the ground interpretting and implementing our protocols and QA directives, what point is there in measuring any sort of QA?
At what point will we finally realize that we aren’t assessing our own skills–let alone actually assessing our patients?
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