The EMS Image

Have We Set the Bar Too High? Bryan E. Bledsoe, DO, FACEP University of Nevada School of Medicine

The EMS Image The EMS Image

The EMS Image The EMS Image The EMS Image The EMS Image

The EMS Image The EMS Image

The EMS Image The Problem

“You wanted to be a doctor, maybe you should have buckled down a little more in high school.” The Problem The EMS Image

We Raise the Dead We Raise the Dead

Researchers watched all 1994- Los Angeles, CA: 1995 episodes of ER and 1-year study (1JUL00- Chicago Hope. 1JUL01). Watched 50 consecutive 2,021 consecutive cardiac episodes of Rescue 911. arrests. Findings: 1,700 met entry criteria as a 65% of cardiac arrests occurred in primary cardiac event. children, teenagers or young 28% received bystander adults. CPR. 75% survived the initial arrest. 67% survived to discharge.

Diem SJ, Lantos JD, Tulsky JA: “Cardiopulmonary resuscitation on television. Miracles and misinformation.” New England Journal of Medicine. 133:1578–1582, 1996.

We Raise the Dead We Raise the Dead

Mechanical CPR devices Results: have not been shown to 1.4% survived neurologically intact. improve outcomes. 6.1% survived from bystander- witnessed ventricular fibrillation. Some actually worsen 2.1% survival with bystander CPR. CPR outcomes. 3.2% survival with witnessed arrest Tucson IRB stopped and bystander CPR. multi-center RCT 1% survival without bystander Yet, many FDs still spend CPR. hundreds of thousands of dollars on these.

Eckstein M, Stratton SJ, Chan LS: “Cardiac Arrest Resuscitation in Los Angeles: CARE- LA.” Annals of Emergency Medicine. 45:504–509, 2005. We Raise the Dead We Raise the Dead

Civilian Trauma deaths occur in No change in a trimodal distribution: survival for Death within minutes = 50% the first group Neurologic and vascular injuries. since the Crimean war. Death within hours = 30% Hypoxia and hypovolemia. Death within days = 20% Sepsis, MODS and other complications. Trunkey DD: “Trauma.” Scientific American. 249:220–227, 1983.

We Raise the Dead We Raise the Dead

“Insanity: Doing the same thing over and over and expecting a different result.”

John Dryden The Spanish Friar (Act II, Scene 1)

We Raise the Dead The EMS Image

This begs the question: Why do we put so much money and resources into cardiac arrest management when the out-of-hospital survival rate remains abysmally miniscule? Hospital will Save Them Hospital will Save Them

Most Australian NAEMSP has had a paramedics have position paper on field never done CPR in a termination of out-of- moving ambulance. hospital non-traumatic cardiac arrest since 1999.

Bailey ED, Wydro GC, Cone DC. Termination of Resuscitation in the Prehospital Setting for Adult Patients Suffering Nontraumatic Cardiac Arrest. Prehosp Emerg Care. 2000;4:190-195

Hospital will Save Them Hospital will Save Them

NAEMSP and the 336 prospective and 135 Conclusion: Protocol American College of retrospective cases of 100% specific for lack Surgeons has had a OOHCA. of survival from position paper on the 12 patients survived to OOHCA. discharge (none met termination of criteria for field TOR). traumatic cardiac 63 patients survived to Cone CD, Bailey ED, Spackman AB. arrest since 2002. admission, 4 were eligible The Safety of Field Termination-of- Resuscitation Protocol. Prehosp Emerg Care. 2005;9:276-281 Hopson LR, Hirsh E, Delgado J, for TOR. Dormier RM, McSwain NE, Krohmer J. Guidelines for Withholding or None of these 4 survived Termination of Resuscitation in to discharge. Prehospital Traumatic Cardiopulmonary Arrest. Prehosp Emerg Care. 2003;7:141-146

Hospital will Save Them Hospital will Save Them

1,068 victims of OOHCA “Rapid transport of adults 189 pediatric patients Those likely to survive treated by Memphis FD. who fail to respond to an with OOHCA studied: had a sinus rhythm and 310 (29%) had ROSC prior adequate trial of 39 (20.6%) received BLS received fewer doses of to transport. prehospital ACLS does only epinephrine in the ED. Admitted: 69% not result in meaningful 150 (79.4%) received ALS. ALS does not improve Discharged alive: 26.5% rates of survival.” 5 (2.6%) survived to survival in pediatric 758 (71%) never regained discharge. OOHCA. a pulse and were No significant transported with CPR Pitetti R, Glustein JZ, Bhende MS. underway. improvement in survival Prehospital Care and Outcome of Kellerman AL, Hackman BB, Somes in those who received Pediatric Out-of-Hospital Cardiac Admitted: 7.0% G. Predicting the Outcome of Arrest. Prehosp Emerg Care. Discharged alive: 0.4%† Unsuccessful Prehospial Advanced ALS. 2002;6:283-90 Life Support. JAMA. 1993;270:1433- †-All had moderate-severe CNS disability. 1436 Hospital will Save Them Hospital will Save Them

