ALS Response Times? Never Mind.

Twenty-five years ago semi-automatic cardiac defibrillators (AEDs) could only be operated by paramedics. Applying electricity was considered as invasive as starting an intravenous line, administering drugs or pushing a tube down the throat of a non-breathing patient.

1st defibrillator Miami 1966

In order for my department to place AEDs on a fire company we had to make sure that there was an ALS credentialed firefighter on the rig. As we were starting the trial period in 1986, the updated national standard curricula allowed use of AEDs by EMT-Basics.

The department did not stop the effort to staff engine companies with a paramedic/firefighter, because it increased the minimum staffing from three to four.

The chiefs were following the drama within the NFPA 1500 committee and believed that Department of Labor or NFPA would recommend four-person staffing of fire companies. Fellow fossils may recall the mass withdrawal of the IAFF representatives from the code consensus process in protest of how the internal workflow was progressing on the Standard on Fire Department Occupational Safety Programs. The final result of this battle was the NIOSH “two-in-two out” ruling for work performed in immediate danger to life and health (IDLH) environments.

EIGHT MINUTES FOR ALS MEANS MANY PARAMEDICS SEEING FEW PATIENTS

There is scant evidence justifying the ems response times that we have treated as gospel. We spent the past decade using the same threadbare data to build large, complex and expensive fire-based ems delivery systems. In many systems, there are so many paramedics that there is almost no opportunity to treat enough seriously ill patients to assure competency in the few out-of-hospital clinical interventions that MAY make a difference in long-term patient outcome.

Dr. Paul Pepe on-scene direction

While fire-based systems were building resource rich systems, private/public agencies were finding the limits of high performance ems systems by overloading transport unit workload. Somewhere in the middle is probably the best system.

A WORD FROM EMS MEDICAL DIRECTORS FROM THE LARGEST CITIES

The Consortium of U. S. Metropolitan Municipalities’ EMS Medical Directors developed a statement that was published in the April/June 2008 issue of Prehospital Emergency Care. PEC is a peer reviewed professional journal. I explained how medicine develops and shares knowledge earlier this year: http://firegeezer.com/2008/02/05/secret-handshakes-and-decoder-rings/

Dr. Copass helps unload a Seattle cardiac arrest patient in the 1990's

This group has a State of the Science professional meeting in February. From their website http://gatheringofeagles.us/ :

The U.S. Metropolitan Municipalities EMS Medical Directors Consortium (The “Eagles” Coalition) is comprised of most of the jurisdictional EMS Medical Directors for the nation’s largest cities 9-1-1 systems as well as the FBI and the U. S. Secret Service. In essence, this small cadre of leading emergency specialists not only oversee the medical aspects of day-to-day 9-1-1 calls and early resuscitative care in the nations most populous cities, but most of them are also responsible for much of the medical aspects of homeland security in these high-risk venues in which nearly 50 million Americans dwell and make their livelihood.

Some of these medical directors worked as a paramedic before they started medical school. They share our perspective of street emergency medicine.

WHAT URBAN EMS SYSTEMS SHOULD BE DOING

The physicians outlined recommendations for six areas of clinical treatment. ST-Elevation Myocardial Infarction (STEMI), pulmonary edema, asthma, seizure, trauma and cardiac arrest. Their recommendations for cardiac arrest are surprising:

Response interval of less than 5 minutes for basic CPR and automatic external defibrillators (AEDs). No response interval was specified for ALS arrival.

In justifying its cardiac arrest recommendation, the group noted that much of the clinical research used to establish acceptable ALS response time intervals was conducted prior to the widespread dissemination of AEDs and at a time in which the compression component of CPR was not emphasized as it is now. As a result, the consensus group proposed that EMS systems not focus response time measurement on ALS ambulances, but rather pay greater attention to first response/BLS response time to measure what it called the “most important predictive elements for optimal outcome: time elapsed until initiation of basic chest compressions and time elapsed until defibrillation attempts.”

This is a powerful recommendation from emergency medicine physicians with EMS experience and operational authority. It is going to be difficult to promote blanketing a city with paramedic staffed first responder fire companies if all you need is an AED and chest compressions to make a difference in cardiac arrest survival. Maybe fewer paramedics is a good idea.

Go here to download the rest of the Best Practices in Emergency Services summary and the Prehospital Emergency Care article.  14 pages, 137 KB Adobe Acrobat file

Mike “FossilMedic” Ward

Also on FireGeezer…

• Resignation of New Orleans EMS Director Saussy raises questions about perception and physician compensation when working for municipalities. – October 2, 2010
• EMS Expo tidbits: “Had the cruise control set at 105 mph – saw nothing for four hours” – October 2, 2010
• EMS on the Hill Day – May 5, 2011
• A Feline Rescue without pipe-cutting or positive pressure. – July 6, 2011