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Do we make a difference?

Posted Mar 27 2010 4:59pm
My illustrious training captain has sent out a link to the following article. I found it quite interesting, even though most of this is stuff we already know. Might this mean we don't need to abolish ALS programs, but rethink them entirely? We at Paramedicine 101 preach evidence-based medicine quite often. I believe every treatment, every procedure, and all outcomes should be researched and reviewed frequently. If I could add anything to the EMS 2.0 movement, it would be a universal online archive for QI/QA. Compliant with all privacy policies of coarse. I just think every agency should have some sort of review team, that not only reviews protocol compliance, but patient outcomes compared to treatments received as well. Let's progress!

If you are not familiar with the Eagles conference, you should be. I have yet to have the chance to attend, but I hear it is the most impressive clinical-oriented prehospital conference out there. You may not get to play with all the new toys and gadgets, but you would have heard about post-arrest therapeutic hypothermia about two years before everyone else. Maybe the EMS 2.0 movement should implement a similar gathering for those of us actually doing the work. Imagine Rogue Medic with a microphone and a room full of people.

Insights from the Gathering of Eagles - 2010

Shattering the Myths

Once again, Dr. Paul Pepe and the team of illustrious medical directors from the 50 largest municipalities in the United States, Canada and the United Kingdom met in early February to share their insights with over 700 of their closest friends.

As has become tradition at the Eagles Conference, the crowd of mostly pre-hospital EMS professionals was intrigued and oft times confused by the paradigm shifts proffered as a result of the research findings presented during the two day event.

In addition to the startling discovery that most of us who thought we resided in the United Stated were informed that we actually live in "Southern Canada" (during the peak of the Winter Olympic Games in Vancouver), the most startling themes to much of the information presented were:

-ALS care does not really make a difference in patient outcomes in almost all life threatening patient conditions
-Response and transport times in pre-hospital medical emergencies really don't make a difference in patient outcomes
-Many of the things we thought helped people may not!

In his opening presentation, Dr. Corey Slovis from Nashville reviewed the most important research papers published in 2009. Dr. Slovis' opening comments brought a hush over the crowd and set the stage for many of the presentations to come...

In the early 1970's the nationwide survival to discharge rate for out of hospital cardiac arrest was about 5.5%...

Today, the survival to discharge rate for out of hospital cardiac arrest is about 5.5%.

Blasphemy you say? How can that be? We have spent billions of dollars in advanced emergency medical service systems - certainly we have had a HUGE impact in patient outcomes - right!(?)

Consider the following ACLS study findings presented by Dr. Slovis...

Passive Oxygen Insufflation Is Superior to Bag-Valve-Mask Ventilation for Witnessed Ventricular Fibrillation Out-of-Hospital Cardiac Arrest (AnnEmergMed 2009;54:656-662) . Bobrow, et. al. found that for adult, witnessed, ventricular fibrillation/ventricular tachycardia, out-of-hospital cardiac arrest (OHCA) resuscitated with minimally interrupted cardiac resuscitation, adjusted neurologically intact survival to hospital discharge was higher for individuals receiving initial passive ventilation than those receiving initial bag-valve mask ventilation.

Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest ( N Engl J Med 2004;351:647-56) done by Steil, et. al. as part of the OPALS study conducted in 17 cities with 5,638 patients included found that the addition of advanced-life-support interventionsdid not improve the rate of survival after OHCA in a emergency-medical-servicessystem previously optimized with rapid defibrillation. BCLS patients had a 5.0% survival rate and ACLS patients had a 5.1% survival rate.

Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial ( JAMA 2009 Nov 25;302(20):2222-9), by Olasveengan, et. al. analyzed the admission and discharged alive rate for 851 cardiac arrest and found that there was no significant difference in survival to hospital discharge for the intravenous drug group vs. the no intravenous drug group.

Ok, Ok, we get it, but certainly modern EMS systems and protocols make a difference in trauma care and airway management! I mean, paramedics have been doing intubation for decades, and we have Level I and Level II Trauma Centers and numerous aeromedical systems. Certainly that matters, right?

Consider these findings regarding trauma and advanced airway care...
Emergency medical services intervals and survival in trauma: assessment of the "golden hour" in a North American prospective cohort (Ann Emerg. Med. 2010 Mar;55(3):235-246.e4. Epub 2009 Sep 23) by Newgard, et. al. analyzed trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was in-hospital mortality. The study looked at call processing, activation, response, scene and overall task times for the response. The study found that there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field.

A Prospective Multicenter Evaluation of Pre-hospital Airway Management Performance in a Large Metropolitan Region ( Prehosp Emerg Care 2009 ; 13:304-310). This is the latest in a series of studies evaluating the efficacy of paramedics doing endotracheal intubation. The study evaluated 1,200 paramedics in 34 EMS transporting agencies. 58% were fire-based, 30% private and 12% were single agency systems. The procedural success rate for the 825 attempted intubations was 74.8%. This is consistent with the findings by others such as Dr. Wang in Pittsburg. Most of the Eagles agreed that intubation, if performed at all, needs to be limited to a single attempt and many were mandating that King airways be used as the main advanced airway procedure.

