EMS 2.0: An Inconvenient EMS Truth

This talk of rebooting EMS has spurred a few additional thoughts on the subject.

I’ve said before that I believe EMS 2.0 should mean a leaner, more efficient version of prehospital care than what we have now, with the future equivalent of an EMT-Basic as the default EMS provider for most communities. Paramedics will be a relatively few, exquisitely trained providers capable of providing what we have always professed EMS to be, but so rarely is: an extension of the Emergency Department into the field.

To do that, we’re going to have to re-educate the general public and public officials about the capabilities and limitations of EMS, and probably the Emergency Department as well.

We’ve done a pretty fair job of educating the public about the capabilities of EMS, despite the fact that quite a few of my patients seem to think I drive a smaller version of a mass transit bus, only with Bandaids and free morphine. Where we have monumentally failed is in educating the public about what EMS cannot do.

That isn’t a failing unique to EMS. The public has totally unrealistic expectations of the capabilities of medical care in general.

Despite what you see on House, the best doctors are not unredeemable Vicodin-addicted assholes, nor are they geniuses with encyclopedic knowledge of every disease pathophysiology ever identified. I’ve never seen an episode of ER that showed the legions of people in the waiting room with toothaches, or demanding work excuses or inappropriate antibiotics for their viral syndromes. Despite what we saw on Emergency, 95% of our cardiac arrest patients stay that way despite our best efforts, and the camera never showed Johnny Gage showing up on a call at oh-dawn-thirty with dragon breath and his uniform shirt tucked into his underwear.

And before you comment on his bed head, everyone’s hair looked like that in the 70’s.

I watched Rescue 911 for years, and yet to this day, I’ve never been invited to a patient’s “new” birthday party. On the other hand, I have been subpoenaed invited to attend the lawsuit one filed against me to commemorate the day I saved his life.

In fact, if you want to see the most realistic medical show on television, just watch Scrubs. The medicine is generally correct if not terribly exciting, but the interpersonal relationships are spot-on.

#1 Dinosaur’s First Law states “The art of medicine consists in amusing the patient while nature cures the disease.” She may have cribbed the quote from Voltaire, but the reason she considers it her First Law of the Dinosaur is that nothing has come along in the 200+ years since Voltaire’s death to prove it demonstrably untrue.

So, if we’re going to re-invent EMS, we must first start with dispelling some of the dogma in EMS – not just in the care we provide, but in system design as well. So now I’ll channel my inner Al Gore (although, hopefully, without the blandness), and speak some Inconvenient EMS Truths. Actually, there are a number of Inconvenient EMS Truths, but I’ll confine this post to the biggie, the one that affects everything from EMS system design, to trauma triage guidelines, to the justification of EMS helicopter transport:

Inconvenient Truth #1: Very few of our calls are actually all that time-sensitive.

That admission alone can utterly transform EMS, folks.

With the exception of stroke, evolving MI, hypoglycemia and severe respiratory distress, very few of our calls require a rapid EMS response, and for most of those categories, prompt response usually only has the potential to effect morbidity, not mortality. I’ll even include multi-systems trauma in the category of calls that are not all that time-sensitive.

Most current research on trauma deaths indicates a trimodal distribution of trauma mortality: death within minutes due to neurological or vascular causes; death within hours due to hypoxia or hypovolemia; and death within days or weeks due to sepsis, Multiple Organ Dysfunction Syndrome, or other complications.

Of those three identified categories of trauma death, EMS has the potential to positively impact only one: those who would die within hours due to hypovolemia or hypoxia. Funny thing is, the outcomes in those patients don’t seem to reflect much difference between the patients who made it to surgery within the Golden Hour and those who made it in the Aluminum Afternoon.

And if you look at the reasons that middle group die – hypoxia and hypovolemia – one might argue that a good, old-fashioned EMT-Intermediate trained under the 1985 curriculum would be the most appropriate EMS provider for them.

That is, unless you pay attention to Ken Mattox’s research supporting permissive hypotension, and the studies that show poorer outcomes in trauma patients who are intubated. Then, you might say that the best EMS provider for a critically injured trauma patient is someone who can plug the holes, apply oxygen, and make an intelligent decision as to appropriate receiving facilities. That provider would be an EMT-Basic, pretty much the same critter as envisioned in the EMS White Paper way back in 1966.

We’ve built an entire belief system based on the myth of the Golden Hour, and extrapolated from it our own proprietary myth of the Platinum Ten Minutes. Nowadays, that Platinum Ten Minutes has more relevance to maximizing Unit Hour Utilization than to patient care, although your system’s managers will be loathe to admit it.

