On May 16 and 17, the Resuscitation Academy provided a comprehensive look at the cardiac arrest quality improvement programs that have led to a more than 50% survival rate for witnessed ventricular fibrillation (v-fib) patients in Seattle. The intensive program, presented by Seattle Medic One and King County EMS, is offered free of charge to EMS managers and directors from throughout the U.S. The cost is underwritten by sponsors and the Medic One Foundation, a local, nonprofit organization that funds prehospital emergency care in Seattle and King County by providing paramedic training, research and medical review of paramedic performance.
At a recent two-day Academy, 115 attendees representing 45 different agencies were welcomed by King County EMS Medical Program Director Mickey Eisenberg, MD, PhD; Thomas D. Rea, MD, MPH, medical program director for King County Medic One; and Michael K. Copass, MD, medical director for Seattle Medic One.
Rea said that what works for Seattle and King County won’t necessary work everywhere. The challenge is to apply appropriate elements to each community. “It’s not complicated, but it’s not easy,” he advised.
Seattle and King County employs a two-tier system, which is staffed by approximately 4,000 EMTs and 260 paramedics for a population of 1.8 million. Each paramedic treats six to 20 out-of-hospital cardiac arrests annually and performs about the same number of intubations.
Although there’s no magic bullet for improving cardiac arrest survival rates, each presenter emphasized that high-performance CPR is the centerpiece of resuscitation. The programs developed by King County and Medic One reflect a community-wide effort that centers on enhancing the effectiveness of each step in the chain of survival.
At the beginning of the chain is a rapid dispatch protocol that starts an EMT crew to a suspected cardiac arrest patient within seconds of a 9-1-1 call. Dispatchers are trained to ask two questions of every caller: “Is the patient conscious?” and “Is the patient breathing normally?” If the answer is “no” to both questions, the dispatcher directs the reporting party to begin compressions-only CPR, providing instructions, if necessary. A paramedic unit is also dispatched (usually simultaneously with the EMT unit) when a cardiac arrest is suspected. And an AED registration program allows dispatchers to provide bystanders with the location of the nearest AED, prior to EMS arrival.
For EMS crews, the focus is on high-performance CPR—a team approach that dictates tight coordination and communication. Using a “pit crew” approach, providers deliver excellent chest compressions with minimal interruptions.
For example, they gain critical seconds by continuing compressions while the AED is powering up. Compressions are stopped only to allow for the analysis and shock—no more than 10 seconds. Responders return to compressions immediately after the patient is shocked.
Such interventions as intubating, placing an IV or intraosseous line, and administering drugs are completed without interrupting chest compressions.
Because perceived performance doesn’t always match observed performance, one of the most significant elements of the Seattle and King County model is a quality assurance review of every cardiac arrest call. Rhythm and voice recordings are downloaded from the defibrillator involved and reviewed. Then a report is sent to the CPR team, sometimes within a couple of days.
“Protocol and compliance [are] important,” says Copass, director of the Medic One Paramedic Training Program, as well as medical director for Seattle Medic One. “The people who did the work need to know how they did.”
Along with team effectiveness, the quality assurance program assesses system performance, identifying trends and potential training needs. Reports are provided by stations, allowing for some healthy competition. An annual report is published and available to the community.
Despite the exceptional survival rates, Eisenberg sees room for improvement. “There’s no reason in the world we can’t achieve a 75% survival from v-fib,” he says.
To learn more about the Resuscitation Academy, visit their website: www.resuscitationacademy.org.
—Teresa McCallion, EMT-B, and editor of
EMS on Segways
Life Flight Event Medicine (LFEM) is the ground component of Vanderbilt University’s EMS agency. The group provided EMS services at this year’s Country Music Association Fest June 9–12.
Medical Director Jared McKinney, MD, says it was hot in Nashville those days with lots of heat issues in addition to the normal injuries that occur in a crowd of thousands. McKinney estimates their crew of EMTs, paramedics, doctors, nurses and athletic trainers treated about 750 patients over the four days.
