Pediatric Infectious Airway Emergencies

Most of us in EMS are pretty good with the typical adult respiratory illnesses — your asthmas, your COPDs, your CHF exacerbations. Maybe the occasional pneumonia. But upper airway illnesses can be harder to keep straight, and two of them are known for occurring especially in pediatrics.

Croup

Croup is an infectious disease, usually caused by viral infection of the upper airway. Once upon a time, it was typically caused by diptheria; with the widespread adoption of diptheria vaccination in the US, this has become rare, and the most common cause is now the parainfluenza virus.

Croup is typically seen in children from 6 months to 6 years of age; approximately 15% of all children will contract it at some point.

Its characteristic finding is a coarse, barking, “seal-like” cough. High-pitched stridor is also often present, as is hoarseness of voice, and dyspnea at late stages. All are caused by narrowing of the upper airway due to inflammation from the infection.

This inflammation is normally at the level of the trachea, possibly stretching down into the large bronchi and up into the larynx, but below the level of the glottis.

The onset is usually gradual, lasting from several days to two weeks. Often, there will be fever or coryzal (cold-type) symptoms, such as congestion or headache. A sudden onset is uncommon; usually there will be a day or two of cold symptoms prior to the onset of cough or hoarseness. The upper airway symptoms are often worse at night. (Occasionally, croup may have a spasmodic cause, sometimes triggered by an allergic reaction [akin to asthma]; in these cases coryzal symptoms are rarely present.)

The main differential here should be croup vs. epiglottitis vs. an aspirated foreign body or anaphylaxis. In most cases, these last can be ruled out by a thorough history. As for epiglottitis, it can best be revealed by the severity of symptoms. In almost all cases, croup does not cause significant airway obstruction leading to major dyspnea or hypoxia. A poor general impression (“big sick”), diminished responsiveness, or respiratory failure should point you towards epiglottitis instead. Drooling is not normal. Death is possible but very rare.

Other signs and symptoms are as typical for respiratory difficult in children, including tachypnea, tachycardia, hypotonia (weak or flaccid muscle tone in the exhausted child), chest retractions, and potentially low O2 saturation. In severe cases, as respirations become shallow and weak, stridor and coughing may not be audible.

Treatment is generally supportive. Keep the child comfortable and reassured, if possible with their mother or other caretaker — panic will increase their oxygen demand and may increase stridor. Provide supplemental oxygen as tolerated; blow-by may be most appropriate. Nebulized racemic epinephrine is appropriate field care for significant cases, and most will receive steroids in the hospital. Steam or humidified oxygen is an old standby, and is anecdotally popular, but research suggests it has no benefit.

Epiglottitis

Epiglottitis is similar in presentation to croup. Its cause is also infectious, but bacterial instead of viral, and historically the microbial agent was almost always hemophilus influenza type B, a bacterium unrelated to the flu except by name. Effective HIB vaccine became widespread in in the late 1980s; as a result, epiglottitis in the US today is actually more common in adults than in vaccinated children. When it does occur in pediatrics, it is typically between the ages of 3 and 7.

Like croup, epiglottitis is a narrowing of the upper airway. However, it occurs higher, above the glottis, and primarily involving the epiglottis and surrounding tissue. Due to inflammation of this flap at the gate of the airway, a sore throat and difficulty swallowing are almost always present. Fever, stridor, and hoarseness of voice are common, as is a muffled speaking voice and tenderness of the larynx, which may present as severe pain provoked by even gentle external palpation. Typically in children there are no other prodromal symptoms such as congestion; adults often do experience coryzal symptoms.

The chief distinction between epiglottitis and croup is the severity. Although far less common, epiglottitis should be considered an acute emergency, and the narrowing of the airway can lead to significant or total obstruction and resultant respiratory failure. The classical late clinical presentation is the young child found in a “sniffing” position, tripodding or sitting upright, with audible stridor (or quiet respirations as failure approaches), drooling and close to exhaustion. (Drooling results from the inability to easily swallow.) Symptoms can be insidious in onset, but usually progress very rapidly. Mortality in adults with epiglottitis is around 7%, although less than 1% in children.

