(Almost) Everything You Know About EMS Is Wrong Amy Gutman MD EMS Medical Director / email@example.com
Overview • From the very new to the very experienced, all providers, administrators & medical directors must continually ask, “Does this practice, procedure, or drug improve outcomes?” • Then ask… “Really?” • When you get the answer… ask again! It is better to not understand something true, than to understand something false. Neils Bohr
“All of these are things in which some people desperately wish to believe, despite the utter lack of credible evidence of their existence” Greaves I. Fluid resuscitation in prehospital trauma: J.R.Coll.Surg.Edinb. 2002.
Myth: Prehospital Diuresis Fixes CHF • Historical prehospital CHF treatment: O2, MSO4, diuretic • Many SOPs include furosemide for respiratory distress despite few studies on effectiveness • Rationale: utilize rapidly acting medication to decrease work of breathing
Reality: No Data Prehospital Diuresis Effective or Safe • Evaluation of prehospital use of furosemide in patients with respiratory distress. PEC 2006. • 144 pts receiving prehospital furosemide • 59% CHF; furosemide “appropriate” • 42% no respiratory dx; “inappropriate” • 17% sepsis, dehydration, pneumonia; “harmful” • Conclusion: Prehospital furosemide frequently inappropriately administered & harmful • MSO4+ furosemide resulted in increased ETI, ICU admissions, longer hospitalizations, higher mortality • Many CHF pts taking furosemide; boluses have little acute effect Morphine and outcomes in ADHF: an ADHERE analysis. EMJ.2011 Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary edema. Lancet. 1998 Comparison of NTG, MSO4 & furosemide in treatment of presumed prehospital pulmonary edema. Chest. 1987
Reality: Other Modalities Have Greater Immediate Benefit With Less Risk • Hubble. Effectiveness of prehospital CPAP in the management of acute pulmonary edema. PEC 2006 • All pts presenting to ED via EMS in 1 year with impression of “pulmonary edema” • Control: O2, nitrates, furosemide, MSO4, +/- ETI • Intervention: CPAP +/- standard therapy • Results: • Pts on standard Rx 4 times more likely to be intubated/die than those receiving standard therapy w/CPAP • Intubation: 9% CPAP, 25.3% control • Mortality: 5% CPAP, 23.2% control
Myth: Tasers Kill Patients • Electrical current disrupting voluntary muscle function causing “neuromuscular incapacitation” via involuntary muscle contractions • High-voltage, short-pulse • 3 microsec pulse followed by 100 microsec pulses • Low-impedance current pathway across propelled barbs • Multiple animal studies demonstrated safety, with “clinically irrelevant” arrhythmia, QT prolongation, acidosis • Tasers attracted media attention for “contributing” to deaths of violent individuals by police
Reality: Tasers “Less Lethal”, Not “Non-Lethal” • Increased VF / VT vulnerability: • Cardiac disease, long QT, pre-excitation • Increased adrenergic tone • Electrolyte abnormalities • Acidosis • Post-Taser • Metabolic acidosis • QT prolongation • VT/VF secondary to “r on T” • Additive risk of death from excited delirium
Taser-related death series 37 males, 18-50 yrs 54% cardiac disease 84% illicit drugs 76% deaths from “excited delirium” 27% TASER “contributory” COD Vilke: No “clinically relevant ECG changes” in 32 healthy males post 5 sec taser shock QT shortened / widened “insignificantly” in 50% Low pH immediately post shock Levine: QT short / wide, tachycardia in 105 healthy police volunteers after 5 sec taser shock Reality: Conflicting Human Studies Strote. PEC. 2006 Vilke. AJEM. 2008 Levine. JEM. 2007
Reality: Tasers Less Lethal Than Gunfire • 218 individuals subdued by police with firearms vs Tasers • 1.4% mortality (TASER group) • 50% mortality (firearm group) Ordog GJ. AEM 1987; 16:73-78.
