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Helicopters Provide Lifeline for Trauma Victims Ambulance Choppers Save More of the "Golden Hour" By Jeffrey R. Orenstein, Ph.D. Executive Editor.

Since seconds often make the difference between life and death in treating medical emergencies, there is no question that the Bayflite helicopter ambulance service is a lifesaver. It's flying mini-emergency rooms have evolved as an integral component of the greater Tampa Bay region's medical infrastructure. Manatee and Sarasota counties are frequently served and one copter is based locally.

Bayflite usually responds to paramedics' calls to pick up critically-injured accident victims. But they handle other emergencies too. They also occasionally fly specialized medical emergency teams from area hospitals to bring help quickly to patients at hospitals not equipped for the sophisticated care required in some trauma cases, allowing the on-board medical team to start lifesaving during the flight back to the trauma center, saving precious minutes.

Critical Care Medical Needs
All Bayflite personnel are experienced in providing critical care and transport for victims of multisystem trauma (adult and pediatric), cardiac, including intra-aortic balloon pump patients, pediatric medical emergencies, severe burns and high-risk obstetrics.

Flight nurses are required to be graduates from an accredited nursing school and to have a Florida nursing license and at least current EMT Florida certification and are accompanied by onboard paramedics. Together, they can provide rapid-sequence intubations, give anesthesia, provide airways with advanced techniques perform surgical thoracotomies and put in chest tubes, among other things. They are constantly training and work with surgeons and Bayflite's three medical directors, Dr's Michael Lozano, Charles Sands and Steven Epstein. The three M.D.'s frequently fly with Bayflite crews. While the Bayflite crew is at the emergency scene, the copter is standing by, engines running, and the trauma-center hospital is on alert - in the emergency department, radiology, laboratory, operating room and critical care units. Blood is ordered and equipment moved in place. Again, precious seconds and minutes are saved by the process.

Bayflite is called when ground-based emergency medical service rescue crews judge (aided by state guidelines) that the patient needs expert trauma care in a distant facility and might not survive a trip by ground transport. Then paramedics call the Bayflite dispatch center located on the top floor of Bayfront Medical Center in downtown St. Petersburg , sandwiched between two helipads. From there, the dispatchers send the nearest available chopper to the scene. Beside a St. Petersburg based helicopter, there are four others regionally, based at Sarasota-Manatee Airport, St. Joseph's Hospital in Tampa, Tampa Bay Executive Airport in Odessa and in Brooksville in Hernando County. Two others from the Lifenet system in Bartow and Bushnell are also on call.

Operating like a ground-based Emergency Medical system, the nearest helicopter is dispatched to where it is needed. Once it arrives on the scene into a landing zone of at least 75 feet by 75 feet during the day and 100 feet by 100 feet at night prepared by paramedics, it is usually airborne with the patient within five minutes of landing. "Only a prolonged extrication of a victim keeps us on the ground longer," said Jeff See, Director of Flight Nurses. If a large area of the service region is left uncovered by a major accident or unusual demand, a helicopter from a distant area will move into the area to be closer to potential calls.

The dispatch center, the most sophisticated in Florida , tracks helicopters in real time. Dispatchers and flight crews are linked with local and regional 911 communication centers as well as Pinellas County 's Central Dispatch. Each twin-turbine powered Kawasaki BK117 helicopter also carries sophisticated electronics for communications and as much (usually more) medical equipment that a typical EMS ambulance.

Each crew member is required to be an expert in all aspects of trauma care. Even the dispatchers are at least EMT's. Flight nurses and paramedics work independently at the scene and in the air to quickly evaluate injuries and begin advanced life-saving care en route to the hospital. Bayflite is also one of only a few air ambulance systems in the nation that carries blood on board every flight, giving it another lifesaving edge.

"We try to be 90% reliable for the first call 90% of the time within 15 minutes," said See. "We are usually on the ground at the scene with our response team within that time frame."

Michelle Kenly, RN, Flight Nurse at the St. Petersburg base said, "On the way there, we get landing zone instructions. Each fire department is trained for it. If there is time, they'll give us a brief patient report with key words to help us get stuff ready on the way there. Once we land, we spring into action and are prepared to administer advanced practice care. When we get here, we do a quick assessment of the patient and get a full report from the scene."

