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I occasionally appear on EMS Garage. I had to work and missed this episode.[1] I guess that a lot of people will be glad. Just listening to the first few minutes got me started on this post.
First, Mickey S. Eisenberg, MD is the special guest. He has just written a book called Resuscitate!: How Your Community Can Improve Survival from Sudden Cardiac Arrest.[2] He is an excellent person to talk with about this topic. He is one of the people everyone recognizes as an expert. Certainly, I cannot disagree with him, but I do.
Greg Friese is explaining about one of the ideas from the book. That cardiac arrest survival is the best way to determine the quality of a system. I agree that cardiac arrest survival is important, but since cardiac arrest has only been shown to be improved by BLS treatments (compressions and rapid defibrillation - both of which used to be physician-only treatments), it is a mistake to think that this tells you a lot about the quality of an ALS system.
ALS has been shown to worsen the outcome of cardiac arrest, by interfering with good chest compressions, but no ALS treatment has been shown to improve outcome from cardiac arrest. I might even turn that around and say that cardiac arrest outcome may be improved by no ALS.
This may not be entirely true,[3] but it is not unreasonable. There is evidence to show that rapid ALS leads to worse outcomes.[4] There is also evidence to show that ALS leads to worse outcomes.[5]
I do not see evidence that ALS is important in resuscitation. Therefore, how can cardiac resuscitation be an effective measure of the effectiveness of an ALS service?
Cardiac arrest represents about one percent of the EMS calls in any given community, but the management of this one percent encapsulates everything good and bad about a communities EMS system.[6]
In discussing this, Jamie Davis (I think) comments that resuscitation rates are the easiest metric to quantify. I agree that this is easy to quantify. Being easy to quantify and being important do not necessarily go together. The story of the drunk searching for his keys under the streetlight is relevant. He lost his keys elsewhere, but he is looking where the light is better. It will not improve his ability to find his keys, but he will feel better while he is looking. We should not be imitating a drunk, who cannot find his keys. For all we know, they could still be in his pocket, or the bartender might have taken them.
Now that I got that rant out, the rest of the show was excellent. Everybody asked good questions. A lot was covered. The only complaint I have about the rest of the show is that it was too short. There is so much to cover that much, much more than an hour needs to be devoted to this. If I had been involved, the show might have gotten bogged down on the topic I just covered, and never covered some of the much more interesting material that they did cover.
I will write several posts about the many wonderful, positive points in the show.
Footnotes:
^ 1 EMS Garage Special Edition: How to Improve Survival from Sudden Cardiac Arrest Episode 48
EMS Garage
Links to broadcast and downloads
^ 2 Resuscitate!: How Your Community Can Improve Survival from Sudden Cardiac Arrest
By Mickey S. Eisenberg, MD
Amazon.com link with a good video review by Greg Friese.
^ 3 Impact of advanced cardiac life support-skilled paramedics on survival from out-of-hospital cardiac arrest in a statewide emergency medical service.
Woodall J, McCarthy M, Johnston T, Tippett V, Bonham R.
Emerg Med J. 2007 Feb;24(2):134-8.
PMID: 17251628 [PubMed - indexed for MEDLINE]
Conclusions: Highly trained ACLS-skilled paramedics provide added survival benefit in EMS systems not optimised for early defibrillation. The reasons for this benefit are multifactorial, but may be the result of greater skill level and more informed use of the full range of prehospital interventions.
My highlighting, but that may be all that is necessary to explain the benefit. The big question is, Where are the studies showing a benefit from prehospital ALS in cardiac arrest? We can theorize endlessly about potential benefits, but where is the evidence of benefit. It is silly to theorize about the reason for a benefit, when we do not even have evidence that the benefit exists.
Maybe we should be optimizing these systems for early defibrillation or look at systems that have already done this.
^ 4 Cardiac Arrest Survival Rates Depend on Paramedic Experience
Michael R Sayre, Al Hallstrom, Thomas D Rea, Lois Van Ottingham, Lynn J White, James Christenson, Vince N Mosesso, Andy R Anton, Michele Olsufka, Sarah Pennington, Stephen Yahn, James Husar, Leonard A Cobb.
Academic Emergency Medicine; Volume 13 Issue s5; May 2006; pages S55 - S56; abstract number 121
The abstract is available here.
^ 5 Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation
Henry E. Wang, MD, MS
Scott J. Simeone, BS, NREMT-P
Matthew D. Weaver, BS, NREMT-P
Clifton W. Callaway, MD, PhD
Presented at the Society for Academic Emergency Medicine annual meeting, May 2008, Washington, DC.
Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
The abstract is available here.
^ 6 Resuscitate!: How Your Community Can Improve Survival from Sudden Cardiac Arrest
The Big Picture
Page 18.
Same as footnote [2].
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For me ALS in King County means when something bad happens you have a good chance of EMS experts showing up. I have met a number of county medics who have been there in the 20 year range. In fact you can instantly tell if one of those medics are in the 20 year range because they wear gray instead of white. I think that in itself is key. You need people who have successfully ran hundreds of resuscitations.
ReplyDeleteWake County EMS is a relatively "young" EMS system and yet they are posting cardiac arrest numbers comparable to King County.
ReplyDelete@Rogue Medic (I know you blew your cover already but that's besides the point), I think terms like ALS and BLS are meaningless in this day and age. The procedures we perform either help, hurt, or make no difference. It doesn't matter what labels we attach to them. We should not be emotionally attached to procedures or labels.
