Visions from a Visionary - @

Visions from a Visionary

Perspectives on the past and future of EMS



Eugene Nagel, MD | | Monday, May 11, 2009

One can't discuss the early beginnings of EMS without including resuscitation. The early attempts to provide artificial ventilation now seem ludicrous. But, in their day, they were accepted as better than doing nothing. In the decades that followed, many variations on the chest-compression/arm-lift theme were decided empirically rather than by clinical trial and experimentation.

Early EMS practice was based either on experimentation by J. Frank Pantridge, MD, in Belfast, Northern Ireland, or by following hospital resuscitation protocols. Again, the adopted methods used were justified by empirical acceptance rather than by any controlled study. In general, a comparison was made between doing nothing in the field and performing some of the common methods being used inside the hospital. It was in this manner that systems adopted cardiac rhythm identification, defibrillation, IV drug therapy and intubation. Empirical acceptance of a method of treatment was less risky legally, in terms of questions of patient-informed consent issues and human experimentation protocols as it is now.

Only in recent years have studies been performed comparing airway control devices and methods versus intubation. Acceptance by the institutional review board (IRB) of studies in prehospital medicine is increasingly difficult to obtain. However, the need for scientific data and evidence-based decisions is increasingly necessary. It is made more difficult because of "privacy" issues introduced by legislation like HIPPA. However, studies on recent changes in how CPR is performed and taught, as well asdrug therapy,are obviously needed.

About 30 years ago, the medical director of San Francisco EMS, Dr. Michael Callaham, shocked everyone by challenging EMS directors to show that prehospital treatment of medical conditions benefited patients more than simple transportation to a medical facility. He went even farther, saying that taxicabs might be the better mode of transportation for some patients.

In the intervening years, comparison studies have been made between regions employing BLS versus ALS. These studies can be done when a region is upgraded from basic to advanced care, whereas a study where patients within a system are compared by random selection wouldn't pass IRB scrutiny.

If two methodologies are shown to be comparable in terms of morbidity and mortality, then comparison studies might be allowed. An example of this type of study is when the mechanical chest compressor was compared to manual compression, and the results were proven to be equivalent. Today's need for consistent compressions leads us back to the use of devices -- such as the ZOLL AutoPulse, Michigan Instruments Life-Stat and the Physio-Control LUCAS Chest Compression System -- to deliver uninterrupted compressions.

The need for an evidence-based, decision-making standard is clear, as is the difficulty in providing such evidence. The major hurdle we face is the protection of individual rights in such a study, and the legal challenges that it would present.

Curbing Budgetary Problems

As the U.S. faces increasingly severe budgetary problems, what will the effects be on our current EMS systems? The cost of providing service will certainly come under increasing scrutiny. Third-service EMS will be compared to fire-based EMS. But, the key factor will be the determination of quality of service, which is difficult to quantify in the extreme.

In regions where EMS is a third service, the fire service may now be interested in consolidation for such reasons as elimination of two command structures and the revenue that EMS can bring in. However, EMS and fire service are two completely separate career tracks, and failure to recognize this can only result in degrading one or both of the services. The exception may be where they've grown together from the beginning of EMS, because they will almost always have solved these problems during the intervening years.

The cost of sending two expensive vehicles with corresponding staffing needs to be examined and controlled wherever possible. In many parts of the country where dual response is now provided, limiting such response to calls where true need is demonstrated at the dispatch level may become more important.

Another cost that should be evaluated is vehicle expenses. Ambulances have become increasingly heavy and expensive, both in initial cost and maintenance. A heavy-duty ambulance can cost $150,000.00 and its operating cost can be correspondingly high. The need for this expensive style of vehicle must be evaluated.

System design will be affected by budgetary constraints. Staffing of vehicles by two paramedics may be reduced to one paramedic and an EMT. Or systems may use a decreased number of paramedic-staffed vehicles and depend more on BLS first response with backup paramedic-staffed vehicles similar to successful Seattle and Boston models.

Response times may have to be increased to accommodate the budgets provided. Federal mandates may have to be modified so that each community can decide on its own system design based upon the community resources and needs.

In the face of a decreasing tax base, government agencies will have to choose which of their needs to support, and at what level. The prevailing view by the ruling governmental authorities is that decreasing support will become all too common. EMS is also part of a larger health-care system, and overall support will dictate what cuts are necessary.

We need controlled studies that clearly demonstrate the direct and positive effect of EMS systems in either saving, maintaining or improving lives. Studies that attempt to grapple with optimal system designs, which offer the highest effectiveness at least cost, are rare. An example is that the gold standard has and still is the percentage of cardiac arrest victims who are successfully resuscitated and leave the hospital in their previous state of life. It's clear from published articles on this subject that Seattle, King County and Rochester, Minn. are ahead of all others. However, even in these systems, the outcome is discharge from the hospital without being able to determine the physical and mental state of the resuscitated patient.

Moving Forward

The increasing employment of emergency care personnel in hospital emergency departments and intensive care units can offer hospitals economy and an additional supply of non-nursing personnel. EMTs and paramedics may find such employment a welcome alternative to their present prehospital duties.

We commonly see traditional fire personnel viewing their employment as a lifetime occupation, whereas personnel involved in EMS only often leave the field within 10 years. As systems evolve, the stresses of long hours and difficult working conditions may shorten the working life of emergency care personnel. "Burn out," increasing technical requirements and job pressures negatively impact the worker in street medicine.

In the earliest days of EMS, health hazards to EMS workers were mainly thought to be vehicular in nature. Such hazards as contamination or assault seemed small by comparison. Blood and bodily fluid now pose an increasing risk of serious infections, such as AIDS or antibiotic resistant strains. New problems and job injuries incurred when packaging and transporting the morbidly obese patients will occur more frequently.

The education of emergency care personnel in the future will depend more on simulation as in the case of present-day medical training. The role of managers and administrators may require additional formal training over and above experience and on-the-job performance.

From the perspective of those who were involved with the earliest systems, the number of definable problems has increased significantly. Empirical trial and error is no longer possible in most cases and will be replaced by more rigorous trial and proof. In much the same way as flying evolved from the "seat of the pants" era in the 1930s to present-day pilot training, emergency medicine will require definition and a sound scientific basis for change in the future.

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Related Topics: Cardiac and Circulation, Leadership and Professionalism, History of EMS

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