Cold Genius

Brent Myers, MD, pioneers prehospital hypothermia & delivers the proof

• Cynthia Kincaid
• 2009 Apr 1

Back when Brent Myers, MD, was a second-year medical resident in North Carolina, he spent time with the Seattle Police Department and Seattle Fire Department’s Medic One program as part of a summer internship program. The director of Seattle’s poison control center at the time told him something that would forever change his career path—and his life. 

"She told me that I could be a great clinician and work hard seeing, perhaps, 15 to 20 patients a day in the emergency room," he says. "Or, I could fix a system of care and multiply that impact several fold." This convinced Myers that EMS could make a big impact on people’s lives, and he has devoted himself to just that.

Now director of the Wake County Department of EMS in Raleigh, N.C., Myers’ department "sees" 200 patients a day, which he admits would be impossible for him to do one on one. "We [in EMS] have the opportunity to have a greater reach and impact on a much larger patient population," he says. 

To achieve this continuing impact, Myers has worked tirelessly to teach, inspire and encourage first responders, EMTs and paramedics to give their best at all times. And he has practiced what he preaches by helping to develop and enhance life-saving procedures in 2008.

The Science Prevails
At the 2008 Society for the Academic Emergency Medicine conference, Myers presented co-authored research that illustrated improved outcomes for cardiac arrest patients resuscitated after induced prehospital hypothermia. But the groundwork for this landmark presentation goes back several years. 

In 2006, Myers established and expanded partnerships with Rex Hospital and WakeMed Health & Hospital’s Raleigh campus to implement an induced hypothermia procedure for patients resuscitated from cardiac arrest. This procedure, which is initiated by paramedics in the field, reduces the core body temperature of resuscitated cardiac arrest patients and is designed to protect neurological function in survivors.

Through these same hospital partnerships, Myers has also worked to initiate a cutting-edge protocol that moves patients suspected of ST-elevated myocardial infarction (STEMI) to the heart catheterization labs in a fraction of the time. This program has helped prevent a second STEMI, stroke or death in one of every 15 affected patients.

"What makes me happiest about the STEMI management and hypothermia programs is that we have cardiologists, emergency physicians, hospital administrators, EMS, firefighters and political folks front all of this, and we can bring the data back and prove that they did get return on their investment," Myers says.

This return on investment is important to Myers. "When the economic climate tightens, you see those things that are data-driven, and that can produce outcomes, continuing to get funded, and those things that don’t are the things that get pushed by the wayside," he says. "So, more than ever, we’ve got to be focused on demonstrating return on investment and justifying that this is a cost savings to the community."

The focus on cost savings seems to be working. Wake County EMS has an annual operating budget of $19.5 million a year. The hypothermia program cost EMS $5,000 to start and now costs them $4 a patient. That’s right, $4.

When the procedure was adopted by Wake County EMS in October 2006, only three other EMS systems in the U.S. had implemented similar protocols.

The life-saving part is working, too. Initially, Myers and his staff recognized that cardiac patients could be resuscitated, but many of them weren’t leaving the hospital because of the ensuing complications. "That’s what drove us to start looking at hypothermia and the science behind it," Myers says. "We got everyone around the table and said, ‘This is what we need to be doing for our patients; how are we going to make that happen?’"

Myers estimates that the hypothermia program, along with improved CPR, saves 25 people a year. "Every other week, somebody [is going] home who would not have gone home if we left the system the way it was," he says. "That can drive you to keep trying."

The STEMI program has been equally successful, and Myers attributes that, in part, to taking patients where they will receive the best care, even if that location is further than other facilities. "This is probably the revolutionary part from the EMS side," he says. "We want to take care of patients, and if that means bypassing two other facilities and driving 30 miles with a STEMI, we will do it, because we know that our patients will do better if they are at that facility."

A Matter of Perspective
The success of both of these programs, says Dr. Myers, is due to the measures that have been taken to emphasize patient focus, not necessarily EMS protocols. "We view measures not as to what EMS did, but how the patient did," he says. "So when we look at it from that perspective, the evidence is very clear about what we need to do with cardiac patients and patients who are not neurologically intact after a cardiac event."

Myers says it was this "leap of logic" that they were not in it for better response times and making people happy, but to provide the very best in patient care and good outcomes, that resulted in their focus change. "We spend a lot more time looking at clinical measure than we do operational measures," he says. "It’s not that operational measures don’t matter. Those are a part of it, but not the end." 

For the programs to be successful, Myers had to get EMS and the hospitals together to come to a consensus about how patients were going to be treated in the community. "We had to do this in the light of day, sitting around the table, and not waiting until three in the morning when it happens and then trying to recreate the wheel," he says.

So far, the city of Memphis, Tenn., has adopted a similar protocol, and Miami and Fort Lauderdale, Fla., have done the same. Austin, Texas, is also utilizing these programs, and the Fire Department of New York City rolled out a hypothermia resuscitation protocol on Jan. 1, 2009. "It’s not all because of us," says Myers, "but they are certainly using our information."

A scientific manuscript on the original research on resuscitated patients is under peer review. Myers is also the lead author of a position paper from the U.S. Metropolitan Medical Director’s Consortium published in Prehospial Emergency Care. The paper outlines an approach for the measurement of clinical success in EMS systems, presenting critical interventions for serious medical conditions commonly treated by EMS. This approach to clinical quality measurement highlights a way to calculate "number-needed-to-treat," which allows EMS systems to calculate the number of lives saved, or degree of harm avoided, when EMS responders intervene in evidenced-based ways.

"This is a way to measure the success of an EMS system beyond response time," says Myers. "Right now, we report EMS success by, say, ‘I met my response time goal, and I resuscitated X number of people from cardiac arrest.’ But that has nothing to do with how well we do in the other 98% of patients we encounter. Less than 2% of our patients are in cardiac arrest."

He adds, "What about patients with heart attacks, what about patients with strokes, what about patients having seizures, what about patients having trauma, and what about patients having respiratory distress? What are the measures that we should be reporting about how we care for those people?"

Myers’ research and the resulting paper are the culmination of two years’ worth of work outlining the impact that these programs are having on cardiac patients. "Every time we do [these procedures], we can prevent someone from having a second heart attack, or stroke, or dying," says Myers. "So we encountered 45 people having a heart attack, and we prevented four of them from having a second heart attack, just by what we did." 

In 2008, Myers also spearheaded the effort to launch a new category of EMS provider—the Advanced Practice Paramedic (APP). After attending a special EMS academy, the APPs now respond to calls and conduct focused follow-ups with high-risk patients to ensure they’re on the proper road to recovery. It’s a program that much of America is watching closely.

Myers sees his role in all of this as getting a group of people around a table to talk and create methods that will ultimately impact a lot of lives. "Five percent of my job is determining the right thing to do, and that’s generally not difficult," he says. "Ninety-five percent of my job is convincing the players all the way across the spectrum that this is what we need to be doing—and then making it happen."

And make it happen, he does. 

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