Vanderbilt sent two ambulances, a mountain bike, two golf carts—one equipped with a stretcher—and two Segways on the Saturday and Sunday of the show. It turns out the new owner of Segway of Nashville was an EMT student of Leigh Sims, the director for event medicine. Because LFEM doesn’t own a Segway, they didn’t have anyone trained to ride it. Sims says, “We used an International Police Mountain Bike Association-certified medic.”
Paramedic Eric Gallup, one of the lucky riders, says of the Segways, “You could take them pretty much anywhere you wanted to ... into a place that you couldn’t take a cart or ATV. It doesn’t hurt that they are a pretty good conversation starter when you are out roaming around.”
Ambulance Diversion hurts patients
According to a new survey, emergency departments (EDs) that divert ambulance arrivals for lengthy periods of time because of overcrowding put patients experiencing heart attacks at a greater risk of dying. The study was conducted by Yu-Chu Shen, PhD, of the Naval Postgraduate School (Monterey, Calif.) and National Bureau of Economic Research (Cambridge, Mass.), and Renee Y, Hsia, MD, MSc, of the University of California, San Francisco. And the mortality rates aren’t just higher immediately after the onset of the critical condition but for up to one year later, reported the Journal of the American Medical Association.
“I think this is going to add to the growing realization that hospital diversion kills,” says JEMS Editorial Board member Keith Wesley, MD, FACEP. “Now it raises questions about how do we address it.”
Between 2000 and 2005, researchers tracked 13,860 Medicare patients admitted at hospitals in four California counties: Los Angeles, San Francisco, San Mateo and Santa Clara.
Patients diverted from their closest hospital to one farther away had higher death rates in the first 30 days when compared with those who were seen at the nearest facility (19% vs. 15%). In the first 90 days, it was 26% vs. 22%. Nine months after the incident, the death rate was 33% vs. 28%. And a year later, the rate was 35% vs. 29%.
Wesley suggests ambulance diversions have a more dramatic affect on the patient who walks in the door of the ED with a critical condition than those taken by ambulance. Walk-ins will wait longer, he says, whereas if they were delivered by EMS—even to another hospital—they’d have a better shot at survival.
“This [study] clearly answers the question that when hospitals go on diversion there are bad outcomes,” Wesley says.
Researchers found there were even differences in the care given to those who were diverted when compared with those who weren’t sent elsewhere. Patients who weren’t diverted got catheterization procedures 49% of the time compared with 42% for those whose closest hospital were diverting ambulances to another site. The rate of patients getting stents and angioplasty was 31% for those who weren’t diverted compared with 24% for those who were.
Officials at the American College of Emergency Physicians responded to the study by saying the key to solving ED crowding is to move patients who have been admitted to the hospital out of the ED and into inpatient areas to better coordinate elective surgery schedules and to discharge patients before 12 p.m. to clear up hospital space.
Wesley also believes a key is considering specialized diversions, during which the ED may be closed but the catheterization lab is still open to help critical patients.
“As policy makers and medical directors, we need to look at our own systems,” he says. “Make determinations and set up a system to ensure the greatest good for the greatest numbers.”
—Richard Huff, NREMT-B
Dealing with Distractions
In the age of smartphones, social media and other technological innovations, an almost limitless number of distractions exist that can divert the attention of EMTs and paramedics from the performance of their duties. EMS agencies should take steps to ensure these distractions don’t compromise patient care or hinder operations. EMS agencies should, with the input of their legal counsel, implement policies and procedures to ensure the safety of patients, crew members and the public.
The temptation to send text messages, post Facebook status updates or send tweets using personal cell phones while on duty is a constant threat to their safety. When these distractions occur during EMS operations, providers can take the focus away from where it should be—the patient and the public. Even in cases in which the patient is stable, all necessary care has been provided and the patient is resting quietly and comfortably on the stretcher during transport, EMS providers shouldn’t be texting, tweeting or engaging in other non-patient-care-related pursuits. The patient’s condition should be continuously monitored; EMS providers can work on the patient care report and should focus on work-related tasks.
