The realities of prehospital care vs. myths of the past
Two recent reports, one from the National Academy of Sciences and the other from the American College of Emergency Physicians, have shed light on problems in the EMS system in the United States. However, the applicable answers to these problems aren't found in scholarly writings or in the hallowed halls of medicine. Instead, I believe they can best be found in the teachings of W. Edwards Deming and similar business icons.
Deming was a mathematician with a PhD from Yale University who applied analytical methods to quality improvement in business. Deming and other leaders in the business quality movement emphasize the importance of knowing customer expectations and ensuring customer satisfaction. In fact, many business leaders have proposed the formula in Figure 1 as an indicator of customer satisfaction.
The denominator in this formula is "customer expectations." That is, what does the customer expect from the service? Two simple words ƒ customer expectations ƒ describe a major problem in prehospital care today. EMS customers expect far more than we can ever deliver. And we're responsible in many ways for the development of expectations that can never be attained. How has this come about? Can public expectations be changed?
The Perceived World of Emergency Care
In their day-to-day lives, most people rarely think about EMS. Only when an emergency arises do we enter their conscious thought. In those moments, the cultural images and ideas called to mind about EMS come from Hollywood. In the 1950s and '60s, television shows depicted ambulance personnel as simple medical attendants, clad in white, who drove a station wagon or hearse with the lights and sirens on at all times. They often both rode in the front, and patient care was essentially nonexistent. The public didn't expect much of prehospital providers from a medical standpoint ƒ other than rapid horizontal transport ƒ and they didn't receive much, either.
Then, on Jan. 15, 1972, the pilot for the television seriesEmergency! aired on NBC. The series was the brainchild of Hollywood legend Jack Webb and featured two intrepid Los Angeles County Fire Department paramedics, Johnny Gage and Roy DeSoto, who spent each shift responding to crisis after crisis. There was no emergency this pair couldn't handle, and for the most part, their patients survived.
The show ran for five seasons (1972-1977) and many years thereafter in syndication. People who grew up watchingEmergency! are today's taxpayers and politicians, and they think every community should receive the same impeccable care provided by paramedics Gage and DeSoto on TV. But reality in Hollywood isn't reality in the rest of the world.Emergency! didn't always portray EMS accurately ƒ and is certainly different from today's prehospital care. In essence, most EMS calls are fairly mundane. Very few people are saved from cardiac arrest. Complex rescue situations are few and far between.
Other outdated ideas have been planted in the minds of viewers by the series, as well.
First, there was the image that virtually all EMS interventions were successful. Second, the show made it appear that ambulance transport plays a minor, secondary role in the EMS system. Ambulance crews were still portrayed as medical attendants who did nothing more than obey the paramedics' orders and drive the ambulance to the hospital.
Many of our images and ideas about EMS come from Hollywood, especially for those who grew up watchingEmergency! Finally,Emergency! inaccurately portrayed the emergency department (ED) environment. In the series, a bed was always available, and specialists, such as neurosurgeon Joe Early, MD, were always waiting in the special doctor's room to immediately respond and assist in the ED. It was Hollywood at its best.
TV shows in the 1980s and '90s continued to cast EMS in a glorified light. Such programs asRescue 911 andParamedics depicted the real world of EMS, but they were heavily edited to focus on the more critical calls. They didn't show the less glamorous runs, such as nursing home transfers, dialysis center trips and those that involve chronic inebriates. We also hadSaved, which began its run on TNT in June 2006 (and was cancelled in December).Saved focused on a medical-school dropout turned paramedic who had a gambling addiction. The series illustrated the dark side of EMS and, like the TV programs before it, inaccurately depicted real field care.
Movies about EMS that have made it to the big screen haven't falsely glamorized the profession, but haven't depicted it realistically either.Bringing Out the Dead was the story of a burned-out New York City paramedic whose behavior became pathologic. Even the classicMother, Jugs & Speed, although entertaining, didn't represent EMS well. It depicted EMS providers as societal rejects concerned mainly with drinking and sex, and portrayed private ambulance companies in an extremely bad light. Oliver Stone's 2006 epicWorld Trade Center minimized and distorted the role of EMS providers who responded on that fateful day in 2001.
The Ticking Clock
EMS and other public education programs have emphasized the role of speed in EMS. The "Call first, call fast, call 9-1-1" campaign has been widely adopted. Although a good motto for the public in principle, it can lead to a misperception about the role of response times. It seems intuitive that the shorter the response time, the better the chance of saving lives. In fact, empiric research has clearly shown that response times less than four minutes from the time of patient collapse are highly correlated with improved resuscitation rates. Response systems that consistently provide care in four minutes or less, such as is seen in Las Vegas casinos, can effectively save lives. However, few, if any, EMS systems can consistently offer response times of four minutes or less. The cost of ensuring a four-minute response time would be massive.