LA and Orange “Given that there were no 235 OOHCA patients: County (CA) SIDS survivors, new 131 (56%) met criteria for TOR. study: prehospital policies are needed governing the All expired at the hospital. 114 SIDS patients use of lights and sirens, No mitigating reasons 6 (5%) had ROSC resuscitation decisions found to justify transport. 0 (0%) survived including termination of TOR protocols are not 50 (44%) received resuscitation.” being followed. Smith MP, Kaji A, Young KD, O’Brian E, Hendricks D, Cone CD. lights and siren Field Termination of Gausche-Hill M. Presentation and Resuscitation: Analysis of a transport. Survival of Apparent Prehospital Newly-Implemented Protocol. Sudden Infant Death Syndrome. Prehosp Emerg Care. 2008;12:56- Prehosp Emerg Care. 2005;9:181- 61 185

Hospital will Save Them Hospital will Save Them

This begs the question: Why do we put our resources and personnel at risk in transporting CPR cases when the results are always futile?

The “Golden Hour” exists The “Golden Hour” exists

“Patients must arrive The concept of the at a trauma center “Golden Hour” was within one hour of developed to promote their injury in order to the newly-opened have their best chance of survival.” University of Maryland R. Adams Cowley, MD “Shock Trauma” center. The “Golden Hour” exists. The “Golden Hour” exists

“This article Nobody wants to talk discusses a about the false notion detailed literature of a “Golden Hour” and historical because it so shakes records search for the roots of EMS and support of the trauma care.” ‘Golden Hour’ concept. None is

identified.” Lerner ED, Moscatti RM: “The Golden Hour: Scientific Fact or Medical ‘Urban Legend’?” Academic Emergency Medicine. 8:758–760, 2001.

The “Golden Hour” exists The “Golden Hour” exists

Our old trauma This begs the question: practices may have Why are we putting our personnel and been harming more patients at risk to meet the constraints of the patients than it was ‘Golden Hour’ when there is no evidence that helping. the ‘Golden Hour’ exists? Large volume crystalloids. Endotracheal intubation.

Lights and Sirens Save Lives Lights and Sirens Save Lives

In a North Carolina, Hunt and colleagues found only a 43.5 second mean time savings with lights and siren compared to transport without lights and siren. Hunt RC, Brown LH, Cabinum TW et al. Is ambulance transport time with lights and siren faster than that without? Annals of Emergency Medicine. 1995;25(4):507-511 Lights and Sirens Save Lives Lights and Sirens Save Lives

Upper New York Pediatrics? (Syracuse) study. “In our preliminary “L&S reduce ambulance study, inappropriate response times by an use of L&S in the average of 1 minute, 46 transport of pediatric seconds. Although patients in stable statistically significant, this condition is common.” time saving is likely to be clinically relevant in only a Brown LH, Whitney CL, Hunt RC, et al. Lacher ME, Bauscher JC. Lights and Do warning lights and sirens reduce sirens in pediatric 911 transports. Are they very few cases.” ambulance response times? Prehospital being misused? Annals of Emergency Emergency Care. 2000;4(1):70-74 Medicine. 1997;29(2):223-227

Lights and Sirens Save Lives Lights and Sirens Save Lives

A 1994 study evaluated patient outcomes when an EMS agency used a medical protocol directing the use of lights and siren. They found, “No adverse outcomes were Kupas DF, Dula DJ, Pino BJ. Patient identified as related to outcome using medical protocol to limit “lights and siren transport. Prehosp Diast non-L&S transport.” Med. 1994:9(4):226-229

Lights and Sirens Save Lives Lights and Sirens Save Lives

This begs the question: “Why do we continue to endanger our employees and our patients by significantly overusing lights and sirens response?

With lights and siren transport, the “clinical benefits” do not outweigh the risks for the vast majority of patients. The EMS Image 7 Minutes, 59 Seconds (90%)

Where is the safest place in America to have your cardiac arrest?

