Copter crash raises doubt

Rules on trauma are questioned

Sun Exclusive

October 01, 2008|By Gadi Dechter and and Brent Jones | Gadi Dechter and and Brent Jones, and

The two young women whose car crash in Charles County prompted a medevac flight that turned fatal early Sunday had only bruises and pain after the auto accident but no apparent injuries so severe they indicated need for a helicopter transport to a trauma center, officials said yesterday.

Still, the ill-fated medevac call fit within national guidelines used by Maryland's emergency medical system - guidelines the system's head now says need to be studied and perhaps revised.

Dr. Robert R. Bass, executive director of the Maryland Institute for Emergency Medical Services Systems, which oversees the medevac program, said paramedic reports showed that the car crash victims had "chest pain, neck and back pain" and one had a large bruise between her ribs and hips. Those injuries, Bass said, "in and of themselves would not have been indicators to take to a trauma center."

The helicopter was summoned because one of the "mechanisms" of the accident suggested a probability of serious injury of more than 20 percent. In this case, the deciding factor was that an external part of the car "intruded" by more than a foot into the passenger compartment.

In Maryland, emergency medical personnel use triage guidelines developed by the American College of Surgeons when deciding whether to take a patient to a trauma center. If a trauma-bound patient is more than a 30-minute drive from the nearest trauma center, state helicopters are used.

Under the triage guidelines, EMTs first look for physiological signs of serious injury, such as trouble breathing. Then, they look for anatomical indicators of grave injury, such as gunshot wounds or puncture wounds to the central part of the body. If none of those indicators is present, first-responders look at the mechanism of injury, such as the height of a fall.

Some of these mechanisms are statistically linked with a likelihood of serious injury that may not be immediately apparent at the accident scene, such as internal bleeding. If first-responders only rely on visible signs of severe injury, "people will die," Bass said.

Still, deciding which mechanisms should automatically equate to a trauma transport has become a years-long "struggle" within the trauma medical community, Bass said, because relying on mechanisms alone leads to "over-triage," or unnecessary hospitalization in expensive trauma centers.

The controversy flared up in Maryland last month, when some state lawmakers noted that almost half of the patients flown by helicopter to Maryland trauma centers are released within 24 hours - suggesting to them that the helicopters are overused.

When transport to a trauma center involves medevac helicopters - which have been involved in a spate of nighttime accidents across the country recently - the risk of over-triage is magnified, according to Bass. This week's accident "raised the issue for us about what is the relative risk, and what is the right thing to do in terms of deciding to transport patients from the scene?" Bass said.

While a federally funded project has recently come up with revised decision-making guidelines designed to reduce unnecessary trauma-center usage, there hasn't been a formal effort at building into triage criteria the added risk of helicopter transport, Bass said.

The MIEMSS director said that Maryland's vaunted medevac operation - which until this weekend had not had a fatal accident in more than 20 years - is particularly well-suited to that task of making those calculations, and Bass said he will suggest to his board of directors that Maryland take up the issue.

"Maybe it's time to grab the bull by the horn and get that done and see what kind of consensus guidelines we can come up with, because this is obviously an issue of national interest," Bass said.

Del. Dan K. Morhaim, co-chairman of the Joint Committee on Health Care Delivery and Financing, called last month's hearing, which was prompted in part by a legislative audit that criticized the state police's fiscal management and helicopter fleet maintenance.

Morhaim, in an interview yesterday, said he still sees a need for medevac service but added that the system's reliance on the national triage guidelines needs to be re-evaluated. Between 4,500 and 5,000 patients are transported to hospitals by the state's medevac unit every year, at a cost to taxpayers of about $4,000 per trip.

"One of the significant differences in Maryland as opposed to other states is we have excellent paramedics able to deliver outstanding care in field and stabilize patients. Sometimes the need to transport by helicopter isn't as grave as in other states," Morhaim said.

Killed in the crash were the pilot, Stephen H. Bunker, 59; Tfc. Mickey Lippy, 34, a flight paramedic; Tonya Mallard, 38, an emergency medical technician from the Waldorf rescue squad; and Ashley J. Younger, 17, a passenger in one of the cars that collided.

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