Facts & Figures
Since the first mission in November, 1986, Bayflite has served more than 24,000 people, a far cry from the original single helicopter that answered 47 calls the first year. Fifteen counties are served, but most missions are flown in the greater Tampa and Sarasota areas.

Bayflite is currently looking for a home in the Manatee Sarasota area outside of the Sarasota-Bradenton airport and is investigating possible sites in East Manatee.

On Washing Hands and Hospital Infections

  By Atul Gawande

Each year, according to the U.S. Centers for Disease Control, two million Americans acquire an infection while they are in the hospital. Ninety thousand die of that infection. The hardest part of the infection-control team's job, Yokoe says, is not coping with the variety of contagions they encounter or the panic that sometimes occurs among patients and staff. Instead, their greatest difficulty is getting clinicians like me to do the one thing that consistently halts the spread of infections: wash our hands.

There isn't much they haven't tried. Walking about the surgical floors where I admit my patients, Yokoe and Marino showed me the admonishing signs they have posted, the sinks they have repositioned, the new ones they have installed. They have made some sinks automated. They have bought special five-thousand-dollar "precaution carts" that store everything for washing up, gloving, and gowning in one ergonomic, portable, and aesthetically pleasing package. They have given away free movie tickets to the hospital units with the best compliance. They have issued hygiene report cards. Yet still, we have not mended our ways. Our hospital's statistics show what studies everywhere else have shown -- that we doctors and nurses wash our hands one-third to one-half as often as we are supposed to. Having shaken hands with a sniffling patient, pulled a sticky dressing off someone's wound, pressed a stethoscope against a sweating chest, most of us do little more than wipe our hands on our white coats and move on -- to see the next patient, to scribble a note in the chart, to grab some lunch.

This is, embarrassingly, nothing new: In 1847, at the age of twenty-eight, the Viennese obstetrician Ignac Semmelweis famously deduced that, by not washing their hands consistently or well enough, doctors were themselves to blame for childbed fever. Childbed fever, also known as puerperal fever, was the leading cause of maternal death in childbirth in the era before antibiotics (and before the recognition that germs are the agents of infectious disease). It is a bacterial infection -- most commonly caused by Streptococcus, the same bacteria that causes strep throat -- that ascends through the vagina to the uterus after childbirth. Out of three thousand mothers who delivered babies at the hospital where Semmelweis worked, six hundred or more died of the disease each year -- a horrifying 20 percent maternal death rate. Of mothers delivering at home, only 1 percent died. Semmelweis concluded that doctors themselves were carrying the disease between patients, and he mandated that every doctor and nurse on his ward scrub with a nail brush and chlorine between patients. The puerperal death rate immediately fell to 1 percent -- incontrovertible proof, it would seem, that he was right. Yet elsewhere, doctors' practices did not change. Some colleagues were even offended by his claims; it was impossible to them that doctors could be killing their patients. Far from being hailed, Semmelweis was ultimately dismissed from his job.

Semmelweis's story has come down to us as Exhibit A in the case for the obstinacy and blindness of physicians. But the story was more complicated. The trouble was partly that nineteenth-century physicians faced multiple, seemingly equally powerful explanations for puerperal fever. There was, for example, a strong belief that miasmas of the air in hospitals were the cause. And Semmelweis strangely refused to either publish an explanation of the logic behind his theory or prove it with a convincing experiment in animals. Instead, he took the calls for proof as a personal insult and attacked his detractors viciously.

"You, Herr Professor, have been a partner in this massacre," he wrote to one University of Vienna obstetrician who questioned his theory. To a colleague in Wurzburg he wrote, "Should you, Herr Hofrath, without having disproved my doctrine, continue to teach your pupils [against it], I declare before God and the world that you are a murderer and the 'History of Childbed Fever' would not be unjust to you if it memorialized you as a medical Nero." His own staff turned against him. In Pest, where he relocated after losing his post in Vienna, he would stand next to the sink and berate anyone who forgot to scrub his or her hands. People began to purposely evade, sometimes even sabotage, his hand-washing regimen. Semmelweis was a genius, but he was also a lunatic, and that made him a failed genius. It was another twenty years before Joseph Lister offered his clearer, more persuasive, and more respectful plea for antisepsis in surgery in the British medical journal Lancet.

