Posted by: medicblog999 | April 26, 2010

CoEMS – A Double Edged Sword

Also posted over at Paramedicine 101 & Chronicles of EMS

DoubleEdgedSwordI’ve been struggling lately.

Struggling with all of the information I am absorbing from all of the professionals I get to communicate with on a daily basis these days.

I am suddenly exposed to a wealth of EMS knowledge and experience which would, I assume, be seen as a gold mine of information to many people. Indeed, that is how I see it also, and I have gained so much from that, that sometimes my head hurts from the combined thoughts of hundreds of people’s experience.

The Chronicles of EMS has given me so much more than I would have ever thought possible, but there is a flip side to it also, and this is what is affecting my day to day work life.

I have had a post in the back of my mind for a number of months, one which constantly sits there and sometimes raises its head asking to take up its place in the archives of this blog.

It was going to question whether EMS 2.0 is a purely American thing. Does the UK need EMS 2.0 or are we already there?

I mean look at what I can do? I can tell people that they don’t need to go to hospital, I can organise for alternative care providers to come and see the patient at home instead of transporting them to the hospital. I can make autonomous decisions about what is best for my patients and have them agree with that treatment plan. Surely that is already EMS 2.0, right?

Well yes, I would say that that part of my role is definitely part and parcel of what Justin, Chris Kaiser and I hope to see develop from the Chronicles of EMS and EMS 2.0. However, what I am learning and what I am finding more and more difficult to accept is the fact that in other ways, the UK ambulance services are far behind our brothers and sisters in EMS across the great pond.

Before all of this crazy show started, I lived and practiced in my own little bubble. I used to naively think that we were the best at what we can do. If a patient needed emergency care, then they would get the best the world has to offer. In some cases I still believe that, but not in all.

Now, I can say this because I am not criticising my service here, I am looking at the NHS ambulance service as a whole and recognising that what has happened for years and years still happens now and will continue to happen. That is that we follow US developments in the field of medicine, usually anywhere from 2-5 years after the new development has been tried and tested in the USA.

That’s never been a problems for me before because I have never had the awareness that I have now from spending so much time in the US and talking so much to operational staff, managers, Chiefs and industry professionals.

Now, it is becoming a huge frustration for me because I can see what I should be doing and I can see what will be coming, but until that happens I feel angry that we are lagging behind.

Let’s take one example.

Out of hospital cardiac arrest.

I used to think that we were as good as this as anyone else. But now I know that there is so much more that could be done, like:

More hands on scene – that has always been a role I would like to see our colleagues in the UK fire service take on. If not, then even getting more ambulance responses on scene would be a benefit. One crew, 2 members of staff, no matter how well trained cannot perform continuous compression CPR on a patient from arrival on scene until handover at hospital, it is impossibility. As much as I can see flaws in a Fire Based EMS model at times, the one thing I saw which has obvious benefits is the amount of hands on a patient when necessary. There is no point in me looking for someone to swap in for some compressions when I am in the back of an ambulance alone, and if we can’t have extra hands then why not look at equipment that can help us.

Compression assist devices such as the Zoll Autopulse and the Physio-Control Lucas device could take the place of the extra pair of hands needed for a UK paramedic crew on scene. This will come, without doubt, but it will be a couple of years down the line.

What about the apparent holy Grail of prehospital induced therapeutic hypothermia? How long before that hits the UK shore.

Please don’t get me wrong, I’m not saying that all of these things will bring real benefit to patient care (well, actually I guess I am), but why does it take so long for them to make their way over here?

Why should I have to go to some of my patients knowing that there may be better ways of caring for them, which I may well not have access to for a number of years?

Uk pre-hospital care isn’t the yard stick for all other EMS systems to be judged against, far from it, but maybe this just goes to show the value that The Chronicles of EMS and the EMS 2.0 movement can have…..bringing new thoughts and ideas to services which feel that they may be doing things the best way they can already.

I have had my eyes opened and I can see the future of prehospital care, and it includes every bit of knowledge and experience that I can gather, and more importantly share, with services throughout the world.

Until that day comes though, I will remain hopeful and proud to work in my system, but also frustrated waiting for best practices to make their way over here as well as some of ours making their way over the the States.