Most urban EMS systems in this country operate on an artificially contrived response time standard of eight minutes or less. Read the municipal ordinances that govern such things, and you’ll often see it actually required by law that the EMS system in a given area  arrive at the scene of emergency calls in eight minutes or less, 90% of the time.

Ask the city council members or lawyers as to why it’s written that way, and you’ll get a chorus of blank looks, much like you’d get if you asked a chimpanzee to perform calculus.

You may find an occasional one that will bloviate on and on about how the standards were derived, but – and primate experts and political commentators will back me up on this – the only thing worse than a chimp that can’t do calculus is a pompous chimp who pretends otherwise.

I’ll tell you what that eight minute response time standard is based on:

chain_of_survival

See that fourth link there, the one about Early Advanced Care?

Yeah, that one. For as long as I’ve been teaching their courses, the American Heart Association has stated that ALS care within eight minutes of arrest improves survival rates. That is what we’re basing that response time standard upon. There are only two problems with that:

  1. That number is based less upon science than conjecture, and the only two interventions proven to improve survival to hospital discharge are early and uninterrupted chest compressions, and early defibrillation – both BLS interventions. The benefit of ALS is, at best, theoretical. Now, with the advent of things like post-ROSC induced hypothermia, that may indeed change. But for now, there is precious little evidence to support the efficacy of ALS in cardiac arrest.
  2. It’s a chain. Take out any of the first three links, and the best ALS care in the world is essentially meaningless. Fact is, the only meaningful response time standard is four minutes or less. If you can’t meet that standard, then the next best bet is just as reliably derived by using the Magic Eight Ball as it is by copying the ambulance ordinance from the next town over.

While we’re on the subject of time, and its overstated importance in what we do, let’s look at lights and siren transport, shall we?

I’ve often said that twin water-cooled .50 caliber machine guns and a snowplow bumper would be more effective than lights and siren, and I was only half-joking. Lights and siren usually don’t buy you that much time, but throwing a burst of armor-piercing rounds into the Prius plodding along at 45 mph in the left lane would improve my job satisfaction by an order of magnitude.

In a North Carolina study, lights and siren response saved an average of 43.5 seconds. In Syracuse, NY, it was 1 minute, 46 seconds. In Minneapolis, it was a whopping 3.02 minutes. Yet, as I’ve pointed out earlier in this post, unless those time savings represent, consistently, the difference between a four minute response and something more than four minutes – on the 1% of EMS calls that involve cardiac arrest – then the end result is simply rapid conversion of money into noise and diesel fumes.

When it comes to the benefit of transporting with lights and siren, I’ll refer you to this quote from an article by Bryan Bledsoe, another EMS heretic who does a much better job than I at questioning EMS dogma:

“…Pennsylvania researchers studied a county-wide, single-provider, private EMS system that used 11 ALS ambulances. Annual call volume for the service area was 14,000, and the county population was approximately 90,000. A medical protocol was developed, and carried on each ambulance, that provided medical criteria for lights and siren transport. A total of 1,625 patients were entered into the study. Based on the medical protocol, 92% of patients were transported without lights and sirens, while 8% were transported with lights and sirens. No adverse outcomes were identified as being related to non-lights and siren transport.”

From later in the article, comes this:

“Do the benefits of lights and siren transport outweigh the possible risks? Again, this must be a local decision. A recent study estimated that the fatality rate for EMS personnel is 12.7 fatalities per 100,000 EMS workers annually, which compares with 14.2 for police, 16.5 for firefighters, and a national average of 5.0 during the same time period. Most fatalities were due to traffic accidents.7 Some industry experts have estimated that there are 12,000 ambulance-related crashes annually in the United States, causing nearly 120 deaths.”

It’s pretty clear that, despite what we tell the public, despite what we tell ourselves, that the vast majority of EMS calls aren’t a life-or-death struggle set to the ominous ticking of a clock. It’s time we stopped pretending otherwise, and started doing research to determine exactly what calls are that time-sensitive, and what is the optimum response time standard for those types of calls.

And while we’re at it, start the long and arduous task of educating John Q. Public that, should he call an ambulance for the knee pain he’s had for a month, he can expect an ambulance in roughly the same time frame he can expect his cable television installer – some time next Thursday, between the hours of 8:00 am and 5:00 pm.

**********

That’s all the preaching I’ll do for now. There may be Inconvenient Truths to come, unless my ADHD kicks in and I – Hey guys, let’s all go ride our bikes!