7 minutes, 59 seconds (90%) 7 minutes, 59 seconds (90%)

The time it takes to EMS “visionaries” have travel between two set 8 minutes (7 points is determined by minutes, 59 seconds [90% of the time]) as speed. the goal for an EMS Speed can be affected response. by: This time interval was Traffic based purely on Road conditions rational conjecture and not a shred of science. Vehicle conditions Operator experience

7 minutes, 59 seconds (90%) 7 minutes, 59 seconds (90%)

Various strategies have What does the science tell us? been proposed to decrease travel times. It is impossible, with any degree of accuracy, to predict when and where an EMS call will occur. 7 minutes, 59 seconds (90%) 7 minutes, 59 seconds (90%)

OPALS study: How many EMS 9,273 patients treated 4.2% survival systems can 6.2 minute defibrillation response time. guarantee a 4 minute “There was a steep decrease in the first 5 minutes of the survival curve, beyond response time? which the slope gradually leveled off. Controlling for known covariates, the decrement in the odds of survival with increasing response interval was 0.77 per minute (95% confidence interval 0.74 to De Maio VJ, Stiell IG, Wells GA, Spaite DW; Ontario Prehospital 0.83).” Advanced Life Support Study Group: “Optimal defibrillation response intervals for maximum out-of-hospital cardiac arrest survival rates.” Annals of Emergency Medicine. 42(2):242– 250, 2003.

7 minutes, 59 seconds (90%) 7 minutes, 59 seconds (90%)

A paramedic response “Our data are most time of 8 minutes was consistent with the not associated with inference that neither the mortality or frequency of improved survival to critical procedural hospital discharge. interventions performed in A response time of 4 the field vary substantially minutes did improve based upon this pre- specified (10 min, 59 sec) survival in patients with Pons PT, Markovchick VJ: “Eight minutes or less: Does the ambulance ALS response time.” Blackwell TH, Kline J, Willis J, et al. Lack moderate to high risk of response time guideline impact of association between prehospital trauma patient outcome?” Journal of response times and patient outcomes. Emergency Medicine. 23(1):43–48, Prehospital Emergency Care. mortality. 2002. 2007;11(1):115

7 minutes, 59 seconds (90%) 7 minutes, 59 seconds (90%)

Pennsylvania Study: UK Study: “Although response times were “Overall, there is little evidence differentiated by location, they in the data that faster were not necessarily predictive response times have led to of survival. Factors other than better outcomes.” response time such as patient “The number of patients who population or resuscitation skill might benefit from a fast could influence survival from response is actually very small cardiac arrest occurring in and the benefit in this small

diverse prehospital service group is being ‘lost’ in the Turner J, O’Keefe C, Dixon S, Warren K, areas.” Vukmir RM, Sodium Bicarbonate Study Nicholl J: The Costs and Benefits of Group. The influence of urban, larger group who do not need Changing Ambulance Response Time suburban, or rural locale on survival fast response.” Performance Standards. Medical Care from refractory cardiac arrest. Research Unit School of Health and Related American Journal of Emergency Research, University of Sheffield. 2006 Medicine. 2004;22(2):90-93 7 minutes, 59 seconds 7 minutes, 59 seconds (90%) (90%) This begs the question: This begs the question: “Why do we continue to endanger our “Why do we continue to endanger our employees and our patients by setting employees and our patients by setting artificial response times that have no artificial response times that have no correlation with patient outcomes? correlation with patient outcomes?

Helicopters Save Lives Medical Helicopters

In 2002, Medicare increased the rates for medical helicopter transport. Price for airlift ranges from $5,000 to $10,000, 5 to 10 times that of a ground ambulance. Helicopters in the US have doubled from a decade ago; and with more of them scrambling for business, specialists say that emergency personnel are feeling more pressure to use them. In 2004, the number of flights paid for by Medicare alone was 58 percent higher than in 2001. Spending by Medicare has more than doubled to $103 million over the same period.

Medical Helicopters Medical Helicopters

In FY 2001, the University Bledsoe BE, Smith of Michigan’s flight program “Survival Flight”: MG. Medical $6,000,000 operational Helicopter Accidents costs $62,000,000 in inpatient in the United States: revenues A 10-Year Review. 28% of ICU days Helicopter patients were Journal of Trauma/. twice as likely to have commercial health 2004;56:1325-1329 insurance compared to regular patient profile. Medical Helicopters Medical Helicopter Accidents

1993-2007 (Source: NTSB)

Medical Helicopter Accidents Medical Helicopter Accidents

18 16 1993-2002

14 10 9 12 8 10 7 Fatalities 6 8 5 Accidents Injuries 4 6 3 2 4 1 0 2 M M M A PM PM PM A 2AM 4A 6AM 8A 2PM 2 4PM 6 8PM 0 12 10AM 1 10 1993 1995 1997 1999 2001 2003 2005 2007 Source: NTSB & Bledsoe BE and Smith MG. Medical Helicopter Accidents Source: NTSB in the United States: A 10-Year Review. J Trauma. 2004;56:1225-1229