To finish off, just read this article from the Richmond Ambulance Service in Virginia. This is what I want to be doing for my patients!

Richmond Ambulance Authority nearly doubled prehospital ROSC rate because of the ARCTIC program

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Responses

  1. I can see the points you're making, especially with regards to the theraputic hypothermia (not just in the case of SCA), but also the number of people on scene. However, I must bring up one key point in your argument that is just plain wrong – you're basing a lot of these arguments, in this post, on transporting a dead person.”There is no point in me looking for someone to swap in for some compressions when I am in the back of an ambulance alone” – why are we performing compressions in the back of the ambulance? Chances are, they'll be just as dead at the hopsital as they were on scene. The hospital are unlikely to actualy do anything beyong EMS ALS. I don't believe there is any evidence from the UK, but in the US Rogue Medic has written at length on the subject. By transporting dead bodies, we're putting ourselves at risk (especially as we can't really be strapped in), other road users at risk, and the public at risk by making ourselves and the team at hospital unavailable for alive people.That aside, I would love to see more people on scene at a resus. It's very hard to do with two – two crews would be perfect, or a crew and a RV. But, what's the benefit: risk for sending a fire truck to cardiac arrests? Do we dispatch when AMPDS codes the patient as SCA (in which case, we risk sending giant trucks hurtling through the streets of cities for in what all likelyhood is a drunk) or when the crew confirms it (in which case, are they going to get there in time to do anything about it)I think the crew + RV model is the safest version of EMS we can get to – sure, it may not be *perfect* for a cardiac arrest, but it's good for just about anything that EMS may attend (and we need to remember that cardiac arrests are such a tiny percentage of our workload, and not the one where we can make the most difference).The theraputic hypothermia? Amazing idea. But wait until it's rolled out in A&Es too!

  2. HI Nick, thanks as always for the comment.You have a point on the whole transporting deceased patient argument, I will concur with that, but when you look at the whole picture then thats when it starts to work at my conscience. I agree that we may well be moving towards stopping on scene irrelevant of the patients cardiac rhythm if after 20 minutes of good ALS, there is no ROSC. I can definately see the argument for that. The question to ask though, is does the UK Ambulance services have everything in place to ensure that those 20 minutes of ALS care are actually the best that they can be? If you change the point I make from being in the back of the ambulance to instead being on scene with the patient, then it is still the very same thing. Not enough hands on the patient and not enough available devices to assist me.I hope that it all changes soon. I hope that the UK ambulance services, JRCALC and the European Resuscitation Council look at Cardio-cerebral resuscitation and see what improved results that is bringing, along with other developments in the out of hospital cardiac arrest scenario around the world.I dont want us to be left behind, thats all. I want my patients to be cared by a service that is up along with the best in the world.

  3. In terms of manpower, it comes down to the question of how to get resources there – when do we send backup? Do we send a second crew/the plod/Trumpton at the time the call originates (in which case they'll likely be there in vain watching the crew wake up a drunk on a bus), or when the call is confirmed as a cardiac arrest (in which case it's too late)? In terms of optimal patient outcomes, the former would be the only choice – however, the resources don't exist to send multiple resources to every job (which is the only logical conclusion given the inability of call makers to distinguish SCA), and the safety of the public is compromised significantly in several ways, leading to what I imagine would be a much greater risk to benefit ratio.Equipment is another matter entirely. If/when we start to take CCR sensibly, then compression devices is a clever way direction to take this discussion in. I think the issues that arose from the original compression devices made a lot of MOs wary, but the new machines are almost idiot proof and so would definitely make life easier. At the moment, a two crew resus is almost perfect in terms of rotation of chest compressions while managing airway/drugs, but with a machine doing the manual labour a single crew should easily be able to manage an out-of-hospital arrest (negating all the worries of sending extra resources above).However, I think your mistrust of the way UK EMS handles out of hospital arrests is misplaced. The ALS performed on scene is almost always better than in hospital – a resus bay isn't that good at handling a “simple” resuscitation coming in from the community as a well trained two man crew, nor are they going to do much (if any) more. And even if we run to get the patient there, in the time it takes to get the patient there, without ROSC yet more irreparable damage will have been done to the brain/heart, even if we continue perfect compressions (+/- ventilation).I think an important part of “EMS 2.0″ is that we need to stop seeing the hospital as the magical house of gods, and come to the realisation (doctors and EMS staff alike) that a paramedic is the expert when it comes to (at least the “simple”) out of hospital arrests.

