Resuscitated Systems: Simple innovations radically improve cardiac arrest survival rates

 

 
 
 

From the July 2008 Issue | Saturday, July 26, 2008


"Treatment guidelines [lead] to four-fold increase in survival rate for cardiac arrest" declared a recent press release from the Society for Academic Emergency Medicine (SAEM). At the society's annual meeting May 28ÏJune 1, Brent Myers, MD, MPH, FACEP, medical director of Wake County EMS (WCEMS) in Raleigh, N.C., presented the results of a study showing that the introduction of several inexpensive elements dramatically improved cardiac arrest (CA) outcomes (Hinchey P, Myers JB, Lewis R, et al: "Out-of-hospital cardiac arrest survival after the sequential implementation of 2005 AHA guidelines for compressions, ventilations and induced hypothermia." SAEM Meeting 2008; Abstract 167).

After WCEMS implemented the new American Heart Association (AHA) CPR guidelines, which call for continuous chest compressions and delayed intubation for V-fib and V-tach, the rate of its CA patients surviving to the hospital went from 4.5% to 7.3% and from 1.9% to 4.4% for their patients leaving the hospital neurologically intact between April 2005 and April 2006.

When WCEMS began using the ResQPOD impedance threshold device in April 2006, those numbers shot up even higher, with 8.2% surviving to the hospital and 6.2% going home intact. Then, in October 2006, WCEMS became the first prehospital service to induce hypothermia in CA patients, and outcomes during the next year went to 11.6% for survival to the hospital, with 7.8% of the patients going home neurologically sound.

Patients in V-fib or V-tach did even better: Before WCEMS began using the new AHA guidelines, 12% of these patients made it to the hospital and 10% survived intact to discharge. Now, 37% of V-fib/V-tach patients survive to the hospital and 28% go home to continue their lives. (For more on this study, visitwww.wakeems.com/blog.)

"Our study, along with others, demonstrates that these things matter," says Myers, a member of the JEMS editorial board and a former paramedic. Myers notes that the Wake County study was not a randomized trial. "From the beginning, we said there is just no way we_re going to tell half the citizens that this seems to be a really good ideaƒbut not for you.Ó However, he adds that WCEMS might conduct a randomized trial to determine the best timing for the introduction of chilled IV fluid to induce hypothermia.

WCEMS may be the first to report on a study documenting how simple, inexpensive advances can improve outcomes for CA patients, but it's not the only EMS system to discover such improvements can make a significant difference. For instance, although the Columbus (Ohio) Division of Fire (CDF) does not induce hypothermiaƒyetƒit nearly doubled the "walk-out" rate of CA patients from 6% to 11.3% in 2006 (with 24.8% of V-fib/V-tach patients leaving the hospital intact that year).

CDF Medical Director David Keseg, MD, credits several factors, especially the "intentional focus on quality CPR and uninterrupted CPR," as well as intensive training in the new AHA guidelines, adoption of ResQPOD and the EZ-IO intraosseous insertion device and implementation of the Cardiac Arrest Registry to Enhance Survival Internet database to track treatment and outcomes. (For more on the Columbus program, see the June EMS Insider.)

In Wake County, Myers says a key element to the program's success is "the cooperation between the hospitals and EMS." For example, area hospitals agreed to have WCEMS ambulances bypass facilities to get CA patients to the two hospitals with the highest-volume cardiac catheterization labs, which can perform crucial interventions 24/7. "This is what you can do for your community when you focus on doing the best for the patient and put all other considerations aside," says WCEMS Chief Skip Kirkwood.

According to Myers, WCEMS is now considering a trial of compression-only CPR to see whether it can improve the system's CA outcomes even further.

ƒMannie Garza

National EMS Memorial Service Finds New Home

The National EMS Memorial Service (NEMSMS) will move from Roanoke, Va., where it_s been held since 1991, to Colorado Springs, Colo., in 2010. Colorado Springs won a hard-fought competition that began with 14 possible sites and resulted in three finalists. The NEMSMS board of directors chose the city at the base of the Rocky Mountains over Kansas City, Mo., and Washington, D.C., because Colorado Springs offered the best package of financial incentives, plus ˙a beautiful setting in a park with Pikes Peak in the background,Ó says NEMSMS President Kevin L. Dillard, president and co-owner of LifeCare Medical Transport, Fredericksburg, Va.

Colorado Springsalso committed to raising close to $4 million to create a permanent home for the Tree of Life National EMS Memorial, which displays the names of EMTs and paramedics who_ve died in the line of duty. The memorial will be in a city park ˙where people come to have picnics and where they hold an annual balloon festival,Ó Dillard says.

