Transcript Have We Set the Bar Too High

Have We Set the Bar
Too High?
Bryan E. Bledsoe, DO, FACEP
UNLV
The EMS Image
The EMS Image
The EMS Image
The EMS Image
The EMS Image
The EMS Image
The EMS Image
The EMS Image
The EMS Image
The EMS Image
“You wanted to be a
doctor, maybe you should
have buckled down a little
more in high school.”
The Problem
The Problem
The EMS Image
We Raise the Dead
Researchers watched all 19941995 episodes of ER and
Chicago Hope.
Watched 50 consecutive
episodes of Rescue 911.
Findings:
65% of cardiac arrests occurred in
children, teenagers or young
adults.
75% survived the initial arrest.
67% survived to discharge.
Diem SJ, Lantos JD, Tulsky JA: “Cardiopulmonary
resuscitation on television. Miracles and
misinformation.” New England Journal of Medicine.
133:1578–1582, 1996.
We Raise the Dead
Los Angeles, CA:
1-year study (1JUL001JUL01).
2,021 consecutive cardiac
arrests.
1,700 met entry criteria as a
primary cardiac event.
28% received bystander
CPR.
We Raise the Dead
Results:
1.4% survived neurologically intact.
6.1% survived from bystanderwitnessed ventricular fibrillation.
2.1% survival with bystander CPR.
3.2% survival with witnessed arrest
and bystander CPR.
1% survival without bystander
CPR.
Eckstein M, Stratton SJ, Chan LS: “Cardiac
Arrest Resuscitation in Los Angeles: CARELA.” Annals of Emergency Medicine.
45:504–509, 2005.
We Raise the Dead
Mechanical CPR devices
have not been shown to
improve outcomes.
Some actually worsen
CPR outcomes.
Tucson IRB stopped
multi-center RCT
Yet, many FDs still spend
hundreds of thousands of
dollars on these.
We Raise the Dead
Civilian Trauma deaths occur in
a trimodal distribution:
Death within minutes = 50%
Neurologic and vascular injuries.
Death within hours = 30%
Hypoxia and hypovolemia.
Death within days = 20%
Trunkey DD: “Trauma.” Scientific
American. 249:220–227, 1983.
Sepsis, MODS and other
complications.
We Raise the Dead
No change in
survival for
the first group
since the
Crimean war.
We Raise the Dead
We Raise the Dead
“Insanity: Doing the
same thing over
and over and
expecting a
different result.”
John Dryden
The Spanish Friar
(Act II, Scene 1)
We Raise the Dead
This begs the question:
Why do we put so much money and
resources into cardiac arrest management
when the out-of-hospital survival rate remains
abysmally miniscule?
The EMS Image
Hospital will Save Them
Most Australian
paramedics have
never done CPR in a
moving ambulance.
Hospital will Save Them
NAEMSP has had a
position paper on field
termination of out-ofhospital non-traumatic
cardiac arrest since
1999.
Bailey ED, Wydro GC, Cone DC.
Termination of Resuscitation in the
Prehospital Setting for Adult Patients
Suffering Nontraumatic Cardiac
Arrest. Prehosp Emerg Care.
2000;4:190-195
Hospital will Save Them
NAEMSP and the
American College of
Surgeons has had a
position paper on the
termination of
traumatic cardiac
arrest since 2002.
Hopson LR, Hirsh E, Delgado J,
Dormier RM, McSwain NE, Krohmer
J. Guidelines for Withholding or
Termination of Resuscitation in
Prehospital Traumatic
Cardiopulmonary Arrest. Prehosp
Emerg Care. 2003;7:141-146
Hospital will Save Them
336 prospective and 135
retrospective cases of
OOHCA.
12 patients survived to
discharge (none met
criteria for field TOR).
63 patients survived to
admission, 4 were eligible
for TOR.
None of these 4 survived
to discharge.
Conclusion: Protocol
100% specific for lack
of survival from
OOHCA.
Cone CD, Bailey ED, Spackman AB.
The Safety of Field Termination-ofResuscitation Protocol. Prehosp
Emerg Care. 2005;9:276-281
Hospital will Save Them
1,068 victims of OOHCA
treated by Memphis FD.