Myth: EMT-Initiated Refusals Are Safe • Public Utility Models of EMS care offer transport to everyone who calls delivering “care best for the patient, not necessarily the system” • Risk of error when dispatchers / EMTs attempt to determine who safely can be denied transport • Medico-legal conclusion: eliminate risk by providing every patient requested care
Reality: EMT-Initiated Refusals Often Unsafe • Evaluation of protocols allowing EMTs to determine need for transport PEC. 2000 • 1,300 pts • 79% required transport • 15% told to go to ED via alternative means • 6% no transport • Outcomes: • 30/277 (11%) untransported had critical event • 7 (3%) required resuscitation prior to EMS recall • Medic determinations of medical necessity. PEC. 2009 • 85 pts medics felt transport unnecessary • 15 (18%) admitted • 5 (6%) admitted ICU • Cone “ALS call-offs: • 87% if BLS crew cancelled ALS, pt needed ALS interventions in ED Data overwhelmingly does not support EMS determining if patients require ambulance transport…except…
Reality: EMS Cannot Transport Everyone • “Prospective Evaluation of an EMS-Administered Alternative Transport Protocol” PEC 2009 • Can experienced medics (10 yrs+) using guidelines identify pts who can be safely alternatively transported • 93 pts given taxi voucher • Average time from taxi dispatch to ED 43 mins • 10% transported by taxi admitted to hospital • No emergent procedures or adverse events • Conclusion: Experiences providers using SOPs may be able to triage patients to alternative transport
Myth: ALS Saves Lives in OOHCA • Ontario Prehospital Advanced Life Support Study • 5,638 pts over 7 years • Results: • ALS more expensive with no better outcomes than BLS + AED • OOHCA ~1% EMS run volumes • US & Canadian survival ~5% • Of cities with higher survival, almost all improvement attributed to BLS
Myth: Two Medics Better Than One in OOHCA • Cities with more paramedics have worse pt outcomes • Boston 10:100,000; 40% survival to admission • Omaha 44:100,000; 3% survival to discharge • Paramedics with OOHCA 4.68 cases / yr = 27% discharge • Paramedics with OOHCA 1.63 cases / yr = 4% discharge • 2 cities wth identical demographics, response times & run volumes ~ only difference ALS vs BLS 1st response • 38% ROSC BLS 1st response • 13% ROSC ALS 1st response Sayre. AEM 2006 Dunn. EMS Today 2007
Reality: ALS Does Improve Some Outcomes • ALS clinically & statistically better outcomes for respiratory distress, CP & hypoglycemia vs BLS ONLY if the intervention is ability to initiate IV therapy • Multiple studies show if patient does not require IV meds or BLS initiates CPAP, dextrose & naloxone, BLS patients have better outcomes
Reality: Most Paramedics Are “Inexperienced” Rather than ”Bad” at ETI • Minimum required training ETIs: • Anesthesiologist: 400 • CRNA: 200 • Emergency Medicine: 100-200 • Paramedic USDOT: 5 • Research shows medic students require at least 15-20 intubations to attain basic proficiency Bledsoe B. “The Future of Intubation” 2011. Wang H. Defining the learning curve for paramedic student ETI. PEC 2005
Reality: Some Paramedics Are Good at ETI (Bledsoe 2010) Jenkins WA. The syringe aspiration technique to verify endotracheal tube position. AJEM. 1994 Bozeman WP. EDD versus detection of ETCO2 level in emergency intubation. AEM. 1996 Stewart RD. Field ETI by paramedical personnel. Chest. 1984 Sayre MR. Field trial of ETI by basic EMTs. AEM. 1998 Pointer JE. Clinical characteristics of paramedics’ performance of ETI. JEM. 1988
Reality: More Attempt Leads to Improved Success, But At What Cost? • Prehospital ETI often requires multiple attempts • 1,941 cases of prehospital ETI: • >30% required >1 attempt • Cumulative success (arrest) • 69.9%, 84.9%, 89.9% • Cumulative success (non-arrest) • 57.6%, 69.2%, 72.7% Wang HE. How many attempts required to accomplish out-of-hospital ETI. AEM. 2006
Reality: Paramedic Are Even Worse at Pediatric ETI • 1989 study of pediatric cardiac arrests: • ETI success rate: 64% • 63 pediatric patients in Milwaukee WI: • ETI success rate: 78% Aijian P. ETI of pediatric patients by paramedics. AEM. 1989 Losek JD. Prehospital pediatric ETI performance review. PEC. 1989.
Reality: The More You Do, The Better You Do • Rural Maine ETI success: • 74% in medics with <5 annual ETI • 86% in medics with >5 annual ETI • Rural Pennsylvania 1 yr study of 11,484 ETIs by 5,245 medics: • 67% performed <2 ETIs • 39% had no ETIs Burton JH. ETI in a rural state: procedure utilization and impact of skills maintenance guidelines. PEC. 2003 Wang HE. Procedural experience with out-of-hospital ETI. CCM 2005.
