Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Paramedics resuscitate 17 per cent of heart patients

The East of England Ambulance Trust is being criticized for its cardiac arrest resuscitation rates. Numbers are provided in the article, but we do not know what the numbers are – ROSC (Return Of Spontaneous Circulation), survival until admission, survival until discharge, survival 1 month after discharge, survival 1 year after discharge, survival 5 years after discharge.

A call for more ambulances has been made to improve the numbers of cardiac arrest patients successfully resuscitated by paramedics.[1]

Why ambulances? What is needed is for someone (police, fire, animal control – somebody) to show up and start compressions. As long as the people showing up do not interrupt compressions for irrelevant stuff, the resuscitation rates should increase.

Union representatives from GMB have criticised the East of England Ambulance Trust after it was revealed that just 17.1 per cent of cardiac arrest patients in the region in the 11 months up to February 2012 were successfully resuscitated by paramedics, well below the 22.8 per cent average for England.[1]

17.1% ROSC?

17.1% alive a month after discharge with good brain function?

They do not specify in the story, but I suspect they are describing ROSC.

He says that more focus is being put on rapid response vehicles (RRVs) designed to get to scenes quickly but which cannot transport patients to hospital, due to an “obsession” to meet the eight-minute emergency call target.[1]

He is GMB regional organiser Tony Hughes. GMB is the union for the ambulance service employees.

He is also clueless about resuscitation.

Who cares if the initial response is people who cannot transport? Transport is only important after ROSC. Putting the transport before the ROSC is is one of the things we have been doing wrong for too long. Rapid transport does not resuscitate, but rapid response can.

A spokeswoman said: “What we do know is the figures are twice the target percentage of eight per cent, that they are improving and that more patients are reaching hospital alive following an out-of-hospital cardiac arrest than ever before.”[1]

Tony Hughes does not appear to know enough to not argue with success, or is he pursuing a different agenda.

If we are going to improve resuscitation rates, which are only a tiny part of what EMS does, rapid non-transport response is important.

The rapid response is not important to stop a clock, but to start compressions and to defibrillate early.

Excellent compressions = improved resuscitation.

Early defibrillation = improved resuscitation.

Stopped clock = political goal.

No stations are closing and no existing staff are losing jobs, indeed we are recruiting over 110 emergency care assistants and several new paramedics.”[1]

A union rep unhappy with increased hiring? Why? He probably wants them to hire more.

Percentage of cardiac arrest patients whose circulation returned after resuscitation.

London Ambulance: 29%.

West Midlands Ambulance Service: 26.2%

South East Coast Ambulance Service: 25.4%

South Western: 24%.

East of England Ambulance Service: 17.1%.[1]

There is not much that is required to improve resuscitation rates.

Rapid response (the only medical condition demonstrated to benefit from rapid response).

Excellent minimally interrupted chest compressions.

Rapid defibrillation.

Therapeutic hypothermia and transport for a cardiac catheterization are looking promising, but they are after resuscitation.

I do not see more union members on that list.

Footnotes:

[1] Paramedics resuscitate 17 per cent of heart patients
By ]adam Uren
Published on Friday 20 July 2012 19:00
Peterborough Telegraph
Article

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Corner Posting – Better, Faster, and Cheaper than Stations – Prove It

A recent article in JEMS has reignited discussion about street-side posting.

Why?

One reason is that it is seen as cheap and some employers become tumescent at the thought of cheap.

The debate to define “acceptable” response times is finally coming to a head, with evidence-based research and customer satisfaction and expectations driving this definition;[1]

Evidence-based research?

Would that be something like clock-based time?

We do not have any evidence (that I know of) that response time is important – except for cardiac arrest.

Cardiac arrest is generally estimated to be about 1% of our calls. Whatever the percentage, it is tiny. Should we respond to every call as if it is a cardiac arrest?

If any of you think we should, please explain why.

If any of you know of any evidence that supports 7:59 response times, or 8:59 response times (on 70%, or 80%, or 90% of calls), please provide that, as well.

customer satisfaction and expectations driving this definition;

That is a part of the problem, we have a system that is poorly understood – even by the people who work in it (the medical directors, employers, and the people in the ambulances), but we let the least informed people tell us how to run things. There will always be some need for public accountability, but they probably do not want to be making decisions based on ignorance.