310 (29%) had ROSC prior
to transport.
Admitted: 69%
Discharged alive: 26.5%
758 (71%) never regained
a pulse and were
transported with CPR
underway.
Admitted: 7.0%
Discharged alive: 0.4%†
†-All had moderate-severe CNS
disability.
“Rapid transport of adults
who fail to respond to an
adequate trial of
prehospital ACLS does
not result in meaningful
rates of survival.”
Kellerman AL, Hackman BB, Somes
G. Predicting the Outcome of
Unsuccessful Prehospial Advanced
Life Support. JAMA. 1993;270:14331436
Hospital will Save Them
189 pediatric patients
with OOHCA studied:
39 (20.6%) received BLS
only
150 (79.4%) received ALS.
5 (2.6%) survived to
discharge.
No significant
improvement in survival
in those who received
ALS.
Those likely to survive
had a sinus rhythm and
received fewer doses of
epinephrine in the ED.
ALS does not improve
survival in pediatric
OOHCA.
Pitetti R, Glustein JZ, Bhende MS.
Prehospital Care and Outcome of
Pediatric Out-of-Hospital Cardiac
Arrest. Prehosp Emerg Care.
2002;6:283-90
Hospital will Save Them
LA and Orange
County (CA) SIDS
study:
114 SIDS patients
6 (5%) had ROSC
0 (0%) survived
50 (44%) received
lights and siren
transport.
“Given that there were no
survivors, new
prehospital policies are
needed governing the
use of lights and sirens,
resuscitation decisions
including termination of
resuscitation.”
Smith MP, Kaji A, Young KD,
Gausche-Hill M. Presentation and
Survival of Apparent Prehospital
Sudden Infant Death Syndrome.
Prehosp Emerg Care. 2005;9:181185
Hospital will Save Them
235 OOHCA patients:
131 (56%) met criteria for
TOR.
All expired at the hospital.
No mitigating reasons
found to justify transport.
TOR protocols are not
being followed.
O’Brian E, Hendricks D, Cone CD.
Field Termination of
Resuscitation: Analysis of a
Newly-Implemented Protocol.
Prehosp Emerg Care. 2008;12:5661
Hospital will Save Them
Hospital will Save Them
This begs the question:
Why do we put our resources and personnel
at risk in transporting CPR cases when the
results are always futile?
The “Golden Hour” exists
“Patients must arrive
at a trauma center
within one hour of
their injury in order to
have their best
chance of survival.”
R. Adams Cowley, MD
The “Golden Hour” exists
The concept of the
“Golden Hour” was
developed to promote
the newly-opened
University of Maryland
“Shock Trauma”
center.
The “Golden Hour” exists.
“This article
discusses a
detailed literature
and historical
records search for
support of the
‘Golden Hour’
concept. None is
identified.”
Lerner ED, Moscatti RM: “The Golden Hour:
Scientific Fact or Medical ‘Urban Legend’?”
Academic Emergency Medicine. 8:758–760,
2001.
The “Golden Hour” exists
Nobody wants to talk
about the false notion
of a “Golden Hour”
because it so shakes
the roots of EMS and
trauma care.”
The “Golden Hour” exists
Our old trauma
practices may have
been harming more
patients than it was
helping.
Large volume
crystalloids.
Endotracheal
intubation.
The “Golden Hour” exists
This begs the question:
Why are we putting our personnel and
patients at risk to meet the constraints of the
‘Golden Hour’ when there is no evidence that
the ‘Golden Hour’ exists?
Lights and Sirens Save Lives
Lights and Sirens Save Lives
In a North Carolina,
Hunt and colleagues
found only a 43.5
second mean time
savings with lights
and siren compared
to transport without
lights and siren.
Hunt RC, Brown LH, Cabinum TW
et al. Is ambulance transport time
with lights and siren faster than that
without? Annals of Emergency
Medicine. 1995;25(4):507-511
Lights and Sirens Save Lives
Upper New York
(Syracuse) study.
“L&S reduce ambulance
response times by an
average of 1 minute, 46
seconds. Although
statistically significant, this
time saving is likely to be
clinically relevant in only a
very few cases.”
Brown LH, Whitney CL, Hunt RC, et al.
