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.