Have We Set the Bar Too High? Bryan E. Bledsoe, DO, FACEP UNLV
The EMS Image “You wanted to be a doctor, maybe you should have buckled down a little more in high school.”
The Problem System Performance Customer Satisfaction = Customer Expectations
The Problem Our customers have expectations we can never meet!
The EMS Image WE RAISE THE DEAD!
We Raise the Dead • Researchers watched all 1994-1995 episodes of ER and Chicago Hope. • Watched 50 consecutive episodes of Rescue 911. • Findings: • 65% of cardiac arrests occurred in children, teenagers or young adults. • 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 • Los Angeles, CA: • 1-year study (1JUL00-1JUL01). • 2,021 consecutive cardiac arrests. • 1,700 met entry criteria as a primary cardiac event. • 28% received bystander CPR.
We Raise the Dead • Results: • 1.4% survived neurologically intact. • 6.1% survived from bystander-witnessed ventricular fibrillation. • 2.1% survival with bystander CPR. • 3.2% survival with witnessed arrest and bystander CPR. • 1% survival without bystander CPR. 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 • Mechanical CPR devices have not been shown to improve outcomes. • Some actually worsen CPR outcomes. • Tucson IRB stopped multi-center RCT • Yet, many FDs still spend hundreds of thousands of dollars on these.
We Raise the Dead • Civilian Trauma deaths occur in a trimodal distribution: • Death within minutes = 50% • Neurologic and vascular injuries. • 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 • No change in survival for the first group since the Crimean war.
We Raise the Dead Despite 30+ years of EMS, and the expenditure of billions of dollars, dead people remain 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 • 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?
The EMS Image IF We DON’T SAVE THEM, THE HOSPITAL WILL!
Hospital will Save Them • Most Australian paramedics have never done CPR in a moving ambulance.
Hospital will Save Them • NAEMSP has had a position paper on field termination of out-of-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 • NAEMSP and the American College of Surgeons has had a position paper on the termination of traumatic cardiac arrest since 2002. Hopson LR, Hirsh E, Delgado J, Dormier RM, McSwain NE, Krohmer J. Guidelines for Withholding or Termination of Resuscitation in Prehospital Traumatic Cardiopulmonary Arrest. Prehosp Emerg Care. 2003;7:141-146
Hospital will Save Them • 336 prospective and 135 retrospective cases of OOHCA. • 12 patients survived to discharge (none met criteria for field TOR). • 63 patients survived to admission, 4 were eligible for TOR. • None of these 4 survived to discharge. • Conclusion: Protocol 100% specific for lack of survival from OOHCA. Cone CD, Bailey ED, Spackman AB. The Safety of Field Termination-of- Resuscitation Protocol. Prehosp Emerg Care. 2005;9:276-281
Hospital will Save Them • 1,068 victims of OOHCA treated by Memphis FD. • 310 (29%) had ROSC prior to transport. • Admitted: 69% • Discharged alive: 26.5% • 758 (71%) never regained a pulse and were transported with CPR underway. • Admitted: 7.0% • Discharged alive: 0.4%† †-All had moderate-severe CNS disability. • “Rapid transport of adults who fail to respond to an adequate trial of prehospital ACLS does not result in meaningful rates of survival.” Kellerman AL, Hackman BB, Somes G. Predicting the Outcome of Unsuccessful Prehospial Advanced Life Support. JAMA. 1993;270:1433- 1436
Hospital will Save Them • 189 pediatric patients with OOHCA studied: • 39 (20.6%) received BLS only • 150 (79.4%) received ALS. • 5 (2.6%) survived to discharge. • No significant improvement in survival in those who received ALS. • Those likely to survive had a sinus rhythm and received fewer doses of epinephrine in the ED. • ALS does not improve survival in pediatric OOHCA. Pitetti R, Glustein JZ, Bhende MS. Prehospital Care and Outcome of Pediatric Out-of-Hospital Cardiac Arrest. Prehosp Emerg Care. 2002;6:283-90
Hospital will Save Them • LA and Orange County (CA) SIDS study: • 114 SIDS patients • 6 (5%) had ROSC • 0 (0%) survived • 50 (44%) received lights and siren transport. • “Given that there were no survivors, new prehospital policies are needed governing the use of lights and sirens, resuscitation decisions including termination of resuscitation.” Smith MP, Kaji A, Young KD, Gausche-Hill M. Presentation and Survival of Apparent Prehospital Sudden Infant Death Syndrome. Prehosp Emerg Care. 2005;9:181- 185
Hospital will Save Them • 235 OOHCA patients: • 131 (56%) met criteria for TOR. • All expired at the hospital. • No mitigating reasons found to justify transport. • TOR protocols are not being followed. O’Brian E, Hendricks D, Cone CD. Field Termination of Resuscitation: Analysis of a Newly-Implemented Protocol. Prehosp Emerg Care. 2008;12:56-61
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 • “Patients must arrive at a trauma center within one hour of their injury in order to have their best chance of survival.” • R. Adams Cowley, MD
The “Golden Hour” exists • The concept of the “Golden Hour” was developed to promote the newly-opened University of Maryland “Shock Trauma” center.
The “Golden Hour” exists. • “This article discusses a detailed literature and historical records search for support of the ‘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 • Nobody wants to talk about the false notion of a “Golden Hour” because it so shakes the roots of EMS and trauma care.”
The “Golden Hour” exists • Our old trauma practices may have been harming more patients than it was helping. • Large volume crystalloids. • Endotracheal intubation.
The “Golden Hour” exists • This begs the question: Why are we putting our personnel and patients at risk to meet the constraints of the ‘Golden Hour’ when there is no evidence that the ‘Golden Hour’ exists?
Lights and Sirens Save Lives LIGHTS & 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 • Upper New York (Syracuse) study. • “L&S reduce ambulance response times by an average of 1 minute, 46 seconds. Although statistically significant, this time saving is likely to be clinically relevant in only a very few cases.” Brown LH, Whitney CL, Hunt RC, et al. Do warning lights and sirens reduce ambulance response times? Prehospital Emergency Care. 2000;4(1):70-74
Lights and Sirens Save Lives • Pediatrics? • “In our preliminary study, inappropriate use of L&S in the transport of pediatric patients in stable condition is common.” Lacher ME, Bauscher JC. Lights and sirens in pediatric 911 transports. Are they being misused? Annals of Emergency Medicine. 1997;29(2):223-227
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 identified as related to non-L&S transport.” Kupas DF, Dula DJ, Pino BJ. Patient outcome using medical protocol to limit “lights and siren transport. Prehosp Diast Med. 1994:9(4):226-229
Lights and Sirens Save Lives In any endeavor you must weigh the benefits and the risks. With lights and siren transport, the “clinical benefits” do not outweigh the risks for the vast majority of patients.
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?
The EMS Image If we can get there in 7 minutes, 59 seconds, you’ll live!
7 Minutes, 59 Seconds (90%) • Where is the safest place in America to have your cardiac arrest?