Survival from cardiac arrest may be easy to quantify for those motivated enough to track it, but the Utstein template is complicated and requires the cooperation of the receiving hospitals.
It that's so easy to achieve, why do so few EMS systems do it? The EMS systems that take the time to create these mechanisms tend to be a cut above the rest.
Show me an example of a terrible EMS system that reports their survival statistics using high quality data.
Our raison d'être is to save lives, no matter how much we try to pretend otherwise. Just ask the average citizen why they tolerate our existence.
I would argue that tracking our survival statistics for cardiac arrest is the necessary but insufficient precondition to declaring ourselves a successful EMS system.
I think a lot of the EMS systems that complain that cardiac arrest survival is not a fair barometer of system performance probably know their chain of survival is broken for a multitude of reasons and they lack the desire or courage to correct the problems.
They much prefer the muddy waters within which they can hide like cowards and feed off of the Rescue 9-1-1 myth.
The public deserves to know what level of protection they're getting for their tax dollars.
Tom
Timothy Clemans,
ReplyDeleteFor me ALS in King County means when something bad happens you have a good chance of EMS experts showing up.
That is important, but not initially necessary. I think that is why they spend so much time on the by-stander CPR and dispatcher pre-arrival instructions.
Having well experienced people on the job says a lot about how a system treats its people. Do they value competence? Do they just want people who will follow orders? Do they just want the cheapest people they can get? Do they burn their people out? Et cetera.
I have met a number of county medics who have been there in the 20 year range. In fact you can instantly tell if one of those medics are in the 20 year range because they wear gray instead of white.
They probably are using the wrong detergent. Some sort of color-safe formulation will prevent the uniform from turning gray. Perhaps a vision check-up every 10 or so years, so that they can recognize the difference in the colors. :-)
I think that in itself is key. You need people who have successfully run hundreds of resuscitations.
There was one study that looked at this. The odd thing was that the experience of the person running the code did not matter. The experience of the person starting the IV, or intubating, or pushing the medications, was what mattered. I think that this indicates that it is easy for a less skilled person to significantly interfere with the BLS, which does affect outcome, when medics are performing these unnecessary procedures.
The effect of paramedic experience on survival from cardiac arrest.
Gold LS, Eisenberg MS.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):341-4.
PMID: 19499471 [PubMed - indexed for MEDLINE]
Tom,
ReplyDeleteWake County EMS is a relatively "young" EMS system and yet they are posting cardiac arrest numbers comparable to King County.
So, it is not out of anyone's reach, just because they are a young system.
@Rogue Medic (I know you blew your cover already but that's besides the point), I think terms like ALS and BLS are meaningless in this day and age. The procedures we perform either help, hurt, or make no difference. It doesn't matter what labels we attach to them. We should not be emotionally attached to procedures or labels.
I agree.
I disagree with the people, who think that it is important to rush a medic to the scene, in order to deliver the magic ALS treatments. I limit myself to what seem to be the convention distinctions of ALS and BLS. In the post, I do mention that both defibrillation and CPR used to be physician-only practices.
Survival from cardiac arrest may be easy to quantify for those motivated enough to track it, but the Utstein template is complicated and requires the cooperation of the receiving hospitals.
I think that the point was compared to other outcomes, this is easier to quantify. I think you will agree with that.
If that's so easy to achieve, why do so few EMS systems do it? The EMS systems that take the time to create these mechanisms tend to be a cut above the rest.
Admitting there is a problem is not the first step to recovery. Asking if there is a problem needs to come first. If we never look at what we do, it is easy to remain blissfully ignorant of the damage we do.
Show me an example of a terrible EMS system that reports their survival statistics using high quality data.
I think that a lot of the intubation studies are examples of blissful ignorance. Fortunately, the medical directors seem to try to improve, once they are aware of just how dismal, dismal is.
Our raison d'être is to save lives, no matter how much we try to pretend otherwise. Just ask the average citizen why they tolerate our existence.
I agree that the average citizen thinks this, but I do not think we should allow the average citizen to dictate what we do. If that were the case, they would have fire departments taking over EMS, because the average citizen can't tell the difference between a fire and a medical emergency. And the average citizen does not speak French. ;-)
I would argue that tracking our survival statistics for cardiac arrest is the necessary but insufficient precondition to declaring ourselves a successful EMS system.
I completely agree. That was my point. I think that EMS can have excellent citizen CPR/AED, first responder CPR/AED, and BLS CPR/AED. I don't think that tells us that the paramedics will also be excellent. It is more likely, because understanding quality in one area makes it more likely that they will understand quality in another. However, it is far from a guarantee.
I think a lot of the EMS systems that complain that cardiac arrest survival is not a fair barometer of system performance probably know their chain of survival is broken for a multitude of reasons and they lack the desire or courage to correct the problems.
Again, I completely agree.
They much prefer the muddy waters within which they can hide like cowards and feed off of the Rescue 9-1-1 myth.
Once more, I completely agree.
The public deserves to know what level of protection they're getting for their tax dollars.
Yet again, I completely agree. You are going to ruin my reputation as a cantankerous old coot, who can never agree with anyone else. So, . . . let's talk politics. ;-)
Not to worry. You're reputation as a cantakerous old coot is intact!
ReplyDeleteTom