Treatment may involve supplemental oxygen, but maintaining a patent airway should be your main concern. Intubation may be necessary, sometimes suddenly, so prepare for a difficult airway even if the situation seems relatively controlled. Cricothyrotomy is appropriate as a last resort. Direct manipulation can provoke further inflammation, so the use of basic airways (OPA/NPA) is unhelpful and unwise. Although laryngoscopy can help confirm the diagnosis of epiglottitis (the epiglottis and arytenoids will be cherry red and swollen), it can also provoke spasm and further inflammation, so it is discouraged in the field unless immediate and unhesitating intubation is intended.

Albuterol is not indicated, and epinephrine has no benefit. In-hospital care includes antibiotics to clear the infection, and possibly the use of steroids to manage swelling.

Acceptable Risk

Following up on our previous post where we discussed patient refusals, it behooves us to say a few things about risk.

The culture of “everyone goes to the ED” is not writ in stone, and in some places, efforts are underway to expand it into a more sophisticated system. For instance, some patients might be transported directly to detox programs, homeless shelters, urgent care facilities, or psych treatment. Some, of course, don’t need to be transported at all, and can stay home, perhaps with instructions to follow up with their PCP. A few areas are experimenting with, or at least moving towards, the concept of an “Advanced Practice Paramedic” or “Advanced Paramedic Practitioner” who could sensibly and intelligently perform this assessment and triage, determining whether patients need immediate definitive care, or (in essence) “clearing” them of acute high-risk pathologies. Ideas like this may prove central to solving the many problems of healthcare in general and EMS in particular, such as ED overcrowding and the inefficient use of available resources.

However, just like the issue of patient refusals, to even discuss the possibility of such a system requires a fundamental shift in our thinking. At the moment, the approach is, “Try to recognize and treat Sick People — but if you don’t, that’s okay, because they’ll recognize them at the hospital.” Obviously, this practice is based firmly on the presumption that most or all of our patients do end up being evaluated in a full-fledged emergency department. Even the very notion that a patient can refuse to be transported ends up as a grudging allowance — we reluctantly acknowledge that we can’t actually kidnap people, but we still make them jump through hoops to make it entirely clear that we wanted them to go all along.

What if we started to accept that some of these patients don’t need an emergency room? Realistically, and retrospectively, it’s obvious that many of them don’t. Other destinations are more appropriate, and in some cases, no transport at all is necessary. But in order to make decisions like that, we need to be able to accept the assessment, clinical decision-making, and risk stratification of our field providers.

It goes without saying that instituting such a practice would require additional training, and providers (such as this mythical APP) practicing at a higher level than our current EMTs and medics. But it’s bigger than that. We have to be willing to let go of the safety net of everyone filtering through the ED. We have to be willing to accept the field workup as final — or at least, good enough that no further evaluation is immediately needed.

Closely wedded with the prehospital culture that treats patient refusals as bogeymen is the in-hospital culture that says every patient needs a comprehensive workup to rule out every possible killer. It doesn’t matter if the odds are 1,000,000 to 1 that the problem is benign rather than a massive MI or hidden PE; that 1/1,000,000 chance of missing the Badness is still unacceptable, so the patient gets the works.

We have the mindset that any miss is one miss too many.

This costs a lot of money. It puts patients through a lot of hell. But most of all, if we’re going to imagine a world where not every patient ends up even going to the emergency department, we have to accept a world where the ones who don’t will not receive that exhaustive workup.

Certainly, this triage process be handled sensibly, and conservatively, because we’re here to help people, not let them die at reasonable rates. So where do we draw the line? Is one miss in a thousand acceptable? One in a million? One in a billion?

We can draw the line wherever we want, but no matter where, there’s going to be a qualitative difference between a reasonable risk and “we did everything.” Because eventually, we’re going to miss one. A well-trained and conscientious clinician is going to assess a patient in their home, and appropriately conclude that their complaint is not dangerous, and that patient is going to die.

