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Date last updated: Wednesday, October 1, 10:30 PST

Md. medevac crash raises question about trauma procedures

Gadi Dechterand Brent Jones
The Baltimore Sun

BALTIMORE — 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.

Ashley called her mother from the accident scene, which her mother went out to. "It's like I keep hearing her say, 'Mom, it's going to be OK. It's OK,' " Stephanie Younger told WJZ TV.

The lone survivor was Jordan Wells, 18, a college freshman who was driving the car in which Ashley was a passenger. She was in critical but stable condition last night at Maryland Shock Trauma Center.

State police spokesman Greg Shipley said in a news release last night that one of the 11 remaining medevac helicopters had been cleared for service. Shipley added that police hope to put others into operation as inspections and flight tests are completed over the next couple of days.

Baltimore Sun reporter Michael Dresser contributed to this article.


Maryland emergency workers use these guidelines to determine whether a patient needs to be taken to a trauma center rather than a local hospital emergency room. If a trauma center is more than 30 minutes away by ambulance, the patient is transported by medevac helicopter. The fatal medevac trip this weekend was judged warranted based on the intrusion of an object into the car, not the injuries of the patients.

• Vital signs and level of consciousness: Check for signs of head injury, severely low blood pressure or low respiratory rate

• Anatomy of injury: Check for severe wounds such as penetrating injuries to the head, neck or torso; crush injuries; long-bone fractures; skull or pelvic fractures; and paralysis

• Mechanism of injury: Patients are transported if they have suffered falls of 20 feet for adults or 10 feet for children; if an object has intruded into a car by more than 12 inches near an occupant or 18 inches elsewhere; a motorcycle crash of greater than 20 miles per hour; and a crash involving an automobile and a pedestrian

• Other factors: Patients may be transported at the emergency worker's discretion based on criteria such as burns, age, pregnancy or the need for dialysis

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