Sunday, December 8, 2013
Ray Fowler, MD, FACEP
It’s mid-evening on a busy night, and the radio crackles in the emergency department (ED): “General Hospital, this is Rescue 80, on the scene of a 76-year-old woman with right-sided weakness and facial droop. Her speech is slurred, and she appears confused. Her last time to be known normal was about 45 minutes ago, when she said to the family that she didn’t feel well and went to lie down. When they checked on her, they found her in the current condition. Her vital signs are: BP 175/90, pulse 88, respirations and pulse ox are normal. We are eight minutes from your facility or 25 minutes from the Stroke Center at Excelsior Hospital. What do you advise?”
And, so we face the current essence of EMS medicine: The critical care medic’s assessment and field management skills are becoming more and more sophisticated. At the same time, the treatment of many critical care conditions is becoming more and more specialized. Combine the two, and suddenly a dilemma emerges: Would this little lady benefit from bypassing a peripheral hospital that might be pressed to give “state of the art” stroke care, for an extra 17-minute ride to a “stroke center”—while some 2 million brain cells a minute are dying in the ischemic focus inside her head?
EMS Medicine is the practice of medicine in the prehospital area. It is a subspecialty of medicine; the first physician certification examinations were offered in October 2013. With this step, EMS Medicine becomes a new member of the “House of Medicine.” All participants in the process of patient evaluation and management in the prehospital environment must strive to bring the best care possible into play.
Key to this progress: a vast increase in information transfer capability from the field. Electronic medical records—based strictly upon a federal data management and transmission standard authored in part by the principal author of this JEMS supplement, Dr. Greg Mears—now are the standard of clinical practice around which all patient care information is centered. Sophisticated EMS systems across the country and around the world now oversee trauma, stroke, STEMI, burn, pediatric, and soon-to-be sepsis networks to optimize the outcome of these patients. Time intervals in these patients are tracked closely: 90-minute symptom onset to arterial reperfusion for STEMI is a sought-after standard; soon, 60-minute door-to-thrombolysis windows for some 50% of patients who are victim of ischemic strokes will become the norm.
How then, in this increasingly complex technical infrastructure, can EMS systems play the dynamic part that they are destined to perform?
The Need for Standardization
When I started medical school in 1973, if a man came to the hospital having a heart attack, we would put him in the coronary care unit (which were just emerging at the time), treat his pain with morphine, give him oxygen, give him furosemide and digitalis if his lungs filled with fluid, keep him there for two weeks, and hope he wouldn’t die.
Today, the acute coronary syndrome has emerged to be recognized as an acute arterial vascular emergency, the treatment of which is heavily based upon the role that EMS systems play in overall assessment and management.
And brisk progress has been made. STEMI networks have sprung up across the nation. The entire state of North Carolina is an organized acute cardiac care network. Dallas County (Texas) recently completed the organization of a county-wide STEMI network coordinating the care of patients with acute coronary syndrome across 25 EMS agencies and 15 emergency receiving facilities, with a common EMS-hospital linked dataset, uniform EMS protocols and uniform clinical pathways for hospitals. Uniform ECG transmission from all ambulances—across an ECG transmission software platform—has been achieved, and some of the treatment successes are staggering.
A generally standardized set of training programs and equipment exists in the prehospital phase through which all medical emergencies are managed. Training standards are found in federal guidelines. Equipment is generally similar from system to system, with variations induced by the marketing influence of manufacturers.
However, significant variations exist among the various producers of the spectrum of machinery and software used by many systems. For example, at least three different software methods of ECG transfer exist across the spectrum of prehospital care, resulting in the inconsistent ability of municipalities to provide for fully coordinated transmissibility across all platforms for ECGs within any single EMS system. The solution required is generally single-proprietary adherence of product across that given system. In this reality is the opportunity for improvement.
It is reasonable to anticipate that similar pressures that drove computer development—the “plug and play” generation of hardware and software progress across various computer and software makers—will drive similar progress in the realm of open architecture among the producers of ECG transmission technology. This would continue to streamline the free exchange of data across platforms in the provision of field patient care.
Telemedicine & EMS
Telemedicine is driving medical development in an accelerating manner. Example: Tele-neurology, in which a neurologist evaluates a stroke patient remotely, is now considered a normal part of stroke assessment and treatment. Tele-ICU monitoring has also emerged, allowing critical care nurses and physicians to monitor the status of patients from off site in a safe, prompt manner.
EMS telemedicine has emerged more slowly. It is interesting to watch a re-run of one of the old Emergency! shows and watch the live transmission of the patient’s rhythm to Rampart Hospital. One would have thought that by now, some 40 years later, the streaming of patient information on a live platform from the field would be customary. I recall well the live-streaming waveform on the old Motorola screen in a small ED in eastern Georgia as I discussed the case with the medics in the field.
Vital sign “pushes” in a non-real-time manner are available from equipment producers, giving vital signs updates as frequent as every minute. This availability requires a proprietary software platform. Another manufacturer provides high-quality Web-based audio, video and monitor information to the local base station.
Smartphones & EMS
It’s interesting to wonder when EMS will capitalize on the technology provided by a typical smartphone. Excellent quality audio and video could be sent to the base station in a very inexpensive manner, allowing the medical direction team to hear and see the patient. This would seem very appropriate in the setting of the evaluation of a stroke patient, for example. The assessment of infants, of accident victims, of burn patients, and of other cases would also seem to benefit from this process. And patients refusing transport could be videotaped and the records filed for medico-legal purposes.
One has to be cautious, however, with the application of new software and devices directly into the stream of patient care, as opposed to “after the fact review” within a quality management program. The FDA has a direct role in the approval of items that fall within the evaluation and management of a patient, requiring what is called a “510K Clearance.” A recent article by a medical student in a prominent newspaper asked, “Will your next physical be done by smartphone?”1 However, it says almost nothing about the smartphone participating in the direct line of patient evaluation from a critical care perspective.
Thus, at this time, EMS providers should be cautious about using any sort of audio and video devices directly in the line of patient care. An example of this would be calling the hospital and sending a video of the patient directly to a receiving device, most likely another smartphone, through which a provider at the ED, such as an emergency physician, would then make a treatment decision. It theoretically might not be allowed under FDA rules, and it certainly has the potential for a HIPAA violation with regard to patient privacy.
The Evolution Continues
Advancing EMS opportunities, such as the community paramedic effort sweeping the world, will dictate the need for continuing to improve the communication resources between providers. Optimizing what can be assessed on the scene, providing the care in the field that is based on best evidence, and linking up appropriate providers to assist in management while preparing hospital-based facilities where indicated, will continue to evolve as patient needs, provider skills and technology development lead us. ✚
1. Parikh R. (July 22, 2013) Will your next physical be done by smartphone? Washington Post.