This special supplement to JEMS, prepared in cooperation with the U.S. Metropolitan Municipalities EMS Medical Directors Consortium (the "Eagles" Coalition"), addresses issues important to all EMS systems. In the past five years, emergency treatment and technology have been advancing at an unprecedented pace, with prehospital systems leading the way in many regions and gaining support from their hospital systems to continue and advance the care in their emergency departments and critical care units. Such procedures as end-tidal CO2 airway monitoring, adult intraosseous infusion, continuous positive airway pressure (CPAP) by ALS and BLS crews, intranasal medication delivery, 12-lead ECG and STEMI response systems, and therapeutic hypothermia are now becoming standard of care in the most advanced EMS systems.
Many factors led to this advancement of clinical care, but chief among them are: 1) an increase in physician involvement in EMS system development and oversight; 2) position statements by the U.S. Metropolitan Municipalities EMS Medical Directors Consortium, the National Association of EMS Physicians and the American College of Emergency Physicians; and 3) research innovations, scientific reports and educational supplements, such as this one, that review and disclose important concepts as they evolve.
Because of these factors, the "State of the EMS Science," as we know it today, is not only advancing but evolving rapidly. This means that best practice treatment protocols, medications, equipment and techniques are also changing rapidly.
In this special supplement, we will present some highlights and previews of the much anticipated and upcoming EMS State of the Science ("A Gathering of Eagles") Conference at the Fairmont Hotel in Dallas, Texas, Feb. 26–27, at which many of these advances will be presented for the first time.
An Atmosphere of Change
One of the major changes in the past few years is that out-of-hospital and sustained in-hospital cooling of patients has become a mainstream intervention, and experts now recognize that the best approach to therapeutic hypothermia (TH) may depend more and more upon the actions of EMS personnel. Joseph Ornato, MD, chair of the Department of Emergency Medicine at the Virginia Commonwealth University (VCU) School of Medicine, operational medical director of the Richmond Ambulance Authority (RAA) and a veteran member of the Eagles Coalition , is one such expert.
"Cooling the brain as quickly as possible, and ideally before the heart even restarts, slows its metabolism so it can't generate a large quantity of 'free radicals,'" says Ornato. "Maintaining precise temperature control for 24 hours and gradually re-warming patients in a precise manner prevents large swings in the body temperature, which can result in a surge of metabolism and 'free radical' production."
Through an initiative known as the Advanced Resuscitation Cooling Therapeutics and Intensive Care Center (ARCTIC), the VCU Medical Center and RAA have dramatically improved their cardiac arrest resuscitation and survival rates in Richmond. The ARCTIC program not only uses therapeutic hypothermia in the field during resuscitation, but also ensures follow-up at the hospital with a host of progressive strategies, including insertion of a high-tech plastic coil into a large vein to cool and monitor the patient in a precise way.
According to Ornato, the initiative greatly improves the odds of survival and has resulted in an almost twofold improvement in the return of spontaneous circulation (ROSC) in RAA patients, from 25% in 2001 using conventional treatments, to 46% in 2008 using a combination of care and treatment technologies. In turn, the survival rate to hospital discharge has improved from 9.7% in 2003 to 17.9% at the end of 2008. In comparison, the national average is less than 7%.
"What we know now is that we have to protect the brain and vital organs during resuscitation and after the heart is restarted, and this has led to a totally new strategy for how we treat cardiac arrest patients," Ornato says. He adds that RAA's treatment strategy also includes performing high-quality CPR using a mechanical device that provides truly continuous CPR that "allows RAA crews to achieve better blood pressure and oxygen delivery than that achieved with just standard CPR."
Supplement Articles & Concepts
It's with this success story in mind that we're pleased to share other expert content from the Eagles Coalition. In the lead article of this supplement, "Beyond Ventricular Fibrillation: Other uses for therapeutichypothermia," J. Brent Myers, MD, another veteran Eagle, discusses situations other than ventricular fibrillation arrest in which TH may also have a clinical impact but are currently in limited use in many EMS systems. These include atypical patient situations that have resulted in anoxic insult, such as traumatic brain injury (TBI), drowning and electrocution. In addition, because of positive results being observed, certain pediatric cases have been found to benefit from TH.
In an accompanying article, "In My Own Words," New Jersey paramedic Robert Ball provides a first-person account of his brush with death after experiencing sleep apnea induced cardiac arrest and his resuscitation, which involved therapeutic hypothermia. The details of his recovery offer you a rare look at the post-resuscitation phase of cardiac arrest.
In "Evolving AMI Care, 2010," Jared McKinney, MD, Jeremy Brywczynski, MD, and senior Eagle Corey Slovis, MD, give us an insightful update on five (yes, five) major changes that have occurred in the prehospital treatment of acute ST elevation myocardial infarction (STEMI), including 1) the role of morphine, 2) beta blockers, 3) a focus on minimizing the time from EMS arrival to balloon therapy (E2B), 4) the role of paramedics and emergency department (ED) physicians in cardiac catheterization laboratory activation, and 5) the changing role of EMS in the use of thrombolytics.
In "Reducing Interruptions in CPR: Continuous chest compression CPR and minimally interrupted CPR result in improved survival," longstanding Eagle David Keseg, MD, illustrates how critical it is for crews (and the public) to deliver uninterrupted compressions to resuscitate and maintain their patients. He also highlights the importance of educating EMS providers to consistently perform the most optimum quality of CPR.
In the truly provocative article, "Sex, Drugs and R and R (Resuscitation and Reanimation)," Jane Wiggington, MD, Paul Pepe, MD, and Ahamed Idris, MD, explore the real possibility that ALS crews may someday routinely administer the female hormone estrogen for cardiac arrest, post-traumatic shock, severe head injury, myocardial infarction, stroke, massive burns and a myriad of other illnesses and injuries. This visionary article heralds in the groundbreaking era of "resuscitative endocrinology." The authors, who have helped pioneer and bring this innovative concept into the clinical area, review the original clinical observations and the basic laboratory evidence supporting the benefits of sex hormones in resuscitation medicine.
And, in "EMS and the DEA: Experience can help prevent exposure," Jeff Beeson, DO, and Chris Ayres, JD, EMT-B, present actual case examples to illustrate comprehensive investigations and stiff fines that have been handed out by federal and state drug enforcement agencies to providers, administrators and medical directors responsible for monitoring controlled substance utilization within their agencies. This "in your face" article is a wake-up call, not only for EMS agencies, but also EMS crews and their medical directors.
Read this supplement carefully and with an open mind. You'll get a snapshot of the rapidly evolving issues and advances in the science in EMS, and likely a first glimpse at future changes in your own EMS system. As an added bonus, go to www.jems.com/eagles2010 to read additional insights offered by members of the Eagles Coalition about the impact of current treatment modalities and future changes they envision in EMS systems.