One hundred and forty years of doctors' plagues later, however, you have to wonder whether what's needed to stop them is precisely a lunatic. Consider what Yokoe and Marino are up against. No part of human skin is spared from bacteria. Bacterial counts on the hands range from five thousand to five million colony-forming units per square centimeter. The hair, underarms, and groin harbor greater concentrations. On the hands, deep skin crevices trap 10 to 20 percent of the flora, making removal difficult, even with scrubbing, and sterilization impossible. The worst place is under the fingernails. Hence the recent CDC guidelines requiring hospital personnel to keep their nails trimmed to less than a quarter of an inch and to remove artificial nails.

Plain soaps do, at best, a middling job of disinfecting. Their detergents remove loose dirt and grime, but fifteen seconds of washing reduces bacterial counts by only about an order of magnitude. Semmelweis recognized that ordinary soap was not enough and used a chlorine solution to achieve disinfection. Today's antibacterial soaps contain chemicals such as chlorhexidine to disrupt microbial membranes and proteins. Even with the right soap, however, proper hand washing requires a strict procedure. First, you must remove your watch, rings, and other jewelry (which are notorious for trapping bacteria). Next, you wet your hands in warm tap water. Dispense the soap and lather all surfaces, including the lower one-third of the arms, for the full duration recommended by the manufacturer (usually fifteen to thirty seconds). Rinse off for thirty full seconds. Dry completely with a clean, disposable towel. Then use the towel to turn the tap of. Repeat after any new contact with a patient.

Almost no one adheres to this procedure. It seems impossible. On morning rounds, our residents check in on twenty patients in an hour. The nurses in our intensive care units typically have a similar number of contacts with patients requiring hand washing in between. Even if you get the whole cleansing process down to a minute per patient, that's still a third of staff time spent just washing hands. Such frequent hand washing can also irritate the skin, which can produce a dermatitis, which itself increases bacterial counts.

Less irritating than soap, alcohol rinses and gels have been in use in Europe for almost two decades but for some reason only recently caught on in the United States. They take far less time to use -- only about fifteen seconds or so to rub a gel over the hands and fingers and let it air-dry. Dispensers can be put at the bedside more easily than a sink. And at alcohol concentrations of 50 to 95 percent, they are more effective at killing organisms, too. (Interestingly, pure alcohol is not as effective -- at least some water is required to denature microbial proteins.)

Still, it took Yokoe over a year to get our staff to accept the 60 percent alcohol gel we have recently adopted. Its introduction was first blocked because of the staff's fears that it would produce noxious building air. (It didn't.) Next came worries that, despite evidence to the contrary, it would be more irritating to the skin. So a product with aloe was brought in. People complained about the smell. So the aloe was taken out. Then some of the nursing staff refused to use the gel after rumors spread that it would reduce fertility. The rumors died only after the infection-control unit circulated evidence that the alcohol is not systemically absorbed and a hospital fertility specialist endorsed the use of the gel.

With the gel finally in wide use, the compliance rates for proper hand hygiene improved substantially: from around 40 percent to 70 percent. But -- and this is the troubling finding -- hospital infection rates did not drop one iota. Our 70 percent compliance just wasn't good enough. If 30 percent of the time people didn't wash their hands, that still left plenty of opportunity to keep transmitting infections. Indeed, the rates of resistant Staphylococcus and Enterococcus infections continued to rise. Yokoe receives the daily tabulations. I checked with her one day not long ago, and sixty-three of our seven hundred hospital patients were colonized or infected with MRSA (the shorthand for methicillin-resistant Staphylococcus aureus) and another twenty-two had acquired VRE (vancomycin-resistant Enterococcus) -- unfortunately, typical rates of infection for American hospitals.