Reality: Some Paramedics Are Really Good at ETI • San Diego: • 1 UEI/264 PEDIATRIC intubations (99%) • Seattle/King County: • 98.4% success • Bellingham, WA: • 20-year review • 95.5% ETI success • 0.3% UEI Vilke GM. Out-of-hospital pediatric ETI by paramedics: San Diego experience. JEM. 2002 Bulger EM. Analysis of advanced prehospital airway management. JEM. 2002 Wayne MA. Prehospital use of succinylcholine: a 20-year review. PEC. 1999
Myth Corollary: ETI Saves Lives in OOHCA, Therefore We Must Make the Attempt • 2000 LA study demonstrated outcomes for intubated pediatric cardiac arrest patients were no better or often worse than those managed with BVM • 2010 ACLS guidelines: “If advanced airway placement will interrupt chest compressions, providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts, or demonstrates ROSC” • 2010 NEMSIS data showed worse outcomes for ETI OOHCA pts • MI: VF/VT survival to discharge decreased with field ETI • CA: survival to discharge 4 X greater if BVM vs ETI • NC: 5 x greater ROSC in non-ETI
Reality: Alternative Airways Will Replace ETI Within 10 Years (But ETI Will Never Go Away) • Large body of research demonstrates improved safety profile, advanced airway management success & better patient outcomes using alternative airways management (i.e. VGI) • www.theairwaysite.com is an outstanding resource
Q: Is Spinal Immobilization Beneficial & Necessary For Trauma Patients?
Myth: “Spinal Motion Restriction” Beneficial & Necessary • Primary injury: time of trauma; Keeping pt still does not reverse damage • Secondary injury: post-injury cord inflammation, injury from bony fragments, worsening primary lesion. Restricting movement limits potential for more damage • Zero evidence restricting movement if neurologically intact spinal fractures does any good (vast majority are stable fxs)
Myth: Spinal Immobilization Beneficial & Necessary • Gutman. Neck and Back Pain. EMS: Clinical Practices & Systems Oversight. 2009. • No randomized prospective studies demonstrate ANY aspects of immobilization prevent or lessen morbidity of spinal injuries • Baez asked 1,500 EMTs the following “beliefs” about immobilization followed by a Cochrane Review (2006): • Spinal immobilization prevents cord injury • Manual neck stabilization required until C collar applied • C collars inadequate to prevent cervical movement • KEDs reduce paraplegia • Cloth tape acceptable to secure pt • Prehospital skin breakdown does not occur
Malayan C-Spine Study 5 yr retrospective chart review 454 pts with SCI 0/120 Malayan pts immobilized 334/334 New Mexico pts immobilized Neuro disability less for Malayan pts (11% vs 21%) Conclusion: immobilization has no significant effect on neurologic outcome 2002 Maine EMS spinal clearance protocol 16,019 trauma transports 7,014 immobilized 86 (0.01%) spinal fxs 12/86 not immobilized 11 stable fxs, 1 unstable T-spine fx Unstable fx pt w/o neurological deficits Conclusion: immobilization has no significant effect on neurologic outcome Reality: Spinal ImmobilizationHurts Patients
NEXUS (National Emergency X-Radiography Study) criteria minimizes unnecessary x-rays 34,069 pts 818 cervical fxs, all but 8 identified with clinical criteria NEXUS Exam Criteria: No midline c-spine tenderness No intoxication Normal alertness No focal neurological deficit No distracting injuries Canadian C-Spine Study 8,924 pts w/same NEXUS results except: >65 yo greater risk Clearer MOI Injury above clavicles greatest determining factor for neck injury Reality: Providers Can Safely Clear C-Spines
Reality: Spinal Immobilization Has Serious Consequences • Pain / Anxiety • Increased ICP & IOP • Vomiting / aspiration • Respiratory decompensation • Decubitus ulcers can begin within 20 mins • 15% reduction respiratory capacity
Myth: The “Golden Hour” is a Standard of Care • R. Adams Cowley father of trauma care & developer of Golden Hour • PR tool promoting importance of rapid surgical intervention in trauma pts at newly opened U Maryland “Shock Trauma” • “Pts must arrive at a trauma center within 1 hour of their injury in order to have their best chance of survival.” • This “Golden Hour” concept repeated so often that it has been “willed” into truth