The people I have talked to are surprised, when I tell them how the system really works. Some don’t want to know. Some want to know more. If they have any expectation of needing an ambulance, they want to know that it is going to be available and competently staffed. They think that response times are very important, but we still have a lot of people in EMS who think that response times are very important. And nothing good seems to happen quickly when we’re having an emergency.

R Adams Cowley did some good, but he also dragged us deep into the superstition of The Golden Hour.[2] Many of us refuse to escape from that golden cocoon of ignorance. It isn’t gold, it’s urine, but as long as we are warm and wet, we are happy.

EMS is not just package delivery. Even if it were, the outcome for the package is more than just the pick-up time. Should out motto be What can Blue do for you? If you think so, UPS has a position that may interest you, although their slogan doesn’t rhyme. 😉

Prehospital medicine across the U.S. is, for the most part, standardized,[1]

No. EMS care can vary dramatically by travelling across a city line, or a county line, or a state line.

If this is supposed to be justification for ignoring that nasty medical stuff, then Mr. Washko has this backwards. The patients who really need EMS, need the medical care, not a savings of two minutes, or four minutes, or six minutes, just to be bundled into an ambulance for a carefree version of Mr. Toad’s Wild Ride to the closest ED (Emergency Department).

We can initiate care on scene and continue care on the way to the most appropriate ED.

Some services are even providing Community Paramedics, who don’t need to transport patients to the ED. That is a concept that might blow Mr. Washko’s mind – in a grow three sizes kind of way.

Grinch:
How could it be so?
It came without sirens! It came without lights!
It came without yelps, wails, or frights!
Narrator:
And he puzzled and puzzed, till his puzzler was sore.
Then the Grinch thought of something he hadn’t before!
“Maybe EMS,” he thought, “isn’t being first to the door.
Maybe EMS… perhaps… means a little bit more.”
[3]

Some have attempted to correlate survival rates with the number of active paramedics used in the system, but I find this absurd. (I know the e-mail inbox will be filled after this one with those who disagree with this statement.)[1]

Not absurd.

More medics = worse outcomes.

Skills are important. Diluting those skills among a bloated paramedic population that is three, four, or five times larger than it needs to be dilutes skills.

If we dilute skills, and assessment is the most important skill, then maybe we do need to drive fast.

We do not need to dilute skills. We need to educate the public, and those who drink the more medics = better medic Kool-Aid.

Sitting in the front of an ambulance and being placed on a street corner is not as comfortable as responding from a warm bed in a station’s bunk room, but it gets the medicine into a critically ill patient’s veins a lot quicker.[1]

Sleep is important for shift workers. Police, fire, EMS, and emergency medicine. We need to be incorporating naps into our schedules. Lack of sleep may result in the wrong medication going into the patient’s veins.

The results revealed that taking a single 20-min nap during the first night shift significantly improved speed of response on a vigilance task measured at the end of the shift compared with the control condition.[4]

There is a lot to criticize in Mr. Washko’s article.
 

Go read what Bob Sullivan wrote about the rest of the article.[5]
 

Bob also provides links to evidence that more medics means more skill dilution, but there is a lot of evidence, so I will be writing more about that.

And will anyone want us sitting in trucks, with out engines running, with increasing awareness of the connection between diesel exhaust and cancer?[6] Because we often hear people yelling –

Please, put the carcinogens in my backyard!

Footnotes:

[1] EMS Moves Toward New Care Delivery Methods
JEMS.com
Jonathan D. Washko, BS-EMSA, NREMT-P, AEMD
From the July 2012 Issue
Tuesday, July 3, 2012
Article

[2] The golden hour: scientific fact or medical “urban legend”?
Lerner EB, Moscati RM.
Acad Emerg Med. 2001 Jul;8(7):758-60. Review.
PMID: 11435197 [PubMed – indexed for MEDLINE]

Link to Free Full Text Download in PDF format from Acad Emerg Med

[3] How the Grinch Stole Christmas! (TV special)
Wikiquote
The original lyrics.

[4] The impact of a nap opportunity during the night shift on the performance and alertness of 12-h shift workers.
Purnell MT, Feyer AM, Herbison GP.
J Sleep Res. 2002 Sep;11(3):219-27.
PMID: 12220318 [PubMed – indexed for MEDLINE]

Free Full Text from J Sleep Res.

[5] Corner Posting: Better, Faster, & Cheaper than Stations? Prove It.
EMS Patient Perspective
July 7, 2012
Bob Sullivan
Article

[6] Diesel exhaust
American Cancer Society
Information page

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