Medical Helicopter Accidents Occupational Deaths per 100,000 per Year

Accidents by Cause All Workers 5

2% 11% Farming 26

Pilot Error Mechanical Failure Mining 27 26% Undetermined 61% Other Air Medical Crew 74

US 1995-2001 Source: NTSB & Bledsoe BE and Smith MG. Medical Helicopter Accidents in the United States: A 10-Year Review. J Trauma. 2004;56:1225-1229 Source: Johns Hopkins University School of Public Health Fatal Crashes per Million Flight Hours (2001) Medical Helicopter Accidents

20 19 Weather a factor in 18 16 one-fourth of all 14 12 12 Airline crashes. 12 Commuter Source: AMPA. 10 Ground Ambulance A Safety Review 8 All Helicopters 6 and Risk 6 Medical Helicopters Assessment in 4 Air Medical 2 1 Transport, 2002 0

Source: AMPA, A Safety Review and Risk Assessment in Air Medical Transport (2002)

Pressure on Pilots Medical Helicopters

Undue pressure from: Initial studies in the 1980s showed that trauma Management patients have better outcomes when transported by helicopter. Dispatch Today, other than speed, helicopters offer little Flight Crews additional care than provided by ground Pressure to: ambulances. Speed response or lift-off times Launch/continue in marginal weather Fly when fatigued or ill

EMS Line Pilot Survey, 2001

Medical Helicopters Medical Helicopters

Shatney CH, Homan SJ, Sherek JP, et al. The Mean ISS = 8.9 utility of helicopter transport of trauma patients from the injury scene in an urban trauma Deaths in ED = 15 system. J Trauma. 2002;53(5):817-22 Discharged from ED = 312 (33.5%) 10-year retrospective review of 947 consecutive Hospitalized = 620 trauma patients transported to the Santa Clara ISS ≤ 9 = 339 (54.7%) Valley trauma center. ISS ≥ 16 = 148 (23.9%) Blunt trauma: 911 Penetrating trauma: 36 Emergency surgery = 84 (8.9%) Medical Helicopters Medical Helicopters

Only 17 patients (1.8%) underwent surgery for Eckstein M, Jantos T, Kelly N, et al. Helicopter transport immediately life-threatening injuries. of pediatric trauma patients in an urban emergency medical services system: a critical analysis. J Trauma, Helicopter arrival faster = 54.7% 2002;53:340-344. Helicopter arrival slower = 45.3% Retrospective review of 189 pediatric trauma patients Only 22.4% of the study population were (<15) transported by helicopter from the scene in LA. possibly helped by helicopter transport. Median age: 5 years CONCLUSION: The helicopter is used RTS > 7 = 82% excessively for scene transport of trauma victims ISS < 15 = 83% in our metropolitan trauma system. New criteria Admitted to ICU = 18% should be developed for helicopter deployment Discharged from ED = 33% in the urban trauma environment.

Medical Helicopters Medical Helicopters

CONCLUSION: The majority of pediatric Braithwaite CE, Roski M, McDowell R, et al. A critical analysis of on-scene helicopter transport trauma patients transported by helicopter on survival in a statewide trauma system. J in our study sustained minor injuries. A Trauma. 1998;45(1):140-4 revised policy to better identify pediatric Data for 162,730 Pennsylvania trauma patients patients who might benefit from helicopter obtained from state trauma registry. transport appears to be warranted. Patients treated at 28 accredited trauma centers 15,938 patients were transported from the scene by helicopters. 6,273 patients were transported by ALS ground ambulance.

Medical Helicopters Medical Helicopters

Patients transported by helicopter: Cocanour CS, Fischer RP, Ursie CM. Are scene flights Significantly younger for penetrating trauma justified? J Trauma. Males 1997;43(1):83-86 More seriously injured 122 consecutive victims of non-cranial penetrating Had lower blood pressure trauma transported by helicopter from the scene. Helicopter patients: Average RTS = 10.6 ISS <15 = 55% Dead patients = 15.6% Logistical regression analysis revealed that when Helicopter did not hasten arrival in for any of the 122 adjusted for other risk factors, transportation by patients. helicopter did not affect the estimated odds of survival. Only 4.9% of patients required patient care interventions CONCLUSION: A reappraisal of the cost-effectiveness beyond those of ground ALS units. of helicopter triage and transport criteria, when access to CONCLUSION: Scene flights in this metropolitan area ground ALS squads is available, may be warranted. for patients who suffered noncranial penetrating injuries demonstrated that these flights were not medically efficacious. Medical Helicopters Helicopters

