Virginia Commonwealth University (VCU) Medical Center and the Richmond Ambulance Authority have developed a program that dramatically improves resuscitation and survival rates in cardiac arrest patients by starting therapeutic cooling early and ensuring it continues at the hospital. The program, called Advanced Resuscitation Cooling Therapeutics and Intensive Care (ARCTIC), trains and equips paramedics to begin lowering a patient’s body temperature right in the field during resuscitation, then transporting and treating that patient at VCU with a series of high-tech strategies to further improve the odds of survival.
"We were the only hospital in town to start cooling patients in 2003, and we’ve been cooling ever since," says Joseph P. Ornato, MD, chair of the Department of Emergency Medicine at the VCU School of Medicine, operational medical director of the Richmond Ambulance Authority and JEMS editorial board member. "What we are trying to accomplish is to take the interventions and package and organize them as a strategy."
The approach has been working. ARCTIC has resulted in a twofold improvement in the return of spontaneous circulation in patients—from 25% in 2001 to 46% in 2008. What’s more, the survival rate to hospital discharge improved to 17.9% at the end of 2008. The national average is reported to be less than 7%. VCU treats 50–60 patients a year in the program.
Mary Ann Peberdy, MD, FACC, FAHA, professor of internal medicine and emergency medicine at the VCU School of Medicine, and director of VCU’s ARCTIC Program, attributes much of the program’s success to VCU’s interdisciplinary approach to cardiac patient care and the speed with which patients are treated.
"We started developing an aggressive multidisciplinary approach to post-cardiac-arrest care in the hospital through a partnership with our EMS system and referring hospitals," she says. "We also switched to the intravascular cooling method to try to get to the target temperature faster. We believe a lot of the science supports that the faster you can get the temperature down to the time of the cardiac arrest, the better off that person is likely to be."
The ARCTIC program centers on two main goals: to restart the heart as quickly as possible following the onset of cardiac arrest, and to protect the brain by starting cooling as early as possible—then bringing patients to a single specialized post-resuscitation facility.
"We started partnering with Richmond Ambulance Authority with them doing the cold saline in the field," says Peberdy. "Most patients are down a degree by the time they hit our door." The ARCTIC trauma team is waiting and continues cooling procedures, while the emergency department team focuses on stabilizing the patient.
"Richmond Ambulance Authority paramedics are the first in the country to initiate the cooling process during resuscitation," says Ornato. "I’m not aware of any other system that has logistically set up their resources so they start, as we do, during ongoing resuscitation."
ARCTIC uses a precise catheter technique, which controls the cooling and rewarming processes. The procedure is meant to minimize brain injury following cardiac arrest. This comprehensive approach continues to show a greater benefit than just using conventional resuscitation and cooling techniques alone.
"If you look at the data, it strongly suggests that the earlier you cool, the better the likelihood of benefit, and particularly if you can cool before the heart starts," Ornato says. "The neurological outcome of the survivors has been better than anything we’ve seen before."
DHS TACKLES INTEROPERABILITY WITH MULTI-BAND RADIO PILOT
The Department of Homeland Security’s (DHS) Science and Technology Directorate is addressing the long-standing problem of interoperability. It’s conducting a nationwide multi-band radio (MBR) pilot test in cooperation with 14 lead organizations. This is the third phase of the project, following laboratory testing and short-term demonstrations.
The multi-band radios can operate in bands between 136–870 MHz, including the primary public safety bands, 150–174 MHz and 450–512 MHz. DHS spokesman John Verrico says he’s seen first responders carrying as many as eight different radios at large events involving many agencies. MBR can eliminate the need for so many radios. The idea is to remove barriers in communication when agencies from different jurisdictions work together.
The Science and Technology Directorate went to DHS operating arms and local first responders to ask them what they needed. The result is an MBR that can operate on maritime VHF to communicate with the U.S. Coast Guard, communicate directly with ambulances and be programmed to get weather reports and warnings for situational awareness. Project Manager Tom Chirart says MBR isn’t a silver bullet, but it’s a great tool that fills a need.
Factors that have prevented MBR from being successful in the past have been engineering issues, such as unit size, battery life and the need to invent one antenna that would work across all bands. Further requirements addressed this time are battery life, water resistance and a composition that won’t trigger an explosion in hazmat situations.