Rising infection rates from superresistant bacteria have become the norm around the world. The first outbreak of VRE did not occur until 1988, when a renal dialysis unit in England became infested. By 1990, the bacteria had been carried abroad, and four in one thousand American ICU patients had become infected. By 1997, a stunning 23 percent of ICU patients were infected. When the virus for SARS -- severe acute respiratory syndrome -- appeared in China in 2003 and spread within weeks to almost ten thousand people in two dozen countries across the world (10 percent of whom were killed), the primary vector for transmission was the hands of health care workers. What will happen if (or rather, when) an even more dangerous organism appears -- avian flu, say, or a new, more virulent bacteria? "It will be a disaster," Yokoe says.

Copyright © 2007 Atul Gawande from the book Better Published by Metropolitan Books; April 2007; 978-0-8050-8211-1

Atul Gawande, a 2006 MacArthur Fellow, is a general surgeon at the Brigham and Women's Hospital in Boston, a staff writer for The New Yorker, and an assistant professor at Harvard Medical School and the Harvard School of Public Health. His first book, Complications: A Surgeon's Notes on an Imperfect Science, was a New York Times bestseller and a finalist for the 2002 National Book Award. Gawande lives with his wife and three children in Newton, Massachusetts. Visit www.gawande.com for information.

Cholesterol 101: An Interview with Cardiologist John A. Osborne, M.D., Ph.D.

(editor's note: long story, but worth it)

What are some of the biggest myths about high cholestorol?

Dr. Obsorne: I think there are a lot of myths surrounding cholestorol. One is that people in general have kind of gotten the idea that they need
to know their (cholesterol) number. But, to be honest, knowing your total cholesterol is important, but there are a variety of other subfractions: the LDLs -- the bad cholesterols, the HDLs -- the good cholesterols, the triglycerides, the VLDLs..that all contribute to that total cholesterol number that are extremely important as far as assessing your risk of having a cardiovascular event, a stroke or a heart attack.

So, the most important thing is that people need to get their cholesterol checked. Having high cholesterol is a completely asymptomatic disease. No one goes around thinking, 'Oh, I feel bad today because my cholesterol is high.' But, that high cholesterol clearly does contribute to the risk of heart attacks and strokes. The American Heart Association has some new guidelines (that say) that if you're age 20 or older, you need to have your cholesterol checked periodically.

At age 20?

Dr. Osborne: A rteriosclerosis, that is the plaques, the gross in the arteries that causes the blockages and the strokes and the heart attacks, start very early. In fact, (autopsy) studies done from the Korean War and Vietnam War where you had young people dying from trauma, (found) kids that were 17, 18, 19 years old who already had the start of these plaques. Arteriosclerosis .is a chronic, festering process that is completely asymptomatic until the very end of it. When they finally do have a symptom -- a heart attack or stroke -- it may be the first symptom, and that first symptom may be fatal.

What are triglycerides?

Dr. Osborne: Triglycerides are basically a form of fat that's normal. They circulate in our bloodstream, but those levels of triglycerides are probably one of the factors that we've really begun to concentrate on really in the last several years because we realized that these levels of triglycerides that are different from LDL cholesterol and HDL cholesterol actually can be very important markers of what we call the metabolic syndrome. In fact, metabolic syndrome is a relatively newly identified process that with it contributes to very high risk of going on to develop heart attacks and strokes. One of the markers for that is an elevated level of triglycerides, and with that too are low levels of good or HDL cholesterol.

So it's not only the high LDL that you have to worry about, there's more to it?

Dr. Osborne: Right. Not only do you have to focus on your high LDL, the bad cholesterol -- it's bad because it's bad -- but you also need to focus on making sure you have enough of the good cholesterol or HDL in that your triglyceride levels are also checked and monitored as well.

How big of a role is diet and what are the other risk factors you have to consider?

Dr. Osborne: Diet has a large impact on cholesterol, which in many ways is good. If we can look at your cholesterol levels, we can suggest diets that will help you improve it. On the other hand, a lot of cholesterol disorders have more to do with your genes, with mom and dad, and with those sorts of issues, again, you may be very active and exercise all the time and eat right and be doing all the right things. We have many patients that are young and healthy, have no bad habits, their blood sugar is fine, they don't have diabetes, they don't smoke, and yet still come down with heart disease. Many times, it's because of cholesterol abnormalities.