Cunningham P, Rutledge R, Baker CC, Clancy TV. A Moront ML, Gotschall CS, Eichelberger MR. Helicopter transport of comparison of the association of helicopter and ground injured children: system effectiveness and triage criteria. J Pediatr ambulance transport with the outcome of injury in trauma Surg. 1996;31(8):1183-6 patients transported from the scene. J Trauma 3,861 children transported by local EMS 1997;43(6):940-946 1,460 arrived by helicopter 2,896 arrived by ground Data obtained from NC trauma registry from 1987-1993 Helicopter transported patients: on trauma patients and compared: ISS <15 = 83% 1,346 transported by air But survival rates for children transported by air were better than those 17,144 transported by ground transported by ground. CONCLUSION: The authors conclude that (1) helicopter transport CONCLUSION: The large majority of trauma patients was associated with better survival rates among injured urban transported by both helicopter and ground ambulance children; (2) pediatric helicopter triage criteria based on GSC and have low severity measures. Outcomes were not heart rate may improve helicopter utilization without compromising uniformly better among patients transported by care; (3) current air triage practices result in overuse in helicopter. Only a very small subset of patients approximately 85% of flights. transported by helicopter appear to have any chance or improved survival.

Helicopters Medical Helicopters

Wills VL, Eno L, Walker C, et al. Use of an ambulance-based helicopter retrieval service. Aust N Z J Surg. 2000;70(7):506-510 179 trauma patients arrived by helicopter during study year. Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MO. Helicopter 122 male scene transport of trauma patients: a 57 female meta-analysis. Journal of Trauma, Severity of injuries: Injury, Infection and Critical Care. ISS < 9 = 67.6% 2006;60:1256-1266 ISS ≥ 16 = 17.9% 12 (6.7%) discharged from the ED 46 (25.7%) discharged within 48 hours. Results: 17.3% of patients were felt to have benefited from helicopter transport 81.0% of patients were felt to have no benefit from helicopter transport 1.7% of patients were felt to have been harmed from helicopter transport

Medical Helicopters Medical Helicopters

Considerations: 48 papers met initial inclusion criteria. Severe injury: ISS > 15 26 papers rejected: TS < 12 Failure to stratify scores. RTS ≤ 11 Failure to differentiate scene flights. Weighted RTS ≥ 4 Failure to differentiate trauma flights. Triss Ps < 0.90 Non-life-threatening injuries: 22 papers accepted. Patients not in above criteria Patients who refuse ED treatment Span: 21 years Patients discharged from ED Cohort: 37,350 Patients not admitted to ICU Medical Helicopters Medical Helicopters

ISS ≤ 15: RTS > 11: N = 31,244 Insufficient data ISS ≤ 15 = 18,629 TRISS Ps > 0.90: ISS ≤ 15 = 60.0% [99% CI: 54.5 to 64.8] N = 6,328

TS ≥ 13: TRISS Ps > 0.90 = 4,414

N = 2,110 TRISS Ps > 0.90 = 69.3% [99% CI: 58.5 to TS ≥ 13 = 1,296 80.2] TS ≥ 13 = 61.4% [99% CI: 58.5 to 80.2]

Medical Helicopters Medical Helicopters

70 Patients discharged < 24 68 hours: 66 N = 1,850 64 Percentage N=37,350 62 Discharged < 24 hours = with minor 60 injuries 446 58 Discharged < 24 hours = 56 25.8% [99% CI: -0.90 to 54 ISS TS TRISS 52.63] Source: Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MO. Helicopter scene transport of trauma patients: a meta-analysis. Journal of Trauma.

Helicopters Save Lives Helicopters Save Lives

No definitive body of data shows patient “They brought the helicopter in. And benefit from helicopter transport. Billy couldn't feel his legs. Said he'd never walk again. Yet, helicopters are on the increase—each But Billy said he would and his mom transporting more and more patients. and daddy prayed. And the day we graduated, he stood up to say: Unsinkable ships sink…” Nichols, J. The Impossible from Man with a Memory. 2000: Universal South Medical Helicopters Summary

This begs the question: We would never buy a “Why do we continue to endanger our patients car with determining the and employees on medical helicopters when benefit: risk ratio. only a very small percentage stand to benefit? We routinely perform and promote considerably more dangerous EMS practices without considering the benefit: risk ratio.

Summary

Use TOR protocols. Limit lights and siren responses and transports. Use medical helicopters only when the patient has a significant chance of benefiting from transport. Educate the public and PUBLIC OFFICIALS about the benefits and LIMITATIONS of EMS.