Thales Communications Inc. manufactured the MBR used in the pilot test. The Science and Technology Directorate promotes technology, not products, so after the results are in and published—projected completion is summer 2010—they’ll "encourage additional manufacturers to come up with technology to encourage competition and bring down costs," says Chirart.
According to Brent Williams, communications consultant with Michigan EMS (one of the agencies participating in the pilot), that agency will get radios in January to use for a month. Michigan EMS also participated in the short-term demonstration phase of the project this past spring, during which they had radios for a short time for evaluation. One of the problems they identified was that the push-to-talk button was flush with the side of the radio. "It was hard enough to find with a bare hand. [It’s] a real problem with gloves on," Williams says.
But he’s happy his agency has had a hand in shaping the much-needed technology. "We feel very fortunate to be participating in the test," says Williams.—Ann-Marie Lindstrom
Pro Bono Bariatric Patient Charges:Lawful or Discriminatory?
Some ambulance companies have recently made headlines with plans to charge extra fees for transporting bariatric (morbidly obese) patients. This is being called discriminatory by some, but EMS isn’t alone in this debate.
Some airlines force the morbidly obese to pay for two seats, and health insurers have long charged higher premiums to individuals with health risks, including severe obesity. Are these charges lawful, or are they a form of illegal discrimination?
First, it’s important to note that this is still a developing area of the law. However, generally speaking,obesity isn’t a "protected class" under traditional anti-discrimination laws, such as those regarding race, age, gender, religion or national origin.It’s possible, however, that morbid obesity could be construed as a disability under the federal Americans with Disabilities Act (ADA) or similar state laws. Those laws prohibit discrimination in certain public accommodations.
Advocates for the morbidly obese have brought lawsuits against hospitals and others who don’t have the capabilities or equipment to properly care for them. But the question remains: Is the practice of charging extra for bariatric transports lawful?
We’re not aware of any legal challenges or decided cases that could shed light on this issue in the context of ambulance fees. However, it’s likely that the practice of charging extra fees where they bear a demonstrated and documented relationship to the costs of providing services would be defensible.
For instance, if extra charges were related to specific equipment that was required, such as a bariatric gurney or specialized, lift-equipped transport vehicle, or to the need for extra personnel to be able to safely lift, move and transport the patient, and the charges were fairly and consistently applied in all circumstances where these special accommodations were required, such legitimate charges wouldn’t appear to be discriminatory.
Charges for "specialized equipment" or "extra attendants" have long been recognized by some insurers(and even used to be separately paid by Medicare prior to the adoption of the ambulance fee schedule in 2002) and are not related to a specific condition, but to the resources required to safely and effectively treat the patient.
To the contrary,if an EMS agency were to impose a bariatric surcharge or additional fee merely because the patient was obese, the charge could arguably be judged "discriminatory."Terms such as "bariatric charge" or "obesity fee" shouldn’t appear on a bill.
While the debate over bariatric charges will surely rage on, those EMS agencies that wish to impose such fees should consult their legal counsel and carefully craft their policies prior to implementation.
Pro Bono is written by attorneysDoug Wolfbergand Steve Wirthof Page,Wolfberg & Wirth LLC,a national EMS-industry law firm. Visit the firm’s Web site at www.pwwemslaw.com for more EMS law information.
RYAN WHITE HIV/AIDS TREATMENT EXTENSION ACT PASSED
When Congress passed the Ryan White HIV/AIDS Treatment Extension Act of 2009, it reinstated provisions to protect first responders and ambulance staff that were left out of the 2006 Act. After the March 2008 JEMS article "Emergency responder provisions of Ryan White law repealed" noted the removal of EMS rapid reporting requirements, EMS agencies advocated to have them reinstated in the 2009 bill, which President Barack Obama signed Oct. 20. According to White House Director of the Office of National AIDS Policy Jeffrey Crowley, the Ryan White program funds care, medications and support services for more than 500,000 uninsured and underinsured people each year, making it the largest federal program dedicated to HIV care and treatment.
EMS ON THE HILL DAY
Advocate for prehospital care with your brothers and sisters in EMS by participating in the National Association of EMTs (NAEMT) EMS on the Hill Day. NAEMT calls it "the EMS community’s first coordinated effort to visit congressional leaders and staff on Capitol Hill." Scheduled for May 3 and 4 in Washington D.C., it includes a briefing on key EMS issues, a day with congressional leaders and an evening reception. For more information, click on "EMS on the Hill Day" under the "Advocacy" tab at www.naemt.org.JEMS