Although an expanding body of evidence demonstrates that response times of four minutes or less are associated with improved outcomes, many EMS systems use eight minutes as the target response time. Several studies have demonstrated that the eight-minute target is not associated with improved outcomes in patient survival overall. A recent study from an ambulance region in the United Kingdom found that improving response times was not associated with improved outcomes.
So the public expects a rapid EMS response despite the fact that the degree of rapid EMS response needed ƒ four minutes or less ƒ is either physically impossible or cost-prohibitive. Waiting for an ambulance can be a difficult time for the lay public, and in fact, most overestimate the response time when later questioned. Thus, system leaders should consider whether their current response time standards are driven by unrealistic customer expectations rather than empiric evidence.
In 1976, noted Maryland trauma surgeon R. Adams Cowley, MD, coined the term "the Golden Hour" when discussing the newly opened University of Maryland Shock Trauma Center in Baltimore. Cowley stated that the care provided during the first 60 minutes following a severe injury was crucial to ultimate patient survival ƒ thus, the Golden Hour. However, later scholarly review found no scientific evidence to support Cowley's statement. Still, the term has become part of our lexicon. EMTs and paramedics can quote the definition of the Golden Hour by heart and often do so in media interviews and in conversations with patients' family members.
Millions of dollars are spent annually in an attempt to meet the constraints of the mythical Golden Hour. The public and the media have come to believe that the theory is well rooted in science. This promotes the mistaken image that most emergency situations are time-sensitive, and modalities that increase speed, such as lights and siren transport and helicopters, are always necessary. In actuality, the science has demonstrated that, for the most part, the opposite is true.
In 1983, renowned trauma surgeonDonald Trunkey noted that deaths from civilian trauma followed a trimodal distribution. The first peak of deaths occurs within minutes of the event. These injuries are usually non-survivable, even with the most advanced medical resources immediately available. Approximately 50% of trauma deaths are in this group and usually result from neurological or vascular injury.
The second peak occurs in the first few hours after injury and accounts for some 30% of deaths. In this group, death usually results from hypoxia and hypovolemia. This is the group that stands to benefit the most from modern trauma care. The third peak accounts for approximately 20% of trauma deaths. It occurs days after the injury, with death often resulting from sepsis, multiple organ dysfunction syndrome and other complications.
Thus, for 50% of patients who die from trauma, EMS and trauma care provides no significant benefit. Therefore, the emphasis for modern EMS and trauma care should be on the second two groups. Here, too, studies have shown that an eight-minute response time does not improve outcomes with regard to victims of trauma. In all honesty, we don't know whether shorter prehospital response times improve trauma outcomes. Further, we don't know whether care provided in the prehospital setting improves or worsens trauma patient outcomes.
At a 'Higher Level'
Following Cowley's idea of the Golden Hour and the successes that reportedly came from experience in the Vietnam War, it seemed intuitive that medical helicopters would enhance patient outcome. The first dedicated medical helicopters began service in Denver in 1972. Since that time, the medical helicopter fleet has expanded ƒ almost exponentially.
People who grew up in the 1980s and '90s, when medical helicopters were commonly seen, likely believe that helicopters provide a higher level of care and advantage over ground ambulances. Medical helicopters are now routinely expected at accident scenes and, with increasing frequency, are used for non-traumatic emergencies.
We're rapidly approaching 1,000 medical helicopters in the United States. This proliferation continues despite accumulating scientific evidence that helicopters benefit very few patients. Flight crews now commonly report they're transferring stable stroke patients, patients with minor trauma, and even patients who have the capacity to walk to the helicopter.
Although a subset of patients might stand to benefit from helicopter transport, the current utilization criteria are so broad that this mode is significantly overused. Who is responsible for this trend?
First, physicians bear a great deal of responsibility because they're ultimately responsible for medical decision making. Signing a memorandum of transfer or certificate of need puts helicopter EMS operators in the untenable position of having to transport a patient they know does not stand to benefit from such transport. Second, much of the helicopter EMS industry is profit driven. The more transports, regardless of acuity, the greater the chances of billing and being paid.
Granted, many ground transport operations are for-profit. But with helicopter EMS, the risk and costs are often not worth the perceived benefit. Medicare payments for helicopter transport have quadrupled during the past four years, to $157 million. Some services offer coffee cups, pizza dinners, medical equipment or even $500 cash payments to ground EMS agencies that call their particular helicopter service.