That's all fine and dandy, but there must be some time-honored care traditions that DO help - for example, applying cervical collars for suspected spinal trauma, right? Wrong?

Dr. Persse from Houston presented his data from the soon to be published study: C-Collar or De-Collar: Are Cervical Devices Harmful? Dr. Persse demonstrated 3-D CT and MRI scan images of unstable c-spine cadavers after c-collars were applied. In application after application the findings showed that in many cases the patient suffered debilitating spine injuries. Although Dr. Persse indicated that more research is needed, this certainly begins to call into question one of the core processes that we as EMS professionals have performed since essentially the dawning of modern EMS.

So, was there any good news about EMS presented during the conference? Yep...

There was a lot of discussion about a few emerging trends that most Eagles felt should be studied for presentation next year...

Field Termination of Cardiac Arrest Cases - most systems are aggressively pursuing field termination of CPR cases to prevent unnecessary transports. In one notable quote, transporting a patient who has been systolic for 20 - 30 minutes to the emergency department is simply " relocating a corpse".

Community Health and Advanced Practice Paramedics - preventing EMS calls through a targeted approach to frequent emergency service users that can benefit from home visits and dedicated medical homes when they are transported. Similarly, using APPs to do the high risk, low frequency procedures such as endotracheal intubation, hypothermia in ROSC cardiac arrest cases, and medical clearance of psych patients.

Transport CPR cases Non-light and siren - Speaking to the concept of "relocating corpses", anyone who has been in EMS more than a few minutes realizes that if you have worked a CPR case for 30 minutes in the field, there is little to nothing that the hospital can do for the patient than has not already been done. Further, the recent resuscitation studies prove that the most important procedure in CPR is adequate chest compressions. Why then do we risk out lives and livelihood (and that of the public) screaming across town, weaving in and out of traffic, throwing the rescuers around in the back of the ambulance and diminishing the quality of chest compressions all to save 2 - 3 minutes on the transport time?

Those 2 minutes on the tail end of the call makes virtually no difference in the patient's outcome. Besides, if you want to save those 2 minutes, make a more efficient process for moving the patient from the back of the ambulance to the Code Room at the emergency room. Instead of waiting until the ambulance is in "park" at the emergency room, preparing the patient to be taken from the ambulance right away. Change over to portable O2, move the IVs to the stretcher mounted pole(s), buckle the patient safety harnesses, move the monitor to the stretcher, etc. Having all that done IN ADVANCE will make the unloading process more efficient.

Many of the Eagles felt that the time has come to evaluate non-light and siren transports for CPR cases to see if it makes a difference in the patient's outcome. It would improve CPR effectiveness, reduce rescuer injury, reduce the incidence of emergency medical vehicle collisions (and "wake effect" collisions from cars moving out of the way), and overall makes sense.

In my 30ish year career in EMS, I've had the fortune to attend countless conferences. The Eagles conference continues to be one of the most informative, fast-paced and FUN conferences. If you have not had the chance to attend one yet, you should seriously plan on attending the program next year.

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About the columnistMatt Zavadsky is the Associate Director for Operations at MedStar EMS, the Ambulance Authority System serving Fort Worth and 14 suburban cities in North Central Texas. In this role, he is responsible for overall system operations covering the 850,000 people and nearly 100,000 EMS responses.
He holds a Masters Degree in Health Service Administration and has 30 years experience in EMS including volunteer, fire department, public and private sector EMS agencies. He is a former paramedic and has managed private sector ambulance services from 10,000 to more than 100,000 annual call volume in locations including Fairfield, Connecticut; Augusta, Georgia; La Crosse, Wisconsin and Orlando, Florida. He has also served as a regulator in Lincoln, Nebraska and Volusia County (Daytona Beach), Florida.

Matt is a frequent speaker at national conferences and has done consulting on numerous EMS issues, specializing in high performance EMS system operations, public/media relations, public policy, employee recruitment and retention, data analysis, costing strategies and EMS research.

He has served as the American Ambulance Association as Chair of the Industry Image Committee and membership on the Professional Standards, Strategic Development and Management Training Institute Committees.

Matt is an Adjunct Faculty for the University of Central Florida's College of Health and Public Affairs teaching courses in Healthcare Economics and Policy, Ethics, Managed Care and US Healthcare Systems.
So how do you feel after reading this? If it is a sense of uselessness, you are missing the point. In the world of medicine, EMS is a neonate. We, the ones working right now, can make a huge difference. Please share your thoughts.

Thanks for stopping by,

Adam Thompson, EMT-P
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