Not everyone is thrilled by the site choice. The EMS Labor Alliance (EMSLA), which represents large EMS employment organizations nationwide, had been working to get a site in the Washington, D.C., or Arlington, Va., area for the memorial. EMSLA representative James Orsino, an EMT and union leader with Boston EMS, claims a 1998 Congressional resolution that designates Roanoke as the official site of the NEMSMS ˙never empowered NEMSMS to unilaterally make decisions normally left to the federal government.Ó According to Orsino, the move ˙will require the repeal of the existing resolution followed by another renaming of an official site.Ó He then asks, ˙Who, if anyone, would sponsor legislation of this kind given the fact that NEMSMS was never empowered to make a decision?Ó

This year, the NEMSMS honored 73 individuals at a service May 24 as part of a weekend of events for honorees_ families. The names of those EMS responders will be engraved on 73 bronze oak leaves and added to more than 350 existing leaves on the EMS Tree of Life. ˙We_ve normally recognized about 30 people, but we_ve also been recognizing people we_ve been made aware of [who died in the line of duty in] previous years,Ó Dillard says. ˙After 2009, we [will] have recognized everyone from the pastƒas far as we know.Ó

The NEMSMS board will ˙put the word out to the EMS community and ask for input on what the new memorial should look like,Ó Dillard says. ˙Think about what they did in Oklahoma City with lights and chairs and some of the things they do in D.C. We want this to be something unique that the whole EMS community can be proud of.Ó

ƒMG

MRC Units Ready for Disaster

The Medical Reserve Corps (MRC) is a national volunteer organization designed to supplement community emergency and public health resources. Part of the USA Freedom Corps and a partner of the Citizen Corps, the MRC was formed after President George W. Bush called for more volunteerism in his 2002 State of the Union address.

˙As we focus on community resiliency, the MRC is proving to be an integral component in a community_s ability to sustain itself during a disaster situation. This support at the local level is strengthening the entire nation_s ability to come back from major eventsƒwhether natural or man-made,Ó says Capt. Robert Tosatto, director, Office of the Civilian Volunteer Medical Reserve Corps.

More than 150,000 volunteers now participate in 729 MRC units across the country. Most volunteers are physicians, nurses, paramedics, EMTs, pharmacists, dentists or epidemiologists, but non-medical volunteers also serve in support roles as interpreters, chaplains, legal advisers and office workers.

Like EMS, the MRC straddles the line between public health and public safety. An MRC unit may be activated to assist during a natural disaster or to administer flu shotsƒhelpful preparation for a flu pandemic.

MRC units assisted Hurricane Katrina victims all along the Gulf Coast and across the country. Some units sent volunteers to the affected areas and others prepared for evacuees_ arrival in their communities. Last October, the San Diego MRC unit helped people who were evacuated during the huge wildfires.

Some MRCs offer Incident Command System training to their members, and the MRC Web site (www.medicalreservecorps. gov) details other local activities and trainings.

Although most EMTs and paramedics are busy with on-the-job responsibilities during a disaster, opportunities may still exist to volunteer and share your expertise with an MRC unit. After all, a well-prepared community could make your job easier.

ƒAnn-Marie Lindstrom

NAMES IN THE NEWS

Steven Tharratt,
MD, professor of medicine and anesthesiology at University of California, Davis, Medical Center and medical director for Sacramento County EMS and the Sacramento City and County Fire Departments, became director of the California EMS Authority in April.

A former Denver paramedic,Art Kanowitz, MD, FACEP, recently became Colorado_s EMS medical director.

Mary Hedges retired at the end of May after 10 years as Minnesota_s EMS director. She was also secretary/treasurer of the National Association of State EMS Officials and served as president of Advocates for EMS in 2005.

The National Association of EMTs elected four new directors this spring: EMT/FirefighterSue Jacobus, Schuyler (Neb.) Fire Department;KC Jones, director of EMS programs, North Arkansas College, Harrison, Ark.;Charlene Donahue, EMT-P, former president of San Francisco Paramedic Association; andC.T. ˙ChuckÓ Kearns, executive director, Pinellas County (Fla.) EMS Authority.

QUICK TAKES

Stroke AwarenessCampaign Begins

Time is critical in treating stroke, so the American Academy of Neurology, American College of Emergency Physicians and American Heart Association/American Stroke Association recently launched a campaign to teach the public to recognize the signs and quickly contact EMS. This ˙Stroke CollaborativeÓ has developed an easy way for people to remember the five warning signs and asks health-care professionals to help promote it. For more information, visit www.giveme5forstroke.org.

