bbledsoe

The preferred term is now "Golden Period." I see Jeff Salamone made the switch in PHTLS and we are making it in our paramedic texts. The fact is there is no evidence to support a "Golden Hour." The whole concept of EMS getting the "Platinum 10 Minutes" and emergency medicine getting the "Golden Hour" was pretty much refuted when surgeons often take the "Bronze Week" to treat many patients. In the overall scheme of things, the trauma patient who will benefit from rapid transporrt and who requires emergency surgery is quite small. In fact, in Clayton Shatney's 10-year study of helicopter patients at Stanford he found that number to be 1.8%. Guess what? A response time of 8 minutes (the "gold standard") is not associated with improved outcomes in meical OR trauma patients. The secret to survival of EMS is not to raise the dead--but to intervene earlier in the disease/injury process. You will save many more patients with a bottle of aspirin than you will save with a defibrillator. BEB

In an overly technical post I pointed out the problems with CISM. EMS is about humanity and its problems. True, people die and often times we cannot control that. It is OK to grieve and OK to feel bad. We have this ill-conceived notion in this country that we have to feel good all the time. That is far from true. You have to look at the overall scheme of things. Infants and children in the United States and Canada have the best chances in the world to live to adulthood. There are some that will not. In some of these cases, EMS can make a difference. In most, it will not. Despite millions of dollars of research, we still don't know much about SIDS. In over 30 years in this business I can never recall resuscitating a SIDS baby. 1. It is OK to feel guilt--all of us do. 2. It is OK to be sad. 3. It is OK to cry. 4. It is OK to keep your emotions to your self. 5. Just don't let the guilt consume you. Use your personal support system (i.e., spouse, significant other, priest, minister, rabbi, parent, pet, best friend). 6. Learn from each experience and move on. People are overly concerned about PTSD. People who develop PTSD have underlying psychiatric issues--it is not a normal response to stress. It is quite rare. If you are a good EMT, as the poster apparently is, she is suffering a normal reaction to a bad call. The best treatment is tincture of time.