  4. Thought you may be interested in this article (not that it says much) – http://news.bbc.co.uk/2/hi/uk_news/scotland/nor

  5. 'ello. First, just to clarify, your fire department does not come on scene for cardiac arrest as first responders?Second, what I find interesting is that in the research world (where I live when no on an ambulance) and at least in the pediatric oncology world, many new clinical trials and treatments are first performed in Europe, not the US (now I cannot 100% say this includes the UK, but I have a strong feeling it does). It is then very curious to me that you are willing to change the outcomes for pediatric patients, the ones that are the hardest to get clinical trials for in the US, but not for EMS. Is it because it is in the hospital setting instead of in the field? Because it is doctor lead instead of provider lead? I would love to know why.Either way, I know the comment is a little random, but I find the difference interesting.

  6. “I dont want us to be left behind, thats all. I want my patients to be cared by a service that is up along with the best in the world.”The very best large urban/suburban system for bystander witnessed VF (cardiac etiology) survival (49% 2008), Seattle/King County EMS, in my opinion has that survival rate because of a 58% overall bystander CPR rate and a call to scene arrival average of 4:40 (excluding Seattle). Although it does use hypothermia half the time (randomized trial) back in 2006 when only Seattle was doing the trial the survival rate was 41%. Other communities with a high survival rate such as Rochester, Minnesota, United States (46%, 1985 – 2008) like King County have a high bystander CPR rate and fast response time. “The question to ask though, is does the UK Ambulance services have everything in place to ensure that those 20 minutes of ALS care are actually the best that they can be?”ACLS has never been demonstrated in a randomized trial to improve survival, so why are you focusing on ACLS?

  7. Hi There EMT GFP.Correct, our fire service does not respond to medical calls at all. We can request assistance for the likes of difficult extrications due to obesity, or to assist in gaining access to patients but they do not attend any calls to give medical aid.I know that a vast majority of research comes from the European countries, but it seems like UK pre hospital care research is lagging behind some other countries at the moment. This is changing and there is some research now being done, but we have a fair bit of catching up to do.

  8. Thanks Tim,It regularly comes up but is just as quickly beaten down by both unions.

  9. Timothy,”ACLS has never been demonstrated in a randomized trial to improve survival, so why are you focusing on ACLS?”I would argue that what I am writing about here isnt ACLS care at all. It is about the need for good consistent continuous compressions, which I would say is BLS, not ALS. As for therapeutic hypothermia, to be precise, that falls under the remit of post cardiac arrest care.I would also like to know if the survival rates that you quote are actually survival to discharge from hospital or ROSC at hospital? There is a whole load of difference between the two.Lets not get hung up on the usual ALS/BLS argument here. The example of out of hospital cardiac arrest care that I discussed is just one part of the experience I am having with CoEMS

  10. I'm referring to survival to hospital discharge, see http://emscompare.org/compare.php for more survival rates including London's.”I would argue that what I am writing about here isnt ACLS care at all. It is about the need for good consistent continuous compressions, which I would say is BLS, not ALS.” I'm sorry I got confused by “ensure that those 20 minutes of ALS care”

  11. We have the same problem here though, look at some of the stuff Dr. Yamada is doing in north Texas with his Paramedics. It is awesome ground breaking stuff that won't reach the rest of the states for years if ever. From my place in Utah I constantly feel like we are years behind the curve(because we are). Here it really isn't that we have more advanced things overall, its that some select places medical control has caught the vision of what EMS could and should be and are working to change it in their part of the country.

  12. [...] Could reality show Chronicles of EMS be a bad thing? (Medic 999) [...]

  13. When I read the RAA article, I couldn't help but think that High Dose Epi double ROSC, Amiodarone increased ROSC, the Auto Pulse increased ROSC, the Impedence Threshold Device increased ROSC. Unfortunately none of them increased survival to discharge. Therapeutic Hypothermia AFTER ROSC seems to increase survival to discharge, but that's different than using it to increase ROSC. Not everything that increases ROSC increases survival to discharge. The two are different, which fact should be kept in mind when evaluating new therapies. One increases survival, the other increases costs.