Reality: No Data Behind the Golden Hour • 2001 AAEM found no data supporting ‘Golden Hour’ • “Nobody wants to talk about this false notion…because it shakes the roots of EMS & trauma care.”B Bledsoe MD • Little evidence in “Platinum 10 Minutes” • Applies only in setting of hemodynamically unstable trauma pts in which EMS should “be on scene <10 mins” before transporting patient to ED for surgical intervention • Often results in shoddy assessment, care & packaging • Benefit of rapid surgical intervention for trauma pts “obvious”, but no data identifies optimum time frame
Myth Corollary: Lights & Sirens Save Lives • North Carolina • 43.5 sec savings with lights & siren vs without • Syracuse • “L&S reduce response by average of 106 secs” • Unlikely clinically relevant • Philadelphia • Pt outcomes when EMS strictly limited use of lights & sirens • “No adverse outcomes identified related to non-lights & siren transport” Is ambulance transport time with lights and siren faster than that without? 1995 Do warning lights and sirens reduce ambulance response times? PEC 2000 Patient outcome using medical protocol to limit “lights and siren transport. PDM 1994
4 min response associated with increased survival in OOHCA If: Unwitnessed arrest No bystander CPR No AED However, rapid response less important than appropriate scene care & destination facility 9,273 OOHCA pts (OPALS) 4% survival if <6 min to defibrillation “Steep decrease in 1st 5 mins of survival curve, beyond which levels off” ALS 8 min response not assoc w/ improved survival 4 mins response improves survival in pts with high mortality risk Reality: Faster is Better For Some Medical Emergencies
Reality: Response Recommendations Based on Conjecture not Science • 8 mins goal for 90% responses to “save most persons in need” • Time to travel between 2 points determined by speed. Speed affected by traffic, road / vehicle conditions, operator experience • Shorter response intervals not without safety & monetary costs Blackwell. Lack of association between prehospital response times and patient outcomes. PEC 2007 Bailey. Considerations in establishing EMS response time goals. PEC 2003
Q: People Survive Cardiac Arrest on TV All The Time Just Like Real Life…Right?
Myth: The Dead Will Rise • Researchers watched 2 yrs of ER, Chicago Hope & Rescue 911 • 65% OOHCA in children or teens • 75% survived arrest • 67% survived to discharge • Los Angeles: • 2,021 consecutive OOHCA pts • 1.4% survived neuro intact • 6.1% survival bystander-witnessed VF • 2.1% survival bystander CPR • 3.2% survival witnessed arrest & bystander CPR • 1% survival w/o bystander CPR CPR on television. Miracles and misinformation. 1996 Cardiac Arrest Resuscitation in Los Angeles: CARE- LA. 2005
Reality: Despite 30+ Years & Expenditure of Billions of Dollars, Majority of Dead Remain Dead • No change in traumatic arrest survival since Crimean war • Some improvements in medical OOHCA • Bystander CPR / Early AED • Effective compressions • Is there a benefit in saving the very very few vs the safety risk to EMS, public & financial expenditure?
Myth: Aggressive Fluid Resuscitation Saves Trauma Patients • Known for decades, but recent military studies changed trauma resuscitation • Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality, J Trauma 2002. • Hypotensive resuscitation strategy reduces transfusion requirements & severe postoperative coagulopathy in trauma pts with hemorrhagic shock. J Trauma 2011. • Effect of plasma & RBC transfusions on survival in pts with combat related traumatic injuries, J Trauma 2008. • Early aggressive use of FFP does not improve outcome in critically injured trauma patients, Ann Surg 2008.
Reality: Consensus Statement from the European & American Trauma Surgeons • IV en route unless entrapped or delay in transport • Only 2 IV attempts or 1st attempt IO • Transfer should not be delayed to obtain IV access • Saline or blood products as 1st line fluids • 250cc NS boluses titrated against presence or absence of radial pulse (caveats: penetrating torso injury, head injury, infants) Greaves I. Fluid resuscitation in prehospital trauma care: A consensus view. Coll.Surg.Edinb. 2002.
Myths: Prehospital EKG • If you're close to the ED, a 12-lead is a waste of time • Closest hospital not necessarily most appropriate! • ED must repeat ECG to confirm STEMI • Nothing magic about the ED's EKG • Serial ECGs extremely important • If ST elevation resolves by ED arrival, it's not a STEMI • If elevation resolves, pt still has an occlusion. Why else would the segment elevate in the 1st place?