I can't let this CISM stuff pass without comment. These are the facts and they are irrefutable: 1. CISM has never been mandated although some states, such as Tennessee, added it to their statutes. 2. There is no evidence, save some poorly done studies by CISM proponents (and those with a financial interest in CISM), that shows it works. In fact, they really can't define what it is. 3. Most studies supporting CISM are published in their own journal (International Journal of Emergency Mental Health) or are non-published. 4. The best empiric studies have shown CISM to be ineffective in mitigating stress or preventing CISM. In fact, it causes stress in some people. 5. You can't treat stress after it has occurred. 6. The new model is resilliency-based care and psychogical first aid. Remove the person from danger, meet physical needs, activate their personal support system, watch them for 4-6 weeks for maladaptation. NO CISD, NO CISM. If you are ever forced to attend a CISM/CISD session, especially if you did not sign an informed consent form. then you may have a cause of action for negligence--the evidence against CISM is that strong! References: Devilley et al. Ready! Fire! Aim! The Status of Psychological Debriefing and Therapeutic Interventions: In the Work Place and After Disasters. Review of General Psychology. 2006;10:318-345 Sibrandid M, et al. Emotional or Education Debriefing after Psychological Trauma: Randomised Controlled Trial. British Journal of Psychiatry. 2006;169:150-155 Kadet A. “Good Grief!” Smart Money. 2002;June, pp. 108-114 Van Emmerik AAP, Kamphuis JH, Hulsbosch AM, Emmelkamp PMG. Single-session debriefing after psychological trauma: a meta-analysis. Lancet. 2002;360:766-771. Rose R, Bisson J, Wessley S. Psychological debriefing for preventing post traumatic stress disorder (PTSD) (Cochrane Review). The Cochrane Library. 2002;4. Fullerton CS, Ursano RJ, Vance K, Lemming W. Debriefing following trauma. Psychiatric Quarterly. 2000;71:259-276. Harris MB, Stacks JS. A three-year five state study on the relationships between critical incident stress debriefings, firefighters’ disposition, and stress reactions. USFA-FEMA CISM Research Project. Commerce, TX, Texas A&M University—Commerce, 1998 Harris MB, Balo›lu M, Stacks JR. Mental health of trauma-exposed firefighters and critical incident stress debriefing. Journal of Loss and Trauma.2002;7:223-238 Carlier IVE, Voerman AE, Gersons BPR. The influence of occupational debriefing on post-traumatic stress symptomatology in traumatized police officers. British Journal of Medical Psychology. 2000;73:87-98. Carlier IVE, Lamberts RD, van Ulchelen AJ, Gersons BPR. Disaster-related post-traumatic stress in police officers: A field study of the impact of debriefing. Stress Medicine. 1998;14:143-148 Macnab AJ, Russel JA, Lowe JP, Gagnon F. Critical incident stress intervention after loss of an air ambulance: two-year follow-up. Prehospital Disaster Med. 1999;14(1):8-12. Hobbs M, Mayou R, Harrelson B, Worlock P. A randomized controlled trial of psychological debriefing for victims of road traffic accidents. Br Med J. 1996;313:1438-1439 Mayou RA, Ehlers A, and Hobbs M. Psychological debriefing for road traffic accident victims: Three-year follow-up of a randomized controlled trial. Br J Psychiatry.2000;176:589-593. Rose S, Brewin CR, Andrews B, Lirk M. A randomized controlled trial of individual psychological debriefing for victims of violent crime. Psychological Medicine. 1999;29:793-799. Hytten K, Hasle A. Fire fighters: A study of stress and coping. Acta Psychiatr Scand. 1989;80:50-56. National Institute of Mental Health. Mental Health and Mass Violence: Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass Violence. A Workshop to Reach Consensus on Best Practices. NIH Publication No. 02-5138, Washington, D.C., U.S. Government Printing Office, 2002. (available at http://www.nimh.nih.gov/research/massviolence.pdf ). World Health Organization. Mental Health in Emergencies: Mental and Social Aspects of Populations Exposed to Extreme Stressors. Geneva. World Health Organization (available at http://www5.who.int/mental_health/download...?id=0000000640). Parry G (Chair, Development Group). Evidence-Based Treatment Guidelines in Psychological Therapies and Counselling. Department of Health, National Health Service, United Kingdom, (available at http://www.aaebhs.org/guideline/BritishDeptHealth.pdf ). North Atlantic Treaty Organization. North Atlantic Treaty Organization (NATO)-Russia Advanced Research Workshop on Social and Psychological Consequences of Chemical, Biological, and Radiological Terrorism. (available at http://www.nato.int/science/e/020325-arw2.htm ). New South Wales Health Department. Disaster Mental Health Response Handbook: An Educational Resource for Mental Health Professionals Involved in Disaster Management. NSW Health Department, Sydney, NSW, 2000 (available at http://www.nswiop.nsw.edu.au) Australasian Critical Incident Stress Association. Guidelines for Good Practice for Emergency Responder Groups in Relation to Early Intervention after Trauma and Critical Incidents (Glenelg Declaration) 1999 (available at http://www.ctsn-rcst.ca/glenelg.html) McNally, R. J., Bryant, R., & Ehlers, A. (2003). Does early psychological intervention promote recovery from post traumatic stress. Psychological Science in The Public Interest, 4, 45–79. Litz, B. T., Adler, A. B., Castro, C. A., Wright, K., & Thomas, J., & Suvak, M. K. (2004, November). A controlled trial of Group Debriefing. In M. Friedman (Chair), Military psychiatry, then and now.Plenary session conducted at the 20th Annual Meeting of the International Society for Traumatic Stress Studies, New Orleans, LA. Litz, B. T., Gray, M. J., Bryant, R. A., & Adler, A. B. (2002). Early intervention for trauma: Current status and future directions. Clinical Psychology: Science and Practice, 9, 112–134. Lohr, J. M., Hooke, W., Gist, R., & Tolin, D. F. (2003). Novel and controversial treatments for trauma-related stress disorders. In S. O. Lilienfeld, S. J. Lynn, & J. M. Lohr (Eds.), Science and pseudoscience in clinical psychology (pp. 243 – 272). New York: Guilford Press. Bledsoe, B. E. (2002). CISM: Possible liability for EMS services? Best Practices in Emergency Medical Services, 5, 66–67. Bledsoe, B. E. (2003). Critical Incident Stress Management (CISM): Benefit or risk for emergency services? Prehospital Emergency Care, 7, 272– 279.

