EMS Insider, News

A Tale of Three Successful EMS Systems, Part 2

In auto racing, seconds can make the difference in winning or losing a race. NASCAR teams have proven the effectiveness of what’s referred to as the “pit crew” approach to rapid, coordinated, race car pit maintenance stops to avoid unnecessary delays, get critically important tasks completed in the minimum amount of time and avoid errors that can cost them time and, ultimately, the race.


In the race to save cardiac arrest patients, it’s now also been shown that the use of a “pit crew” approach by EMS crews can also make resuscitations more effective by reducing interruptions in compressions and peri-shock pauses, reducing delays in interpreting cardiac activity, eliminating pauses for airway management and reducing the time it takes to place and activate mechanical CPR devices.


This series of articles focuses on three progressive EMS systems that have each been highly effective in standardizing their approach to cardiac arrest resuscitation by implementing the pit crew approach to resuscitation, using well-defined process and clinical procedure checklists and other methods to limit delays in the care and resuscitation of patients.


Austin-Travis County, Texas- Many argue that running a cardiac arrest isn’t intellectually or clinically challenging and so dismiss its complexity. Successful management of cardiac arrest, however, is far more difficult than we believe. What makes consistently well-run codes so elusive is the competing needs of various interventions, the need for constant attention in a chaotic environment, and our inherently poor perception of task time. Choreographed, or pit crew CPR, is a great example of EMS innovation and process engineering designed to address these challenges and those of the prehospital environment.



What has made choreographed CPR invaluable to Austin-Travis County and other systems across the outcome spectrum is the consistency it brings. Before utilizing the pit crew approach, every cardiac arrest was carried out in a different manner, adding to the variability of cardiac arrest management and making it difficult to define and describe. Now every cardiac arrest is engineered to be the same.


Like Wichita-Sedgwick County and Wake County, N.C. (see the March edition of EMS Insider), Austin-Travis County uses a uniform process that allows us to better isolate and measure elements of cardiac arrest management. Over the last four years of pit crew, that consistency has contributed to improvement in our outcome measurement, feedback to providers, compression quality, timing of interventions, and bystander CPR and AED availability initiatives.


These represent the easily quantified benefits of choreographed CPR. But, like other EMS systems that have implemented the pit crew approach, we’ve found it improves far more than just the numbers. The following comments on the impact of pit crew are from system providers with different roles. Their comments were provided independently without any input or knowledge of the others’ content.


Battalion Chief Michael Prather, EMTP, of Lake Travis (Texas) Fire Rescue: When Lake Travis Fire Rescue adopted the pit crew model of CPR, it was a change to the standard American Heart Association training for cardiac arrest I’d been doing for years. After training to use the pit crew approach, I quickly realized it made perfect sense.


As firefighters on an engine company, we all have a designated assignment for a house fire. We know before arriving on scene that one firefighter is going to grab an attack line; the other firefighter is going to force entry to the house; the officer will do a 360 of the incident to look for hazards and formulate a plan; and the engineer will get the engine ready to supply water. So, why would we treat cardiac arrest differently?


The pit crew model allows personnel to know what their assignments are before we even walk through the door. It allows for CPR to start rapidly and be performed effectively throughout the duration of the code.


A firefighter is positioned at each side of the patient filling the assignment of compressor—giving 100–110 compressions a minute. They stay in cadence with the metronome and limit pauses during compressions.


The firefighter at the head maintains a mask seal or places an airway, while the person not compressing the chest ventilates the patient.


Initially we were skeptical of the pit crew model. However, after working several cardiac arrests and realizing that the codes ran smoother, everyone accepted the new approach. We all have an assignment that we’re all well-trained to manage. Those assignments allow us to work as a team, just like we would at a fire.


Once the medic unit arrives on scene, they have their assigned positions as well. We integrate additional providers and interventions without interruption of chest compressions or ventilations: we all become one team.


Commander Mark Karonika, EMT-P, FP-C; Austin-Travis County EMS: When we rolled out pit crew, we believed we were already managing cardiac arrest calls at a very high level. How could this improve it?


As a supervisor I respond to every cardiac arrest while on duty, and I have seen the difference this new approach makes. Today I can respond to any cardiac arrest with any first responder or EMS crew in our system and what I will see is the same.


The defibrillator charges, but no one stops what they’re doing until the last possible second. They know we need to keep CPR going to reduce the time off chest until the rhythm and pulse check.


Without being asked or told, compressions start again with a new compressor; a constant focus on high-quality CPR. I see the crews working to solve the problem, and thinking out loud. Any idea is welcome and everyone participates.


This leaves me time to attend to the family to explain what’s happening and care for everyone at the scene.


Our pit crew approach means we run a better and more consistent cardiac arrest but it has changed more than just that. It has changed our relationship with the first responders and fire departments. Now everyone has a role and is equally important to the outcome. Regardless of how you responded to the scene, or what your level of certification, we’re a team.


Paul R. Hinchey, MD, MBA, FACEP, is the medical director for Austin-Travis County EMS System and the National Association of EMTs. A former paramedic, he’s board certified in EMS and has 28 years of experience in the industry. He may be contacted at Paul. [email protected].


Michael Prather, EMT-P, is a battalion chief, field training and performance improvement officer and 15-year veteran of Lake Travis Fire Rescue.


Mark Karonika, EMT-P, FP-C, has 18 years of experience in EMS as a fight and critical care paramedic. He’s a 15-year veteran of Austin-Travis County EMS and currently serves as a commander in the special operations division.