  14. we can all benefit from evidence-based “best practices.” perhaps that is what ems 2.0 is ultimately about.

  15. This has been a great read, from the post itself to the following responses. The area I am in has talked of adding hypothermia to the CPR protocols but has not as of yet. Right now we basically work the patient for a few rounds and if nothing has changed we do not transport so I understand where Nickopotamus is coming from. I stole this link from an old post of ems12lead blog. It's food for thought. And I understand it was a witnessed arrest and it could not have happened in a better place at a better time, still, check it out.http://wcbstv.com/seenat11/joe.tiralosi.back.2….

  16. Agree with all points madeIn london Ambulance Service, it is standard response to send 2 ambulances and a car, or at least 3-4 pairs of hands to any cardiac arrest, Therapeutic hypothermia on ROSC and pre-hospital pacing is also being trialled in London. The HEMS team have one of those chest compression machine thingy's

  17. Also i forgot to add, LAS have now trained paramedic crews who go to VF arrests to stay on scene for 18 shocks, for three reasons: according to research the most effective CPR is generally on scene, its better than moving someone to the vehicle (sometimes this can be numerous flights of stairs, during which compressions are ineffective) and then compressions on the back of a moving ambulance, which again are less effective and unsafe. The emphesis is on the compressionsthe second reason is that moving someone in VF, or post arrest can send them back into arrest/asystole. The third reason is for a sudden cardiac arrest in VF, the hospital dont do anything more than the ACLS the ambulance service do, so research and experience has shown these guys arent gonna survive, so after staying on scene for 18 shocks, the decision to terminate resus is madeExceptions to the rule are obviously traumatic/reversible causes, asystole – 20 mins of ALS the ROLE, and paediatrics.

  18. I read the studies you are referring to. And you are talking about witnessed Vfib arrests, mostly high amplitude Vfib in the King County studies, correct? I actually read the study on the King County website. The study that Medic999 is referring too shows that with their techniques they have a 72% hospital discharge rate on Vfib arrests, using the ARCTIC program. Here's the link. Please correct me if I'm wrong.http://www.news.vcu.edu/news/Resuscitation_and_…Where I work we do not have good hospital discharge rates mostly from long response times. It can take me an hour to get on scene at the far reaches we respond to. Most common rhythm I see in cardiac arrest in asystole. And we almost always have good manpower from volunteer departments. I've only actually done CPR in the rig by myself a handful of times in 7 years. It seems the ARCTIC program is talking about patients that have ROSC that get the hypothermia algorithm. So I believe that would have limited efficacy in my area do to the above mentioned response times. There are a few that come to mind though over the years that I got to the hospital with pulses only to find the patient had no brain activity after four days. The ARCTIC program may have changed that.

  19. [...] heard me, Justin “the Happy Medic” Schorr, Mark “Medic999” Glencorse, and many, many others talking about EMS 2.0 over the last year. Well, this is part of [...]

  20. I can definitely see this as being the norm across the Country within a short time. Maybe once the next edition of the JRCALC comes out?But there does need to be the extra hands on scene to ensure that great effective CPR is being done. I would love to have 2 ambulances and a car on scene!

  21. Medic,It is most certainly a huge part of it!

  22. I completely agree TOTWTYTR, When ever anyone quotes ROSC rates to me, I immediately want to know how they came to that figure. In my career I have only had 8 successful resuscitations from cardiac arrest. I have had many many more ROSCs, but that is not a success to me if they only are pronounced dead in the A&E or the next day on the ITU.

  23. Interesting, what is the reasoning behind not training fire fighters as at least first responders?I'll refrain from the tangent on the lack of research that hit the US. Simply put, why people do not see research as valuable is mind boggling to me.

  24. I think that totwtytr hit the nail on the head. In my system we are currently doing everything that the EMS system in Richmond is doing. While we have seen an increase in ROSC we haven't seem a corresponding increase in patient's walking out of the hospital. I have heard rumblings and rumors that some of the drugs we use to work full arrests may be yanked in the near future. There just isn't enough scientific data proving that any of it improves the long term outcome of the patient. So far it looks like AHA is on the right track with virtually non stop compressions and early defibrillation.