The following is somewhat based on evidence and somewhat on experience. In the overall scheme of things, I would have to say that generally the government operated helicopters are safer and probably a better model. There are several reasons here: 1. They can afford bigger aircraft (Dauphins, S-76, Bell 430) and are often dual pilots with full IFR and winch capabilities. 2. There is no pressure to fly since an owner or stock holder is not constantly on them about productivity. 3. They tend to be selective on who they transport and tend to assure that the patient is more likely to benefit from HEMS. 4. Maintenance tends to be better in some cases. The obvious model is the Maryland State Police. They fly Dauphins and have an excellent safety record. I know there are issues in MD but overall that is a good comprehensive, although expensive, system. In my travels I have seen this: 1. The Australians come as close as any to doing it right. The states of New South Wales and Victoria operate helicopters and fixed-wing aircraft as a part of their EMS operation. Two years ago I attended a meeting in Sydney where the paramedics on the helicopter were concerned about a particular doctor at an outlying hospital calling them for patients who did not stand to benefit from transport. I have ridden with the HEMS in Melbourne. They are Dauphins operated by the police and staffed with MICA medic. It's a very good system. HEMS in Australia are more for rescue and engress/egress issues. Fixed-wing aircraft are used for moving people around. Remember Oz is as big as the continental US. 2. New Zealand is an absolute mess. There are some good operators such as Westpac in Auckland. But, what is happening in NZ is weird. The people that own helicopters (for whatever reason) set up these "shell" charities in order to write off the costs of the helicopter. They get a tax break by making the helicopter available occasionally for EMS. Most of the helicopters are not staffed. When a call comes in, a crew from St. Johns or the Wellington Free Ambulance go and staff the helicopter (the Westpac helicopter is staffed 24/7). There are alot of fund raising and actually some operators are profiting. When I was down there last year I was asked to meet with Crown authorities trying to get the situation under control. 3. The United Kingdom is alot like New Zealand. There are some full-time helicopters but most are community-supported operations (charities) staffed by ground crews. There are also some operations, such as London, which are physician-staffed but only fly 2-3 times a day (it is hard to land in London). The HEMS throughout the UK are always having fund raisers and certain operations are open or closed depending upon funding. 4. Canada has a reasonable system (there are more medical helicopters in Dallas/Fort Worth than all of Canada). The HEMS in Canada functions as a part of their health care system. They are almost all dual pilot and IFR. The Canadians are certainly doing things better than the Americans in this endeavor. 5. In Europe the HEMS is primarily physician-staffed. Some countries forbid night flights. Rescue seems to be the theme. The common thread here is: 1. Government seems to belive that the primary role of HEMS is rescue and engress/egress problems. 2. The scientific evidence is pretty clear in that only a small percentage of patients stand to benefit from HEMS transport. 3. Profit is driving the US system hence the increase from 300 to nearly 1,000 medical helicopters in 5 years. I live south of Dallas/Fort Worth approximately a mile from the Midlothian/Waxahachie community airport. Both Bell and American Eurcopter do their new buyer orientation flights at this airport. Every day, and often weekends, there is a new helicopter being tested here. Yesterday it was a BK-117 that said Life Flight. Today is is a Bell 407 with a name I can't read (but a Star of Life). 4. Many of the US operators fly single-engine or small aircraft (Bell 206-L or Bo-105). The vast majority are single pilot and few are IFR. There is a shortage of helicopter pilots in the US. The Vietnam-era pilts are retiring. The military is offereing cash incentives and other measures to keep pilots in the service. Obtaining a helicopter license in the private sector costs tens of thousands of dollars (all for a job that pays $40-60K a year). With the pilot pool in decline and demand onthe increase, it only means that more and more HEMS is being flown by pilots with considerably less xperience. 5. We let the HEMS give us the criteria when to use HEMS. That is like letting Starbucks tell use when and where to drink coffee. 6. We (doctors, nurses and EMS personnel) are part of the problem and can be part of the solution. That's how I see it. Your mileage my vary. Bryan