Do warning lights and sirens reduce
ambulance response times? Prehospital
Emergency Care. 2000;4(1):70-74
Lights and Sirens Save Lives
Pediatrics?
“In our preliminary
study, inappropriate
use of L&S in the
transport of pediatric
patients in stable
condition is common.”
Lacher ME, Bauscher JC. Lights and
sirens in pediatric 911 transports. Are they
being misused? Annals of Emergency
Medicine. 1997;29(2):223-227
Lights and Sirens Save Lives
A 1994 study evaluated
patient outcomes when
an EMS agency used a
medical protocol
directing the use of
lights and siren.
They found, “No
adverse outcomes were
identified as related to
non-L&S transport.”
Kupas DF, Dula DJ, Pino BJ. Patient
outcome using medical protocol to limit
“lights and siren transport. Prehosp Diast
Med. 1994:9(4):226-229
Lights and Sirens Save Lives
Lights and Sirens Save Lives
With lights and siren transport,
the “clinical benefits” do not
outweigh the risks for the vast
majority of patients.
Lights and Sirens Save Lives
This begs the question:
“Why do we continue to endanger our
employees and our patients by significantly
overusing lights and sirens response?
The EMS Image
7 Minutes, 59 Seconds (90%)
Where is the safest
place in America to
have your cardiac
arrest?
7 minutes, 59 seconds (90%)
The time it takes to
travel between two
points is determined by
speed.
Speed can be affected
by:
Traffic
Road conditions
Vehicle conditions
Operator experience
7 minutes, 59 seconds (90%)
EMS “visionaries” have
set 8 minutes (7
minutes, 59 seconds
[90% of the time]) as
the goal for an EMS
response.
This time interval was
based purely on
rational conjecture and
not a shred of science.
7 minutes, 59 seconds (90%)
Various strategies have
been proposed to
decrease travel times.
It is impossible, with
any degree of
accuracy, to predict
when and where an
EMS call will occur.
7 minutes, 59 seconds (90%)
What does the science tell us?
7 minutes, 59 seconds (90%)
OPALS study:
9,273 patients treated
4.2% survival
6.2 minute defibrillation response time.
“There was a steep decrease in the first 5
minutes of the survival curve, beyond
which the slope gradually leveled off.
Controlling for known covariates, the
decrement in the odds of survival with
increasing response interval was 0.77 per
minute (95% confidence interval 0.74 to
0.83).”
De Maio VJ, Stiell IG, Wells GA,
Spaite DW; Ontario Prehospital
Advanced Life Support Study
Group: “Optimal defibrillation
response intervals for maximum
out-of-hospital cardiac arrest
survival rates.” Annals of
Emergency Medicine. 42(2):242–
250, 2003.
7 minutes, 59 seconds (90%)
How many EMS
systems can
guarantee a 4 minute
response time?
7 minutes, 59 seconds (90%)
A paramedic response
time of 8 minutes was
not associated with
improved survival to
hospital discharge.
A response time of 4
minutes did improve
survival in patients with
moderate to high risk of
mortality.
Pons PT, Markovchick VJ: “Eight
minutes or less: Does the ambulance
response time guideline impact
trauma patient outcome?” Journal of
Emergency Medicine. 23(1):43–48,
2002.
7 minutes, 59 seconds (90%)
“Our data are most
consistent with the
inference that neither the
mortality or frequency of
critical procedural
interventions performed in
the field vary substantially
based upon this prespecified (10 min, 59 sec)
ALS response time.”
Blackwell TH, Kline J, Willis J, et al. Lack
of association between prehospital
response times and patient outcomes.
Prehospital Emergency Care.
2007;11(1):115
7 minutes, 59 seconds (90%)
Pennsylvania Study:
“Although response times were
differentiated by location, they
were not necessarily predictive
of survival. Factors other than
response time such as patient
population or resuscitation skill
could influence survival from
cardiac arrest occurring in
diverse prehospital service
areas.”
Vukmir RM, Sodium Bicarbonate Study
Group. The influence of urban,
suburban, or rural locale on survival
from refractory cardiac arrest.
American Journal of Emergency
Medicine. 2004;22(2):90-93
7 minutes, 59 seconds (90%)
UK Study:
“Overall, there is little evidence
in the data that faster
response times have led to
better outcomes.”