  25. Great article Glen. Next time spit it out soon after it crosses your mind! My philosophy with training and improvement is analogous to flossing. The first time we dig into those rarely disturbed areas of the comfortable shade it may be hurt. We can either retreat and enjoy the temporary status quo or we can dive in and start annoying teeth. At times I can not help but feel as if we are playing in someone else's sandbox, having our treatment protocols researched and created by others. Consider such influential organizations as ILCOR, composed almost entirely of physicians. I have also been frustrated, feeling as if a patient could be receiving a potentially more beneficial treatment were it not for some regulatory issue. Some issue between a doctor and a signature on our paycheque, neither of whom have an influence on this person, here, at three in the morning.That being said, to play devil's advocate, I humbly put forth two questions for everyone:In the current EMS environment, are we too heterogenous to regulate ourselves? There are substantial differences of practice between not only countries but between provinces/states and even municipalities/cities. This extends beyond treatment issues. For example in Canada we can not agree even on the alphabet soup with which we describe ourselves. Alberta has EMRs, EMTs and EMT-Ps. Most other provinces have EMRs, PCPs, ACPs and CCPs. Ontario does not have EMRs. Can you imagine, as a policy maker, listening to such an esoteric argument? Although doctors do have inter-provincial regulatory bodies, such as the Ontario College of Physicians, an MD is an MD. As a profession are we currently offering regulatory bodies, composed “of our own”, at par with a Physician's college? With this heterogeneity in mind, is this even possible in the immediate future?And second, many of us involved in the EMS 2.0 movement spend hours every week, some of us even every day, reading and learning. I know I personally, coming from an academic background in Psychology, average a good dozen or so studies a week. Beyond this we have also spent the time to learn the language of the cardiologists, nephrologists, internists and all the other -ists's who write these articles. A considerable endeavour in and of itself. I have not heard of, and I would not expect anyone to, reject the importance of evidence based medicine (EBM) for our patients. But what of the immense amount of, as Rob Theriault terms it “cerebral overload” involved in this? What proportion of the prehospital care community do we “keeners” represent? Perhaps we do not desire the scale of academic licence granted to physicians on issues such as the use of off-label drugs, but when we include all of the EMS community (and I mean all of us) do we feel a representative sample of prehospital care providers are willing to put this amount of time into evaluating our own protocols?

  26. TOTWTYTR makes some great points. We keep trying to come up with magic ALS treatments. We keep failing.We need to improve the rate of bystander CPR. Dr. Eisenberg has shown us that this can be done. We find excuses to not work on bystander CPR, but spend a lot of time on tubes and drugs.We need to improve the way we do chest compressions. We find excuses to not work on the chest compressions, but spend a lot of time on tubes and drugs.We need to avoid interrupting chest compressions.We find excuses to not work on the chest compressions, but spend a lot of time on tubes and drugs.We do not appear to need to worry about airway or oxygenation, at least nothing more than blow-by oxygen for the first ten or more minutes.We find excuses to worry about the airway and oxygen and spend a lot of time on tubes and drugs.Maybe the ALS treatment we need is some Ativan for the medics, so they can stop worrying about all of the things that don't matter and can start improving resuscitation rates.

  27. TOTWTYTR makes some great points. We keep trying to come up with magic ALS treatments. We keep failing.We need to improve the rate of bystander CPR. Dr. Eisenberg has shown us that this can be done. We find excuses to not work on bystander CPR, but spend a lot of time on tubes and drugs.We need to improve the way we do chest compressions. We find excuses to not work on the chest compressions, but spend a lot of time on tubes and drugs.We need to avoid interrupting chest compressions.We find excuses to not work on the chest compressions, but spend a lot of time on tubes and drugs.We do not appear to need to worry about airway or oxygenation, at least nothing more than blow-by oxygen for the first ten or more minutes.We find excuses to worry about the airway and oxygen and spend a lot of time on tubes and drugs.Maybe the ALS treatment we need is some Ativan for the medics, so they can stop worrying about all of the things that don't matter and can start improving resuscitation rates.


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