It should go without saying that emergency vehicle operators should never engage in texting or the use of personal cell phones while driving. Even the use of radios and other devices should be limited during vehicle operations to minimize driver distractions. The risks of distracted driving are clear and well-documented, and even trained emergency vehicle operators aren’t immune from these risks.
EMS agencies should have policies clearly prohibiting the use of cell phones or other personal electronic devices (iPads, media players, portable gaming devices) for personal business while operating a company vehicle, providing patient care or engaging in any EMS operations.
The use of personal cell phones and other devices for personal reasons should be limited to “down time” when crew members aren’t engaged in any duties and all necessary work has been completed.
In addition, the use of personal digital cameras, cell phone cameras and other imaging devices to take pictures of patients or incident scenes should be absolutely prohibited. If an EMS agency wishes for its personnel to take digital photographs as part of their job duties, the devices should be owned and issued by the agency. All images, videos and other files must remain the sole property of the agency and safeguarded under HIPAA in the same manner as any other protected health information.
If something bad were to happen during an EMS operation, such as an accident, injury or negative patient outcome, it isn’t hard to imagine that a plaintiff’s lawyer would investigate whether the crew might have been distracted during times they were supposed to be paying attention to their duties. Even if text messages or other communications are erased, cell phone records and other evidence can be subpoenaed and damage the defense if they show that the crew was texting or tweeting when they were supposed to be driving or providing patient care. The risks of distracted EMS providers are simply too great for EMS agencies to let the problem continue. JEMS
Pro Bono is written by attorneys Doug Wolfberg and Steve Wirth of 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.
N.J. EMS Bill to Standardize Care
New Jersey Senate bill S.818 may be in force by the time you read this. It’s faced a rocky road since the 2007 report of “The State of EMS.” The state’s officials prompted the New Jersey EMS Council (NJEMSC) to draft recommendations to standardize and improve EMS care.
New Jersey Paramedic Program President Scott Kasper says, “We [NJEMSC] created a patient-focused document truly based on consensus.”
Although the New Jersey State First Aid Council, the organization that represents volunteer services in the state, is opposed to the legislation as written, Kasper doesn’t see the issue as paid vs. volunteer, but rather professional providers vs. unprofessional providers.
“You don’t have to get paid to be a professional,” he says.
A couple of portions of the legislation that may have been overshadowed by the volunteer vs. paid controversy would bring New Jersey EMS up to contemporary models of care. Currently, law requires paramedics to have direct voice contact with a physician during care. And any ALS changes in protocols must go through a regulatory review, which could take months, if not years.
The new regulations may be sweeping and may force some volunteers to struggle to meet them, but it looks as though New Jersey is moving toward a system of improved EMS care.
UK Medics Assess their Own Risk
A year ago in West Cumbria, England, a man named Derrick Bird killed 12 people and injured 11 others over a 45-mile area. He then killed himself. Although the families of the dead and injured still suffer, it might seem the story is over.
As it turns out, Bird’s rampage may end up having serious repercussions on Britain’s ambulance crews and paramedics. Just like most of their American counterparts, the English EMS personnel refused to enter areas to treat patients until those areas were declared safe by law enforcement.
David Roberts, a coroner involved with the shootings inquest, wrote a letter to Health Secretary Andres Lansley criticizing the protocol and asking for a review.
According to the BBC website, Lansley’s reply to Roberts was, “Perhaps ... the normal policy of determining the safety of an incident as a whole was not appropriate. … In future ... personnel attending the incident will undertake a risk assessment of the scene themselves to decide on the most appropriate course of action.”
The issue was to be discussed at the Ambulance Leadership Forum at the end of June, according to London Ambulance Service Medical Director Fionna Moore, FRCS, FCEM, FIMC. Stay tuned for more information about the outcome of the Ambulance Leadership Forum.
For more of the latest news, visit JEMS.com/news
This article originally appeared in August 2011 JEMS as “Seattle’s Success: Witnessed v-fib survival rate tops 50%.”