Because of the proliferation and associated safety concerns of helicopter EMS, the U.S. House of Representatives Committee on Transportation and Infrastructure has ordered a General Accounting Office investigation of the air medical industry. Instead of reacting to accumulating scientific evidence to the contrary, EMS has embraced medical helicopters to a degree that only federal government intervention will remedy. There's a finite amount of federal money that goes to EMS in this country. The $157 million that has been directed into helicopter EMS could have funded the operation of several hundred ground ambulances.
The Young & Arrested
Perhaps the most distorted part of prehospital care is cardiac arrest resuscitation. In an interesting study, North Carolina researchers watched all 1994-1995 episodes of the TV programsER andChicago Hope and 50 consecutive episodes ofRescue 911 broadcast during a three-month period in 1995. They found that 65% of the cardiac arrests occurred in children, teenagers or young adults. This, of course, differs from the real world in that most cardiac arrest patients are elderly. Further, 75% of the fictional patients survived the immediate arrest, and 67% appeared to survive to hospital discharge. Interestingly, the actual out-of-hospital survival rate for Los Angeles is 3.2% if the arrest is witnessed and bystander CPR is provided and 1.0% if bystander CPR is not provided. British television, which has little influence from Hollywood, is apparently more realistic.
Although there have been several critical treatises of the fallacies of CPR, the public still expects CPR to save the vast majority of cardiac arrest patients. Current U.S. television shows, such asHouse, still leave the viewer with the impression that cardiac arrest resuscitation, more often than not, can save even the most ill and complex patients.
Albert Einstein once said, "Common sense is the collection of prejudices acquired by age 18." Common sense and rational conjecture has taken EMS to where it is today, but our biases and emotions still affect our decision making. We must look to science to determine where prehospital medicine should go. An evolving body of literature is available to guide future EMS practices. We should use that information now.
First, EMS must begin to intervene earlier in the spectrum of injury and illness. The literature clearly shows that intervening earlier in the disease spectrum saves lives and improves outcomes. The role of "pre-EMS," that is, citizen responders and bystanders, is more important than once thought. We need to develop programs to enhance "pre-EMS" education and encourage more public involvement.
Although we have an ethical duty to respond equally to all who call, we must recognize that most end-of-life events are exactly that. Adequate tools are available to guide your agency's protocols for terminating resuscitation efforts in the field. We need to educate the general public (e.g., public officials, clergy, nursing facility staff, etc.) about the limitations of EMS, especially in the realm of resuscitation, and help them understand that wasting resources on the dead can possibly deprive the living of needed emergency care.
Prehospital care in the U.S. should follow the lead of several other industrialized countries and embrace disease and injury prevention, and early intervention. We should continue to take a leading role in progressive childhood safety education (bicycle helmets, infant seats, drowning prevention, immunizations and similar endeavors). EMS should take the lead in public CPR instruction and AED training. Although it's a positive development that we now have defibrillators in shopping malls and airports, we're still missing the vast majority of patients who die in their homes ƒ nearly 85% of all cardiac arrests. We should take the lead role in setting up an AED registry in our agencies, reminding citizens with AEDs to refresh their CPR certification and ensure that the batteries in the AED are checked at least semi-annually.
Noted astronomer Carl Sagan once wrote, "We live in a society exquisitely dependent on science and technology, in which hardly anyone knows anything about science and technology." How true! We must embark on a long campaign to educate the public about the importance of prehospital care and dispel the myths that exist. Further, we need to establish boards through our professional organizations to advise the media, Hollywood and similar entities on the accuracy of the EMS-related events depicted in their products. We must bring up the next generation of Americans with the knowledge that EMS is not a panacea ƒ but a necessary service that has the ability to save lives and whose providers are worthy of pay commensurate with the job.
Perception is, unfortunately, reality to the general public. In EMS, we can do the possible but not the impossible. It's time the public understands this. But until we can change their mindsets, we must be proactive in updating our professional image.
Bryan Bledsoe, DO, FACEP, is a board-certified emergency physician and an author. A former EMT, paramedic and paramedic instructor, Bledsoe has written numerous EMS textbooks, including Brady's paramedic textbook series. He's a frequent contributor to JEMSand a regular speaker at EMS conferences worldwide. Contact him firstname.lastname@example.org.
- National Academies of Science, Institute of Science.Emergency Medical Services: At the Crossroads. Washington, D.C.: The National Academies Press, 2006.
- American College of Emergency Physicians.The National Report Card on the State of Emergency Medicine: Evaluating the Environment of Emergency Care Systems State by State. Irving, Texas: American College of Emergency Physicians, 2006.
- Yakaitis RW, Ewy GA, Otto CW, et al: "Influence of time and therapy on ventricular defibrillation in dogs."Critical Care Medicine. 8(3):157-163, 1980.