In fact, if you look statistically at all the people that have heart attacks this year, about half of them have normal levels of cholesterol. Again, cholesterol is extremely important, but you really need to focus on all the different components that make up cholesterol -- the HDL, the LDL, the triglycerides, the VLDLs -- to better assess your individual risk.

How do high-fat diets and intake of trans fatty acids affect cholesterol?

Dr. Osborne: LDL cholesterol is dependent upon fat intake, particularly saturated fats and animal fats. They'll clearly elevate your LDL cholesterol and also really bad fats, called trans fatty acids, which are in a lot of processed foods are particularly bad. (They) are really are only in processed foods, and whenever you see partially hydrogenated whatever, that's a trans fatty acid.

In fact, with new labeling that will come out over the next two years, every product that has nutritional labeling will be required to report the amount of trans fatty acids. There's a huge debate because nutritionists pretty uniformly agree there is no safe level of trans fatty acids, whereas the people who make these products with trans fatty acids in it -- and they're all over the place, they're endemic to our food supply -- don't want to put on a label on the bottom that says there is no safe level of this trans fatty acid that we're listing on our product label.

These trans fatty acids are particularly bad because they elevate the LDL and they lower your HDL and they raise your triglycerides, so they are the neutron bomb of lipids.

Getting back to LDL, saturated fatty acids -- animal fats -- tend to raise the LDL, but the vegetable fats -- canola oil, olive oil, things like that -- tend to lower your LDL cholesterol. What raises your triglycerides, and at the same time lowers your HDL, the good cholesterol, is your intake of carbohydrates, and particularly simple carbohydrates -- sugars that are unfortunately a large part of our typical American diet, and simple starches, again, the white stuff -- potatoes, rice, pasta, bread, and even things that people think of as vegetables that really are mainly simple starches like carrots and corn. They're really not vegetables, they're really starches, and those can elevate your amount of triglycerides.

What if your LDL is high, but your HDL is high too?

Dr. Osborne: High HDL levels are protective in many people against the development of these plaques, and protect against heart attacks and strokes. In fact, certain things that raise HDL very effectively like regular aerobic exercise, certain medications, and interestingly, alcohol, tend to all raise your HDL, and that seems to be very effective in helping to prevent in many people heart disease.

But, unfortunately, there are certainly people who have high amounts of HDL cholesterol and high amounts of LDL that don't get the amount of protection that you'd think they would be getting from their HDL, and so they're not necessarily immune. In general, having a high amount of HDL cholesterol is in general a very, very good thing, and it does help to protect against arteriosclerosis, but having a high HDL alone may not completely protect you if your LDL is high as well.

You talk about arteriosclerosis and the plaque starting to build up. When you lower your cholesterol and you get it back into that normal range, what effect does that have on the plaque buildup? Is the plaque going to go away?

Dr. Osborne: That's a great question. We know now from a whole variety of studies .(that) if you can lower your cholesterol, you can lower the amount of that plaque buildup and perhaps more importantly, you can actually significantly lower your risk of having a heart attack or a stroke.

I put those two things together because a heart attack or a stroke is a manifestation of arteriosclerosis or blockage in those blood vessels, so that the same things that contribute to stroke for the most part, which is a buildup of blockages and narrowing in the blood vessels of the neck, also are the same things that occur in the coronary arteries of the heart. So, as we're lowering your risk for having a heart attack, conversely, and fortunately, we're lowering your risk of having a stroke or vice versa. Those are simply different manifestations of one disease, arteriosclerosis. It just depends upon which bed gets clogged up first.

So it can lower it?

Dr. Osborne: Regression. You can actually regress these plaques, and we know that from lots and lots of different data. Now, you can lower your cholesterol many times with diet and exercise, and for many people, that's a great place to start, but there are a lot of people, depending on risk factors, levels of your cholesterol, that it may require medications. We know that you can certainly lower cholesterol with diet and exercise, but many people, in order to really suppress the growth of that plaque or to regress a plaque that's already there, there's a good chance that it may require medications to do that.

What's new in that area?