“The number of patients who
might benefit from a fast
response is actually very small
and the benefit in this small
group is being ‘lost’ in the
larger group who do not need
fast response.”
Turner J, O’Keefe C, Dixon S, Warren K,
Nicholl J: The Costs and Benefits of
Changing Ambulance Response Time
Performance Standards. Medical Care
Research Unit School of Health and Related
Research, University of Sheffield. 2006
7 minutes, 59 seconds (90%)
This begs the question:
“Why do we continue to endanger our
employees and our patients by setting
artificial response times that have no
correlation with patient outcomes?
7 minutes, 59 seconds
(90%)
This begs the question:
“Why do we continue to endanger our
employees and our patients by setting
artificial response times that have no
correlation with patient outcomes?
Helicopters Save Lives
US Medical Helicopters
1000
900
800
700
600
500
400
300
200
100
0
1998
1999
2000
2001
2002
2003
2004
2005
2006
Medical Helicopters
In 2002, Medicare increased the rates for medical
helicopter transport.
Price for airlift ranges from $5,000 to $10,000, 5 to 10
times that of a ground ambulance.
Helicopters in the US have doubled from a decade ago;
and with more of them scrambling for business,
specialists say that emergency personnel are feeling
more pressure to use them.
In 2004, the number of flights paid for by Medicare alone
was 58 percent higher than in 2001.
Spending by Medicare has more than doubled to $103
million over the same period.
Medical Helicopters
In FY 2001, the University
of Michigan’s flight
program “Survival Flight”:
$6,000,000 operational
costs
$62,000,000 in inpatient
revenues
28% of ICU days
Helicopter patients were
twice as likely to have
commercial health
insurance compared to
regular patient profile.
Medical Helicopters
Bledsoe BE, Smith
MG. Medical
Helicopter Accidents
in the United States:
A 10-Year Review.
Journal of Trauma/.
2004;56:1325-1329
Medical Helicopters
Medical Helicopter Accidents
25
21
19 19
20
15
15
12
10
5
16
15
9
8
3 4
11
10
4
2
0
1993
1996
1999
2002
2005
1993-2007 (Source: NTSB)
Accidents
Medical Helicopter Accidents
18
16
14
12
10
Fatalities
Injuries
8
6
4
2
0
1993
1995
1997
1999
2001 2003
Source: NTSB
2005
2007
Medical Helicopter Accidents
1993-2002
10
9
8
7
6
5
4
3
2
1
0
A
12
Accidents
M
M
M
M
M
M
M
M
M
M
M
M
A
A
A
A
2
4
6
8 10A 12P 2P 4P 6P 8P 10P
Source: NTSB & Bledsoe BE and Smith MG. Medical Helicopter Accidents
in the United States: A 10-Year Review. J Trauma. 2004;56:1225-1229
Medical Helicopter Accidents
Accidents by Cause
11%
2%
26%
61%
Pilot Error
Mechanical Failure
Undetermined
Other
Source: NTSB & Bledsoe BE and Smith MG. Medical Helicopter Accidents
in the United States: A 10-Year Review. J Trauma. 2004;56:1225-1229
Occupational Deaths per 100,000 per Year
All Workers
5
Farming
26
Mining
27
Air Medical Crew
74
US 1995-2001
Source: Johns Hopkins University School of Public Health
Fatal Crashes per Million Flight Hours (2001)
19
20
18
16
14
12
12
10
8
6
6
12
Airline
Commuter
Ground Ambulance
All Helicopters
Medical Helicopters
4
2
1
0
Source: AMPA, A Safety Review and Risk Assessment in
Air Medical Transport (2002)
Medical Helicopter Accidents
Weather a factor in
one-fourth of all
crashes.
Source: AMPA.
A Safety Review
and Risk
Assessment in
Air Medical
Transport, 2002
Pressure on Pilots
Undue pressure from:
Management
Dispatch
Flight Crews
Pressure to:
Speed response or lift-off times
Launch/continue in marginal weather
Fly when fatigued or ill
EMS Line Pilot Survey, 2001
Medical Helicopters
Initial studies in the 1980s showed that trauma
patients have better outcomes when transported
by helicopter.
