Medevac debate: an issue of life, death - and cost

The Baltimore Sun

Inevitably, the altogether appropriate rethinking of Maryland's state-of-the-art shock trauma system will get political.

To put it another way, we are entering the "sausage" phase. That's the moment when our leaders will make important decisions about whether to buy new helicopters for the system, how many to buy and where to base them.

"Sausage," of course, is the image for making laws and setting of policy. It's not a completely fair image, but the prospect of various issues coming together to establish a new system is likely.

Gov. Martin O'Malley's role in crafting a compromise will be central. He and members of the General Assembly will be dealing with a service far less abstract than many that government provides. Marylanders have been taught well about the Maryland Shock Trauma Center. They see the helicopters with the state seal gliding toward hospitals. They know that, next time, it could be them.

All of which does not mean the system can't be improved.

Nevertheless, a crash Sept. 28 that killed four and the age of the 12-helicopter fleet remove the option of standing pat. Mr. O'Malley has not revealed all, but he appears ready to go forward with a plan to begin replacing them. As tax-averse as Marylanders may be, they would likely applaud a decision that further enshrines the "golden hour" principle - the founding idea that competent care within the first 60 minutes of an accident is critical to saving lives.

At the same time, almost no one opposes a review of current operating protocols, including those physicians and administrators who run the program. To say the system doesn't need scrutiny, says Dr. Thomas M. Scalea, Shock Trauma's chief physician, would be silly.

"We have a wonderful system," he says. "How can we make it better?"

There is only once caveat: "We have to protect the patient."

There will be a debate about how to do that. Some critically injured crash survivors look unscathed or only slightly hurt, suggesting they need not be transported to Shock Trauma. The coming debate may well include how to make very difficult diagnoses.

At the same time, the governor and legislators will decide how many new helicopters must be purchased in a down economy.

Among the collision points:

* At least two members of the state Senate, E. J. Pipkin and John C. Astle, are pushing for something akin to contracting out the parts of the system. They would open the service to commercial providers.

* The entire Assembly will be involved in decisions about where the copters will be based. Marylanders are justifiably proud of this lifesaving system, and no one wants to feel they are not covered by it in the event of catastrophe.

The current system has eight bases - two more than it would have had save for the sausage syndrome. Political leaders of consequence insisted on two additional bases, in Montgomery County and on the Eastern Shore. Former Sen. Laurance Levitan, chairman of the Senate Committee on Budget and Taxation, insisted. So did former House Speaker R. Clayton Mitchell of the Eastern Shore. No one was going to resist their demands. Without their support, the whole enterprise would have been in doubt.

Critics of the current system say money could be saved if fewer crash victims were flown to Shock Trauma. It's fair to suggest, as they do, that money could be more efficiently spent in other lifesaving pursuits. A certain amount of risk-taking will be involved. Someone who should have been transported will die if the protocols are not as stringent as possible.

Legislators should be reluctant to choose between saving money and saving lives.

C. Fraser Smith is senior news analyst at WYPR-FM. His column appears Sundays. His e-mail is

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