JEMS-Funded Study Abstract Published

Annals of Emergency Medicine has published the abstract of a study funded by a $1,500 grant fromJEMS/Elsevier Public Safety (Dickinson ET, Reynolds JW, Gentile LF, Wurster FW: ˙The augmentation of ambulance crews with a second advanced life support paramedic enhances the effectiveness of prehospital care for patients with acute coronary syndromes.ÓAnnals of Emergency Medicine. 51(4):550, 2008). The prospective study conducted in two suburbanEMS systems determined that a second paramedic does result in more rapid relief of chest pain (10.9 versus 13.3 minutes). ˙It_s very exciting that this research, done primarily by the medics involved, climbed the hill for peer review,Ó saysJEMS Medical Editor Ed Dickinson, MD, one of the study_s authors.

IN Memoriam

Missouri EMS Medical DirectorJohn William "Bill" Jermyn III, DO, died suddenly May 15 in Jefferson City, Mo., at age 57 of an acute myocardial infarction. The day after his death, the Missouri legislature passed a bill he had been promoting to create the nation_s first statewide STEMI and stroke network of care. Jermyn also taught in the division of emergency medicine at Washington University in St. Louis and was the immediate past chair of both the EMS Committee and the EMS/prehospital section of the American College of Emergency Medicine.

CONTROVERSY: ShouldEMS Save Organs for Potential Donation?

New York Cityis developing a program that could increase the number of kidneys and other organs available for transplant. The program will deploy special ambulances to transport patients who die unexpectedly and maintain the viability of their organs for potential donation.

Some 8,000 people in NYC alone are awaiting a donated organ, and Bradley J. Kaufman, MD, MPH, a medical director for the Fire Department of New York, estimates the program could result in up to 1,000 more organs available for transport each year.

Under the program, EMS would make every effort to save the patient_s life, ˙using advanced life-saving techniques,Ó he says, but if medics are unable to save the patient, a separate, specially staffed and equipped Rapid Organ Recovery Ambulance (RORA) would respond to transport the body to Bellevue Hospital while preserving the organs. Someone from the N.Y. Organ Donation Network would contact the family, and the deceased patient_s kidneys and/or other organs could be donated if the family agrees.

˙No organs would be taken without family permission, but these simple preservation procedures can allow this,Ó Kaufman stresses. ˙We need to consider how we can help other patients live.Ó

The plan has created controversy because the RORA crew would perform procedures on the deceased without consent. But what do you think? Let us know atwww.jems.com.

What do you think? Would your system consider implementing an organ recovery ambulance program?

> Yes, if all donations take place with proper consent, we would do whatever it took to preserve organs.

> Maybe, but we would be concerned about taking such costly measures when consent isn_t guaranteed.

> No, it_s unethical to preserve a deceased patient_s organs for harvesting (family consent or no).

> No, this would open us up to complaints and possibly even lawsuits.

PRO BONO

Hospital Diversions:The Plot Thickens

A recent federal court decision highlights the need for EMS crews to clarify the ˙diversionaryÓ instructions they receive from overcrowded hospital emergency departments (EDs). In theMorales decision on April 18, the First Circuit Court of Appeals (which covers four New England states plus Puerto Rico) ruled that a hospital violated the federal Emergency Medical Treatment and Active Labor Act (EMTALA) after an ED physician ˙abruptly terminated the callÓ from paramedics who were en route with a patient in severe abdominal pain. The physician had asked whether the patient had insurance coverage and, receiving no assurance, abruptly terminated the call. The paramedics interpreted that response as a refusal to treat the patient in that ED.

EMTALA regulations state that a hospital may legally divert an incoming, non-hospital-owned ambulance only when it lacks the staff or facilities to accept any additional emergency patients. The court ruled that, because the hospital was not on formal ˙diversionary status,Ó the facility improperly diverted the patient in violation of EMTALA when the ED physician terminated the paramedics_ call.

TheMorales case marks the second time a federal appeals court has ruled in this fashion. In 2001, the Ninth Circuit (which covers most of theWestern U.S.) issued a similar ruling in the case ofArrington v. Wong.

Although the rulings inMorales andArrington have stirred much debate among health-care attorneys, the clear lesson for prehospital providers (not specifically addressed in either appellate decision) is for ambulance crews to stop interpreting vague and indeterminate responses by online physicians as ˙diversionary orders.Ó

InArrington, an ED physician told the paramedics, ˙I think it_d be OKÓ to take the patient to a more distant facility, which was interpreted by theEMS providers as a diversionary ˙order.Ó

InMorales, it was an ˙abrupt terminationÓ of communications by the ED physician that led theEMS providers to believe they had been ˙diverted.Ó However, in neither case did the physician clearly state their ED was on ˙diversionary statusÓ as that term is defined in the EMTALA regulations. And, in neither case did the ambulance crew attempt to clarify these vague statements (or non-statements) from the online physician.