OK. I give up. What is D. Barns? Inside joke? I'm a newbie. Cut me some slack.

turnip (sic) wrote, Maybe you are onto something. I might try my hand at writing one of these days. :roll: BEB

I just made my first post after many suggested I read this list (which I quite enjoyed). I did not realize I was supposed to use a pseudonym and don't have a clue what an avitar is. Pardon me if I violated the rules. I guess I used my real name because I can't use the pseudonyms my wife calls me.

This is a very timely discussion. This whole air medical thing is a house of cards that is about to fall. Several things are occurring. 1. The accident rate (although better this year) has gotten the attention of the NTSB and FAA. Tougher regulations (135 at all times, NVG, IFR and maybe dual pilots) is probably on the horizon. 2. The costs of HEMS was not on the radar screens of most insurance companies. Now, with the increased usage the insurance companies and Medicare are looking more carefully at HEMS utilization. Payments will stop and many have already been curtailed. 3. The General Accounting Office (GAO) was charged with investigating the HEMS phenomenon by Congress. The results should be out early this year and they will not be pretty. 4. The media in several major markets have keyed in on unscrupulous practices such as selling "subscriptions", paying local EMS agencies and fire departments $500.00 "Landing Zone Fees", and gifts and such. There was a recent story in the St. Louis media and I know of another big media outlets working on a story. One service tells subscribers to call them (HEMS) first and they will call local EMS. Who is to blame? 1. First, us doctors. We set the criteria and sign the memoranda of transport. Perhaps doctors who authorize or sign for flights that are medically unnecessary should be billed when the private insurance fails to pay. 2. The industry. In our great capitalistic society there was an opening when Medicare changed reimbursement rates and criteria for HEMS in 2001. Operators saw this and we went from 300 helicopters to 1000. If this were not the case, why are there 19-20 helicopters in affluent areas (Dallas, Phoenix, Nashville) and few in impoverished areas (Detroit)? 3. EMS. There is nothing more exciting for many EMS providers than stopping traffic on the interstate, calling in the "birds", and shipping patients out under dubious conditions. The smell of the Jet A, the flashing lights, the noise--orgasmic. We rationalize this with such ridiculous arguments as "we sent them by air to keep the ground ambulance free." That is like saying, "We went ahead and removed the gall bladder just in case he gets gall stones later in life." 4. The payers. rest assured they are now aware and reacting. Somewhere along the way we forgot the patient. We are placing patient's at risk when they do not stand to benefit from helicopter transport. We are placing flight crews at risk by asking them to transport non-serious cases. We should be ashamed. HEMS, just like an endotracheal tube and a defibrillator, is another modality that can benefit a very finite number of patients. Can it make a difference? Maybe? Does the literature support HEMS overall? No. EVERY DOLLAR SPENT ON HEMS IS A DOLLAR TAKEN AWAY FROM GROUND EMS. The money spent on a single flight will buy 4-6 AEDs or send two EMTs to paramedic school. Doczilla' is right. A large majority of patients transported by air go home from the ED (in our Jounal of Trauma article the number was 25%). In PEDS it is much higher. I would be pissed if my 6-year-old grandson was placed in a helicopter when he could just as safely and more comfortably gone by ground at 10% of the cost. This one struck a nerve.....sorry for the tirade and my compliments to Doczilla and the others (AZCEP) who have the ability to see this for what it is. Bryan