- Cobb LA, Fahrenbruch CE, Walsh TR, et al: "Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation."Journal of the American Medical Association. 281(13):1182-1188, 1999.
- De Maio VJ, Stiell IG, Wells GA, et al: Ontario Prehospital 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.
- Valenzuela TD, Roe DJ, Nichol G, et al: "Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos."New England Journal of Medicine. 343(17):1206-1209, 2000.
- Price L. "Treating the clock and not the patient: ambulance response times and risk."Quality and Safety in Health Care. 15:127-130, 2006.
- Pons PT, Haukoos JS, Bludworth W, et al: "Paramedic response time: Does it affect patient survival?"Academic Emergency Medicine. 12(7):594-600, 2005.
- Turner J, O'Keefe C, Dixon S, et al:The Costs and Benefits of Changing Ambulance Response Time Performance Standards. Medical Care Research Unit School of Health and Related Research. United Kingdom: University of Sheffield, 2006.
- Harvey AL, Gerard WC, Rice GF Jr, et al: "Actual vs. perceived EMS response time."Prehospital Emergency Care. 3(1):11-14, 1999.
- Shankar BS: "Systems evaluation."In Cowley RA, Conn A, Dunham AM (Eds):Trauma Surgical Management. Vol 1.JB Lippincott: Philadelphia,1987.
- Lerner ED, Moscati RM: "The Golden Hour: Scientific Fact or Medical 'Urban Legend'?"Academic Emergency Medicine. 8(7):758-760, 2001.
- Trunkey DD: "Trauma."Scientific American. 249:28-35, 1983.
- Pons PT, Markovchick VJ: "Eight minutes or less: Does the ambulance response time guideline impact trauma patient outcome?"Journal of Emergency Medicine. 23(1):43-48, 2002.
- Carr BG, Caplan JM, Pryor JP, et al: "A meta-analysis of prehospital care times for trauma."Prehospital Emergency Care. 10(2):198-206, 2006.
- Gausche M, Lewis RJ, Stratton SJ, et al: "Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: A controlled clinical trial."Journal of the American Medical Association. 283(6):783-790, 2006.
- Wang HE, Peitzman AB, Cassidy LD, et al: "Out-of-hospital endotracheal intubation and outcome after traumatic brain injury."Annals of Emergency Medicine. 44(5):439-460, 2004.
- Bledsoe BE, Wesley AK, Eckstein M, et al: "Helicopter scene transport of patients with non-life-threatening injuries: A meta-analysis."The Journal of Trauma, Infection and Critical Care. 60:1256-1266, 2006.
- Pfister B: "Status Symbol."Pittsburgh Tribune Review. Oct. 8, 2006.
- Association of Air Medical Services. "Government Accountability Office Initiates Report on Air Medical Services."www.aams.org/Content/NavigationMenu/MemberServices/ GovernmentAffairs/default.htm#GAO_Report.
- Diem SJ, Lantos JD, Tulsky JA: "Cardiopulmonary resuscitation on television: Miracles and misinformation."New England Journal of Medicine 334(24):1578-1582, 1996.
- Eckstein M, Stratton SJ, Chan LS: "Cardiac Arrest Resuscitation in Los Angeles: CARE-LA."Annals of Emergency Medicine. 45:504-509, 2005.
- Gordon PN, Williamson S, Lawler PG: "As seen on TV: Observational study of cardiopulmonary resuscitation in British television medical dramas."British Medical Journal. 317(7161):780-783, 1998.
- Timmermans S, Shen B:Sudden Death and the Myth of CPR. Temple University Press: Philadelphia,1999.
- Bailey ED, Wydro GC, Cone DC: "Termination of resuscitation in the prehospital setting for adult patients suffering nontraumatic cardiac arrest." National Association of EMS Physicians Standards and Clinical Practice Committee.Prehospital Emergency Care. 4(2):190-195, 2000.
- Hopson LR, Hirsch E, Delgado J, et al:"Guidelines for withholding or terminating resuscitation in prehospital traumatic cardiac arrest: A joint position paper from the National Association of EMS Physicians Standards and Clinical Practices Committee and the American College of Surgeons Committee on Trauma."Prehospital Emergency Care. 7(1):141-146, 2003.
- Morrison LJ, Visentin LM, Kiss A, et al: "Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest."New England Journal of Medicine. 355(5):478-487, 2006.
- Fedoruk JC, Currie WL, Gobet M: "Locations of cardiac arrest: affirmation for community Public Access Defibrillation (PAD) Program."Prehospital and Disaster Medicine. 17(4):202-205, 2002.
- Swor RA, Jackson RE, Compton S, et al: "Cardiac arrest in private locations: different strategies are needed to improve outcome."Resuscitation. 58(2):171-176, 2003.