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Taking a Bird's Eye View: CPAP, Safety and Governing EMS

Taking a bird's eye view, both historically and geographically, three important trends have coalesced this past year that I hope will continue next year and lead to important positive change in EMS. The first is a treatment issue, the second is a safety issue and the third is an administration issue.

1. CPAP (Continuous Positive Airway Pressure)

CPAP has been around for more than 50 years. It was initially used mainly to wean patients from mechanical ventilation. In the 1980s, it was adapted to help patients with sleep apnea and congestive heart failure (CHF). The first academic study of the use of CPAP in the prehospital setting I have been able to find, by J. M. Kosovsky, is from 2000. When my local service adopted CPAP in 2001, we were the first in our state (Indiana), and when I would discuss it with EMS colleagues, most didn't know what I was talking about. By 2006, however, that has all changed.

Although it is not yet the national standard of care, most folks in EMS know about it by now. This year a couple of more studies have been published, and there have been articles in the major EMS journals. As far as I am concerned, CPAP is the greatest single advance in patient therapy since Rescue 51. Some of the drugs have changed since then -- and the monitors have certainly gotten smaller --but few of the actual treatments have changed very much. We still use electricity for v-fib, CPR for dead people, valium or something like it for seizures, sugar for diabetics, epi for anaphylaxis, etc. But what diazepam has been for seizures, naloxone for opiates, and D50 for insulin shock for the past 30 years, CPAP is for CHF. Over the next few years, it will hopefully become the national standard of care.

If anyone out there knows of a service that implemented CPAP, or an article that was written about it prior to 2000, please write me. I would like to give credit to the pioneers!

2. Ambulances are not crashworthy

This year saw a critical increase in the number of articles and lectures about the danger of our ambulances and the fact that they do not protect their occupants. It also has seen the first serious efforts by manufacturers to develop usable restraint devices and safer interiors. This trend will surely continue in the future, as the costs in death, disability and money of unsafe ambulances become more widely known.

3. The United States of America has no central authority governing EMS

It is an outrageous fact that, at the beginning of the 21st Century, the world's most medically advanced country has absolutely no national system in place to provide, oversee, regulate or fund emergency medical services for its population. What state systems are in place are inadequate. An American can more reliably obtain a Big Mac of consistent quality within a reasonable time frame than get an EMS response of consistent quality within a reasonable time.

This year has seen more discussion than previously on the right way to proceed in addressing this problem. Recommendations for a federal EMS agency have been made, and just recently the Secretary of Transportation announced the establishment of a National EMS Advisory Council to advise the Department of Transportation. We can only hope that efforts continue and come to fruition, to raise EMS from its status as a neglected stepchild to one equal to fire and police services in this county.

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