Dr. Osborne: There are a variety of medications. Probably the most-studied class of these medications is what we call statins. This includes medications such as Zocor, Lipitor and Pravachol. In fact, (recently), a new class of that medication, a new member of that class, was introduced called Crestor.

As we talked about before, there are different kinds of cholesterol problems. You can have high triglycerides, low HDL, you can have just an elevated LDL, and we actually have different kinds of medications and different classes of medications that we can use to treat each one of those things. Or, sometimes you may have a combination cholesterol problem where you need a couple of different medications -- one to lower your LDL cholesterol and another to lower your triglycerides and to raise your HDL cholesterol.

I think what's new is certainly there's a new member of this statin class, but I think the other thing that's new as well is we're beginning to appreciate that in many people, to get our maximal benefit, to reduce that arteriosclerotic plaque, and to maximize our opportunities to reduce the risk of heart attacks and strokes and death from heart attacks and strokes, we should use combination therapy that targets not just the LDL cholesterol, for instance, but also the triglycerides and the HDL as well. Many times, that's going to require combinations of medications in order to be able to do that.

What about new ways to detect it or diagnose high cholesterol faster?

Dr. Osborne: We're really focusing on how we can identify people at risk many years before they actually have a heart attack or stroke and treat that plaque early, so that with some simple interventions now, we can avoid things like bypass surgeries, angioplasties, and death from heart attacks and strokes.

One of those techniques has actually been a technique called electron beam CT, or EBCT, which is a way to identify plaque in the coronary arteries in particular.With those techniques, we can actually identify calcium because calcium is part of that plaque. If we can identify that you have a plaque when you're in your 30s or 40s and use the appropriate tools of diet and exercise and put people on the appropriative medications, perhaps we can avoid them from ever having to show up 10 years or 20 years later with a heart attack or stroke or needing bypass surgery. So, that's been a very exciting technique.

There are also some newer techniques to look at other cholesterol, to look even further into various kinds of cholesterols and what are called lipoprotein analysis, where basically we look at LDL cholesterol, for instance, but not just LDL, but looking at the different kinds of LDL cholesterol because it comes in different sizes. Some of those sizes, particularly what are called the small dense LDL, are very atherogenic. They very much contribute to form those plaques.

Other kinds of LDL, despite the fact that it's LDL, are not nearly as dangerous, so we can now do for the test to be able to better identify risk and know if you have a really bad form of LDL cholesterol or if your LDL is not as bad as we might think it is. So, that's been another big advance.

Then, another technique that's caught interest is to use something called intramedial thickness or IMT where we do an ultrasound of the blood vessels of the neck and with that, because these blood vessels, again, reflect arteriosclerosis but are easy to get at, easy to look at, and close to the skin, we can use ultrasound techniques to see if there's any early thickening long before they get to the point where you have a stroke. If you have some early thickening, then we probably need to be more aggressive with you as far as these interventions than someone that doesn't have that early thickening.

What about the super quick blood tests?

Dr. Osborne: The super quick blood tests have been really another major advance as well that I think have helped more patients to be tested. At the same time, with this what we call point-of-care testing (POCT). With that technique, we can assess the problem immediately while I'm sitting in the office talking to you.

We can go beyond "Let's check your cholesterol, and I'll see you at a month to see what the results are.' Instead, we can check your cholesterol, we can get the results back right away, and then make a plan to say: 'This is what we're going to need to do to take care of that.' There's a whole problem with not having the results back immediately where people just lose interest or they think it's OK when it may not be. So, it really helps to foster that direct communication between the patient and the physician to identify the problem and then to start out immediately as far as a plan to take care of it.

Important: Because all information in Doctors Health Journal print, online and on the radio and TV is for general knowledge only and is not intended to be a substitute for medical advice or treatment, Doctors Health Journal does not answer questions about your specific medical conditions.

We strongly recommend that you contact your personal physician about these medical questions.

If you don’t have a physician, call the Manatee Medical Society at 755-3411 or the Sarasota Medical Society at (941) 966-3134 or one of the area hospitals for a referral.

If You Are In Crisis and Need Immediate Help, Call 911.

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