Today, other than speed, helicopters offer little
additional care than provided by ground
ambulances.
Medical Helicopters
Shatney CH, Homan SJ, Sherek JP, et al. The
utility of helicopter transport of trauma patients
from the injury scene in an urban trauma
system. J Trauma. 2002;53(5):817-22
10-year retrospective review of 947 consecutive
trauma patients transported to the Santa Clara
Valley trauma center.
Blunt trauma: 911
Penetrating trauma: 36
Medical Helicopters
Mean ISS = 8.9
Deaths in ED = 15
Discharged from ED = 312 (33.5%)
Hospitalized = 620
ISS ≤ 9 = 339 (54.7%)
ISS ≥ 16 = 148 (23.9%)
Emergency surgery = 84 (8.9%)
Medical Helicopters
Only 17 patients (1.8%) underwent surgery for
immediately life-threatening injuries.
Helicopter arrival faster = 54.7%
Helicopter arrival slower = 45.3%
Only 22.4% of the study population were
possibly helped by helicopter transport.
CONCLUSION: The helicopter is used
excessively for scene transport of trauma victims
in our metropolitan trauma system. New criteria
should be developed for helicopter deployment
in the urban trauma environment.
Medical Helicopters
Eckstein M, Jantos T, Kelly N, et al. Helicopter transport
of pediatric trauma patients in an urban emergency
medical services system: a critical analysis. J Trauma,
2002;53:340-344.
Retrospective review of 189 pediatric trauma patients
(<15) transported by helicopter from the scene in LA.
Median age: 5 years
RTS > 7 = 82%
ISS < 15 = 83%
Admitted to ICU = 18%
Discharged from ED = 33%
Medical Helicopters
CONCLUSION: The majority of pediatric
trauma patients transported by helicopter
in our study sustained minor injuries. A
revised policy to better identify pediatric
patients who might benefit from helicopter
transport appears to be warranted.
Medical Helicopters
Braithwaite CE, Roski M, McDowell R, et al. A
critical analysis of on-scene helicopter transport
on survival in a statewide trauma system. J
Trauma. 1998;45(1):140-4
Data for 162,730 Pennsylvania trauma patients
obtained from state trauma registry.
Patients treated at 28 accredited trauma centers
15,938 patients were transported from the scene by
helicopters.
6,273 patients were transported by ALS ground
ambulance.
Medical Helicopters
Patients transported by helicopter:
Significantly younger
Males
More seriously injured
Had lower blood pressure
Helicopter patients:
ISS <15 = 55%
Logistical regression analysis revealed that when
adjusted for other risk factors, transportation by
helicopter did not affect the estimated odds of survival.
CONCLUSION: A reappraisal of the cost-effectiveness
of helicopter triage and transport criteria, when access to
ground ALS squads is available, may be warranted.
Medical Helicopters
Cocanour CS, Fischer RP, Ursie CM. Are scene flights
for penetrating trauma justified? J Trauma.
1997;43(1):83-86
122 consecutive victims of non-cranial penetrating
trauma transported by helicopter from the scene.
Average RTS = 10.6
Dead patients = 15.6%
Helicopter did not hasten arrival in for any of the 122
patients.
Only 4.9% of patients required patient care interventions
beyond those of ground ALS units.
CONCLUSION: Scene flights in this metropolitan area
for patients who suffered noncranial penetrating injuries
demonstrated that these flights were not medically
efficacious.
Medical Helicopters
Cunningham P, Rutledge R, Baker CC, Clancy TV. A
comparison of the association of helicopter and ground
ambulance transport with the outcome of injury in trauma
patients transported from the scene. J Trauma
1997;43(6):940-946
Data obtained from NC trauma registry from 1987-1993
on trauma patients and compared:
1,346 transported by air
17,144 transported by ground
CONCLUSION: The large majority of trauma patients
transported by both helicopter and ground ambulance
have low severity measures. Outcomes were not
uniformly better among patients transported by
helicopter. Only a very small subset of patients
transported by helicopter appear to have any chance or
improved survival.