Because it happens — because flukes are inevitable. If we throw the kitchen sink at them, and we still lose, then at least we can hold ourselves blameless. But if we take a more reasonable approach, then we have to accept in advance that occasionally, the chips will fall against us. And that has to be okay.

The prevailing belief today is that anytime something goes wrong, something was done wrong. Adverse outcomes are an indicator of error, either an individual error or a flaw in policy or protocol. If I follow our procedures to the letter, and a patient slips through the cracks, it means we need to change the procedure.

Can we get to the point where we understand that if a situation is correctly evaluated, and the risks are correctly balanced, and we simply happen to get unlucky, that the decision was still right? Where we can stop spending ever-increasing amounts of time and money in the pursuit of ever-more-infinitesimal risk?

I don’t know. But if we can’t, then we’re never going to be able to solve some of these problems. Because perfection doesn’t exist, and chasing it is a good way to get very tired.

But it’s Just a Broken Nail!

One of the most common topics of debate in this business is something that should be simple. When is it okay for a patient to refuse transport to the hospital?

On the face of it this is a strange dilemma. When is it “okay”? What does that even mean? When is it okay to have Milano cookies and a bottle of Scotch for dinner? I don’t know. Leave me alone.

The chain of reasoning goes something like this. People call 911 because they have problems, and they don’t know how bad those problems are. By and large, we — the EMTs and paramedics on the ambulance — don’t know either. We don’t have the training or the tools to truly rule out major problems. So the only safe thing is to take the patient to the hospital. There, tall men with white coats, eight years of medical training, large expensive machines, and extensive liability insurance can decide if the patient is dying or not.

Okay. In some ways, that makes sense.

In other ways, it’s absurd. We all experience symptoms or incur injuries from time to time, and for the most part, we do not feel the need to visit the hospital to rule out deadly causes. Although it’s always a remote possibility that something is horribly wrong, in most cases it’s extremely unlikely, and it’s senseless to make an emergency out of every ache or sniffle. As we recently discussed, although it is possible to be very sick without looking like it, it is uncommon. If I woke up today with a minor headache, I wouldn’t want to spend hours of my time and hundreds of dollars at the emergency room “just in case.” So why does that suddenly become a reasonable course of action just because an EMS crew is standing in front of me?

There’s one good answer to this, which is that normally, I wouldn’t call 911 for a headache. So if there’s an ambulance here, it already means that for some reason, I had some special concern about this episode. Perhaps it was unusually bad, or prolonged, or I have medical history which makes me worried about what a headache might entail. Alternately, perhaps a friend or family member called on my behalf, but even then, presumably it’s because they had some reason to be worried.

This is all true. People who call for an ambulance are self-selected to be a higher-risk group than the general population. The headache patient who does dial 911 is more likely to be sick than the headache patient who doesn’t.

However, this isn’t always the case, and even when it is, it isn’t always significant. Some patients, or friends and family of patients, have a very low threshold for concern. Sometimes people misinterpret warning signs. Sometimes things just happen. Consider the hundreds of calls we take each year for minor MVCs. Someone dents their fender in traffic, a concerned passerby calls 911, and we show up to evaluate the occupants. There are no noteworthy injuries, and it wasn’t even the people involved who called for us. Is there a chance they have head bleeds, spinal fractures, pulmonary contusions? There’s always a chance. But do they need to go to the hospital? Or, put another way: they didn’t plan on going to the hospital before we arrived. We performed our medical assessment and found nothing alarming. Does the simple fact that we’re here mean there’s any better reason for them to go to the hospital than before we arrived?

Obviously, the answer is no. But we still tend to default to transporting them.

A cynic might suggest that this is because in most areas, ambulance providers can only bill for transports, not for refusals. In fairness, I don’t think this is usually the main reason.

