The 2015 American Heart Association (AHA) updated guidelines for CPR and emergency cardiovascular care remind us that only 10.8% of non-traumatic adult out-of-hospital cardiac arrests (OHCA) patients who receive resuscitative interventions from EMS survive to hospital discharge.1
This is concerning because 70% of out-of-hospital cardiac arrests occur at home, and 50% are unwitnessed and therefore less likely to receive bystander CPR than arrest victims in public spaces.1,2
With these sobering reminders the AHA separated the chain of survival, identifying one for OHCA patients and another for in-hospital cardiac arrests (IHCA).2 The OHCA chain of survival creates a framework for analyzing data and evidence-based decisions while accounting for the differences between OHCA and IHCA events.
Teamwork among responders is critical for
patient survival. Photo courtesy Benjamin Murry
EMTs and paramedics operate at the intersection of multiple public safety agencies and with other first responders and in-hospital emergency healthcare providers.3 During an OHCA event, EMS is dependent upon the resources within their immediate community and system–teamwork and coordination among providers is paramount to patient survival. EMS and other first responders must provide care despite any constraining or distracting factors that are largely absent from IHCA events.2
This article presents an OHCA case from Nebraska City, Neb., of an off-duty sheriff deputy, that exemplifies the importance of multiagency response and cross-pollination of first responders in supporting the new OHCA chain of survival.
Background
Nebraska City is a town of approximately 7,255 citizens in the southeast county of Otoe. It’s known as the home of Arbor Day and for having the oldest fire department in the state.
In 2008, Nebraska City began evolving from an all-volunteer EMS service to a system that now has full-time and part-time paramedics and part-time EMTs providing 24/7 EMS coverage.
As an ALS emergency service, Nebraska City EMS (NCEMS) responds with an on-duty fire apparatus engineer from the local fire department to emergency calls within city limits. NCEMS also responds to emergency calls within the surrounding county area and provides ALS support to neighboring departments when requested.
In addition to being a 9-1-1 service, NCEMS provides interfacility transports from two hospitals in Otoe County to regional and specialty care facilities in Lincoln and Omaha, Neb. In 2015, the service had a call volume of 1,200, 64% of which were emergency calls and 36% of which were interfacility requests.
Community Resources
On Nov. 1, 2015, at 10:07 p.m., NCEMS was dispatched with Nebraska City Police and fire department apparatus to a private residence for an unconscious party. Many of the first responders quickly recognized the address as that of an off-duty county sheriff deputy.
Two police officers were first to arrive and find the 56-year-old male supine and unresponsive on his bed. While EMS and fire units were en route, the officers urgently moved the patient to the floor and began compressions. The responding officers were equipped with an AED, which advised a shock because the patient was in v fib. The officers applied and administered the first of many defibrillations.
After the arrival of NCEMS and other first responders, the full complement of police, fire and EMS personnel worked on the patient in a fully coordinated manner. It takes a team simultaneously working together to perform basic and advanced cardiac life support interventions, including the application of a LUCAS 2 mechanical compression device.
Crews from Nebraska City EMS, police department,
fire department and hospital staff train together.
Photo courtesy Benjamin Murry
The team continued its coordinated resuscitative efforts out to the ambulance and as the patient was secured for transport. While en route to the ED, the patient received seven biphasic defibrillations, four boluses of epinephrine 1:10,000 1 mg, and amiodarone boluses of 300 mg and 150 mg.
Upon arrival, the patient remained pulseless and apneic. The EMS crew continued providing patient care by assisting the limited number of ED staff. The mechanical CPR device was left on the patient, enabling the ED staff to draw labs and complete other critical procedures. ACLS protocols were followed and meds were given per standard ACLS guidelines.
After return of spontaneous circulation (ROSC) was finally achieved, the patient was transported to a regional cardiac center for specialty care and treatment. As he was being loaded into the ambulance, police and fire department first responders provided words of encouragement to both the unresponsive patient and the transporting EMS crew.
Shortly into the interfacility transport, the patient’s v fib returned and he was immediately defibrillated. His fibrillations didn’t stop, and continuous treatment included four biphasic defibrillations, chest compressions from the LUCAS 2, and the continuation of an amioderone infusion.
Upon arrival at the Nebraska Heart Hospital, the patient had a pulse and was rushed into an operating room for cardiac stenting.
In the end, this OHCA patient received high-quality compressions by the first-arriving police officers, continuous CPR via mechanical chest compressions, 15 defibrillations, 12 doses of epinephrine, 1 mg of atropine, 2 mg of narcan, two doses of amiodorone and a drip of saline.
Three days after the initial call, the patient was discharged from the hospital without any neurological impairment and he returns to service as a county sheriff deputy four months later.
Work Together
During a city council meeting two months after the call, the resuscitated sheriff’s deputy and city leadership gathered to present recognition awards to all fire, EMS, law enforcement and dispatch personnel involved in the patient’s resuscitation. The award ceremony was truly symbolic of the survival of a fellow first responder who was standing without neurological deficits before them because of a small-town, multiagency emergency system that embraces an interdisciplinary approach to OHCA.
Regardless of a service’s size, EMS is dependent upon coordinated community resources. In recognition of this, Nebraska City first responders find opportunities to train and debrief together.
A prime example of this coordinated effort occurred when NCEMS received mechanical CPR devices. Training sessions were held for first responders from multiple agencies, carefully detailing how the device was to be applied and operated. These discussions led to further discussions and training on first responder roles and how to best integrate mechanical CPR from an integrative team approach during an OHCA.
For the first responder agencies in Otoe County, open channels of communication are important and apparent. Following this successful cardiac arrest resuscitation, responders gathered many times to discuss how the call progressed and discussed ways to improve future resuscitations.
First responders working together, communicating and sharing ideas isn’t unusual in Nebraska City. Commonly, responders from various agencies will stop by the fire and EMS station for morning coffee, have an occasional meal together or, more importantly, go through the ambulance and its equipment bags to be sure everyone is familiar with their contents and functions.
The strong belief that “we’re all in this together” is the ethos of first responder services in Nebraska City. Training together is helpful, but having cross-trained first responders enhances a community’s resources. This shared commitment of being able to work together during an emergency shines brightly in the number of first responders who are part of more than one agency.
Conclusion
NCEMS and other first responder agencies have recognized that high-quality patient care and CPR is foundational. This helped foster a mentality of all first responders being in it together and working together as an interdisciplinary team. It’s widely accepted that teamwork and coordination among first responders is a critical determinant of patient outcomes.
This case study serves as an example of this approach with an insight into strategies in a multi-agency response system, some intentional and others organic, which contributed to the successful OHCA of a fellow first responder.
It should also serve to recognize the importance of finding ways to collaborate through shared trainings and debriefings, emphasizing quality care and encouraging all first responders to strive to do better–together.
Recognizing the importance of goal setting, accountability and continuous quality improvement during OHCA isn’t an easy task for a single department, but can be done and can include multiple agencies.
It took years of ups and downs for NCEMS to develop this system. However, it was made possible through the guiding vision and principles of being a small-town department with a big city commitment.
References
1. Kleinman ME, Brennan EE, Goldberger ZD, et al. Part 5: Adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 suppl 2):S414—S435.
2. Kronick SL, Kurz MC, Lin S, et al. Part 4: Systems of care and continuous quality improvement: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 suppl 2):S397—S413.
3. Leggio WJ, D’Alessandro KJ. Support for interdisciplinary approaches in emergency medical services education. Creighton Journal of Interdisciplinary Leadership. 2015;1(1):60—65.