Helicopters
Moront ML, Gotschall CS, Eichelberger MR. Helicopter transport of
injured children: system effectiveness and triage criteria. J Pediatr
Surg. 1996;31(8):1183-6
3,861 children transported by local EMS
1,460 arrived by helicopter
2,896 arrived by ground
Helicopter transported patients:
ISS <15 = 83%
But survival rates for children transported by air were better than those
transported by ground.
CONCLUSION: The authors conclude that (1) helicopter transport
was associated with better survival rates among injured urban
children; (2) pediatric helicopter triage criteria based on GSC and
heart rate may improve helicopter utilization without compromising
care; (3) current air triage practices result in overuse in
approximately 85% of flights.
Helicopters
Wills VL, Eno L, Walker C, et al. Use of an ambulance-based
helicopter retrieval service. Aust N Z J Surg. 2000;70(7):506-510
179 trauma patients arrived by helicopter during study year.
122 male
57 female
Severity of injuries:
ISS < 9 = 67.6%
ISS ≥ 16 = 17.9%
12 (6.7%) discharged from the ED
46 (25.7%) discharged within 48 hours.
Results:
17.3% of patients were felt to have benefited from helicopter transport
81.0% of patients were felt to have no benefit from helicopter transport
1.7% of patients were felt to have been harmed from helicopter
transport
Medical Helicopters
Bledsoe BE, Wesley AK, Eckstein M,
Dunn TM, O’Keefe MO. Helicopter
scene transport of trauma patients: a
meta-analysis. Journal of Trauma,
Injury, Infection and Critical Care.
2006;60:1256-1266
Medical Helicopters
Considerations:
Severe injury:
ISS > 15
TS < 12
RTS ≤ 11
Weighted RTS ≥ 4
Triss Ps < 0.90
Non-life-threatening injuries:
Patients not in above criteria
Patients who refuse ED treatment
Patients discharged from ED
Patients not admitted to ICU
Medical Helicopters
48 papers met initial inclusion criteria.
26 papers rejected:
Failure to stratify scores.
Failure to differentiate scene flights.
Failure to differentiate trauma flights.
22 papers accepted.
Span: 21 years
Cohort: 37,350
Medical Helicopters
ISS ≤ 15:
N = 31,244
ISS ≤ 15 = 18,629
ISS ≤ 15 = 60.0% [99% CI: 54.5 to 64.8]
TS ≥ 13:
N = 2,110
TS ≥ 13 = 1,296
TS ≥ 13 = 61.4% [99% CI: 58.5 to 80.2]
Medical Helicopters
RTS > 11:
Insufficient data
TRISS Ps > 0.90:
N = 6,328
TRISS Ps > 0.90 = 4,414
TRISS Ps > 0.90 = 69.3% [99% CI: 58.5 to
80.2]
Medical Helicopters
70
68
66
64
N=37,350
Percentage
with minor
injuries
62
60
58
56
54
ISS
TS
TRISS
Source: Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MO. Helicopter
scene transport of trauma patients: a meta-analysis. Journal of Trauma.
Medical Helicopters
Patients discharged < 24
hours:
N = 1,850
Discharged < 24 hours =
446
Discharged < 24 hours =
25.8% [99% CI: -0.90 to
52.63]
Helicopters Save Lives
No definitive body of data shows patient
benefit from helicopter transport.
Yet, helicopters are on the increase—each
transporting more and more patients.
Helicopters Save Lives
“They brought the helicopter in. And
Billy couldn't feel his legs.
Said he'd never walk again.
But Billy said he would and his mom
and daddy prayed.
And the day we graduated, he stood
up to say:
Unsinkable ships sink…”
Nichols, J. The Impossible
from Man with a Memory.
2000: Universal South
Medical Helicopters
This begs the question:
“Why do we continue to endanger our patients
and employees on medical helicopters when
only a very small percentage stand to benefit?
Summary
We would never buy a
car with determining the
benefit: risk ratio.
We routinely perform
and promote
considerably more
dangerous EMS
practices without
considering the benefit:
risk ratio.
Summary
Use TOR protocols.
Limit lights and siren responses and
transports.
Use medical helicopters only when the
patient has a significant chance of
benefiting from transport.
Educate the public and PUBLIC
OFFICIALS about the benefits and
LIMITATIONS of EMS.