Have We Set the Bar Too High? Bryan E. Bledsoe, DO, FACEP University of Nevada School of Medicine
The Problem You wanted to be a doctor, maybe you should have buckled down a little more in high school.
The Problem We Raise the Dead We Raise the Dead Researchers watched all 1994-1995 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. Los Angeles, CA: 1-year study (1JUL00-1JUL01). 2,021 consecutive cardiac arrests. 1,700 met entry criteria as a primary cardiac event. 28% received bystander CPR. We Raise the Dead 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. 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. Eckstein M, Stratton SJ, Chan LS: Cardiac Arrest Resuscitation in Los Angeles: CARE- LA. Annals of Emergency Medicine. 45:504 509, 2005.
We Raise the Dead We Raise the Dead Trunkey DD: Trauma. Scientific American. 249:220 227, 1983. 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% Sepsis, MODS and other complications. 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?
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 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;7:141-146 336 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-of- Resuscitation Protocol. Prehosp Emerg Care. 2005;9:276-281 Hospital will Save Them 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;270:1433-1436 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 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;9:181-185 235 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;12:56-61 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. 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. 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 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 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 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 This begs the question: Why do we continue to endanger our employees and our patients by significantly overusing lights and sirens response? With lights and siren transport, the clinical benefits do not outweigh the risks for the vast majority of patients.
7 Minutes, 59 Seconds (90%) Where is the safest place in America to have your cardiac arrest? 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 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. 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. What does the science tell us?
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. How many EMS systems can guarantee a 4 minute response time? 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. 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 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 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
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 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. 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. Bledsoe BE, Smith MG. Medical Helicopter Accidents in the United States: A 10-Year Review. Journal of Trauma/. 2004;56:1325-1329
Medical Helicopter Accidents 1993-2007 (Source: NTSB) Medical Helicopter Accidents Medical Helicopter Accidents 18 16 14 12 10 8 6 4 2 0 1993 1995 1997 1999 2001 2003 2005 2007 Source: NTSB Fatalities Injuries 10 9 8 7 6 5 4 3 2 1 0 1993-2002 12AM 12AM 2AM 2AM 4AM 4AM 6AM 6AM 8AM 8AM 10AM 10AM 12PM 12PM 2PM 2PM 4PM 4PM 6PM 6PM 8PM 8PM 10PM 10PM Accidents 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 Occupational Deaths per 100,000 per Year Accidents by Cause All Workers 5 11% 2% Farming 26 26% 61% Pilot Error Mechanical Failure Undetermined Other Mining 27 Air Medical Crew 74 Source: NTSB & Bledsoe BE and Smith MG. Medical Helicopter Accidents in the United States: A 10-Year Review. J Trauma. 2004;56:1225-1229 US 1995-2001 Source: Johns Hopkins University School of Public Health
Fatal Crashes per Million Flight Hours (2001) Medical Helicopter Accidents 20 18 16 14 12 10 8 6 4 2 0 1 6 12 12 19 Airline Commuter Ground Ambulance All Helicopters Weather a factor in one-fourth of all crashes. Source: AMPA. A Safety Review and Risk Assessment in Air Medical Transport, 2002 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 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. EMS Line Pilot Survey, 2001 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 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%)
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. 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% 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. 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. 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. 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.
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 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 Considerations: Severe injury: ISS > 15 TS < 12 RTS 11 Weighted RTS 4 Triss P s < 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 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
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] RTS > 11: Insufficient data TRISS P s > 0.90: N = 6,328 TRISS P s > 0.90 = 4,414 TRISS P s > 0.90 = 69.3% [99% CI: 58.5 to 80.2] N=37,350 70 68 66 64 62 60 58 56 54 ISS TS TRISS Percentage with minor injuries Source: Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O Keefe MO. Helicopter scene transport of trauma patients: a meta-analysis. Journal of Trauma. 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
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.