An unclear and questionable direction from an ED physician puts an EMS crew in a tough spot. If you receive unclear or vague statements or ˙signalsÓ such as these, speak up and clarify the exact nature of the instructions or advice. Ask the online physician whether the hospital is on formal EMTALA ˙diversionary status.Ó As theMorales andArrington cases demonstrate, some ED physicians clearly don_t appreciate the effect of their conduct on the radio or telephone, which can leave patients and ambulance crews in a bind and expose the hospitals, physicians and even EMS agencies to significant liability.

Pro Bono is written by attorneysDoug Wolfberg andSteve Wirth of Page, Wolfberg & Wirth LLC, a national EMS-industry law firm. Visit the firm_s Web site atwww.pwwemslaw.com for moreEMS law information.

Radiation Response

AnAbstract: Lessons learned from the assassination of former Soviet spy Alexander Litvinenko

by Robin B. McFee, DO, MPH, FACPM, & Jerrold B. Leikin, MD, FACEP, FAACT, FACP, FACOEM, FACMT

Radioactive materials are readily available. They_re used in industry, medicine and military settings, and terrorist groups, including Aum Shinrikyo, Al Qaeda and Chechnyan extremists, have expressed interest in obtaining or have tested and attempted to deploy various forms of radiological weapons. Numerous high-profile toxic events have also been associated with radiation, such as the reactor explosion inChernobyl.

But it was the death of Alexander Litvinenko on Nov. 23, 2006, three weeks after he presented to aLondonHospital, that brought into focus the threat of radioactive materials being intentionally used against individuals or a society, such as Polonium-210 (210Po). Clinicians suspected radiation early on as the cause of his presenting illness, but they pursued other toxic etiologies when initial tests failed to reveal gamma radiation. It_s likely internal radiation was not initially considered. Once Litvinenko was accurately diagnosed, an environmental survey of his last whereabouts was conducted. Numerous individualsƒfrom the worried well to the potentially exposedƒpresented a public-health challenge.

This case sets the stage for several important considerations forEMS and hospital personnel. Medical response to radiation and radiological weapons remains one of the least emphasized aspects of medical education in general and of current terrorism preparedness specifically. And mostEMS providers are ill-prepared to handle events involving radiation. Recently,JEMS posed the question on its Web site, ˙Do you feel prepared to handle victims of a dirty (radioactive material) bomb?Ó Of the 246 respondents, 82% responded ˙No.Ó

Along with the lack of education regarding radiation poisoning, the ubiquitous nature of radioactive materials and the potential for their misuse, Litvinenko_s death demonstrates the need for training in recognizing, diagnosing and treating radiologic threats.EMS providers must become familiar with detector technologies and capabilities. And radiation poisoning should be considered in the appropriate setting as part of the differential diagnosis.

Clinicians at health-care facilities are often insulated from the environmental events associated with arriving patients. ButEMS providers are critical witnesses and the street-level eyes and ears of the health-care system; they have the unique advantage of surveying the surroundings and circumstances associated with victims and can relay valuable insights, suspicions and concerns to hospital staff. Fortunately, the risk forEMS in treating radiation victims is minimal if proper procedures are followed.

The public_s welfare largely rests upon first responders and hospitals being prepared for radiological emergencies. EMS providers and emergency departments (EDs) must be able to recognize a potential radiation event, identify and treat patients suffering from conventional injuries that may be complicated by radiation exposure or contamination, utilize appropriate personal protective equipment (PPE) and alert the proper authorities to initiate a rapid response. Responding to a radiation incident requires advance planning and continuous training.

Editor_s note: To read a detailed case report on Litvinenko_s poisoning and diagnosis, and the incident_s aftermath, and learn the effects of polonium-210 and other radioactive materials on the body and how to identify radiation poisoning, read ˙Death by Polonium-210Ó in the Meridian supplement to August 2008JEMS.

Robin B. McFee, DO, MPH, FACPM, is the medical director of Threat Science and also a toxicologist and professional education coordinator of theLong IslandRegionalPoisonInformationCenter,WinthropUniversityHospital,Mineola,N.Y. Contact her atrbmcfee@pol.net.

Disclosure: Dr. McFee is on the national nerve agent advisory group for King Pharmaceutical, the parent company of Meridian Medical Technologies.

Jerrold B. Leikin, MD, FACEP, FAACT, FACP, FACOEM, FACMT, is the director of medical toxicology, ENH/OMEGA, at Glenbrook Hospital in Glenview, Ill. Contact him atjleikin@enh.org.




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