A bigger reason is liability. There is a real concern on the part of providers, and on the part of the services employing us, that anytime we fail to transport a patient to definitive care, we might be “missing” something bad. As a result, they might later sue us for missing this. Would they have a case? Maybe, maybe not; it would depend on whether we followed the standard of care, and whether we implied to them that we “knew” they were okay with any greater certainty than we truly had. That’s the underlying issue, after all. It’s up to the patient whether they want to go, but we are medical professionals, with impressive uniforms and stethoscopes around our necks, and patients are therefore inclined to think that we know things they don’t. They’re inclined to do what we recommend. But even if we think they’re okay, we don’t know they’re okay, so our “recommendation” is usually to see the doctor, because that’s the only truly “safe” choice from our point of view.

Fair enough. But there’s a small problem with this. We’re lying.

Or at least deceiving. We are trained to assess patients, look for abnormalities, and identify findings that point to the possibility of injury or pathology. If we perform this task, and find nothing alarming or even suspicious, we are going to be thinking, “they’re probably okay. I’m not worried.” Why, then, do we turn to the patient and say, “You should really go to the hospital. I’m worried.”? One major national ambulance company has a policy that you should never ask, “Do you want to go to the hospital?” as it implies a choice — but instead, “Which hospital do you want to go to?” Railroading at its finest.

Certainly, it would be just as misleading to tell a patient, “You’re definitely okay.” We don’t know that, because as we already agreed, we lack the training and resources to diagnose anything for sure. But we do have enough tools to make medical decisions, which we do all the time — what’s the best transport destination? which medication is indicated? — and here, too, we can make an analysis of the risk factors. It’s not the same analysis that would be made by a team of doctors with a hospital at their backs, but as long as we don’t pretend that it is, that shouldn’t be a problem.

Think of it this way. If you were in the patient’s situation, would you want to go to the hospital?

Bear in mind that this isn’t a small thing. Depending on your circumstances, this may involve missing work (even losing a job), arrangements needing to be made for babysitting, housesitting, or pet care, cars retrieved, plans cancelled, and oh yes — a bill ranging from a few dollars to many thousands. Can’t pay that? Now your credit is on the line. You can also look forward to hours of sitting on a series of stretchers, wheelchairs, and beds, while busy people wearing scrubs stick sharp things into your flesh, capture your bodily excreta in plastic cups, and ask you an endless series of the same questions over and over and over. You will miss sleep, get behind on projects or errands, and in the end you will have to find a way to get yourself home and clean up from all this chaos. Possibly with a new infection that you picked up in the waiting room.

If we are responsible, we should view transportation to the hospital as a medical intervention in the same category as medications, invasive procedures, and diagnostic tests. It has certain indications and benefits, but also certain risks and harms associated with it, and we should consider both sides in balance before making a recommendation on the best choice. Certainly, that decision will have to be made by the patient, not by us, because it’s the patient who is undergoing these risks and benefits, so it’s they who get to decide how to weigh them. But they also don’t have the medical understanding of the situation that we do. So that’s our job: to transmit to them what we’ve found in our assessment of their complaint. The risk factors, the positive or negative findings on their physical, any alarming vital signs, and the salient features of their history. In many cases, this process is why they called us — because although they’re experiencing something abnormal, they don’t know if they should be worried or not. We won’t have all the answers, but we can give them more information than they had before, and they can use that information to better inform their decision on whether to seek further care. (Remember, this might include scheduling an appointment with their PCP, visiting an urgent care clinic, getting a ride to the ED or driving themselves, and of course the old “wait-and-see” approach. Even when more care is needed, the ambulance isn’t the only answer.)

For the reasons of liability, and policy, and the general fear-mongering attitude that has swept over the healthcare industry in recent years, this is a very difficult line to walk, and in many cases to preserve your job and license you may need to err on the side of “encouraging” a patient to be transported. However, I find it ethically troubling when we mindlessly push everyone towards the ED, no matter what common sense or their medical situation tell us. When we visit someone with a complaint that we’d ignore in ourselves, our partner, or our mother, and convince them to climb into the ambulance anyway, whose best interest are we looking out for?

Are we hurting the patient to help ourselves?

Are we okay with that?

The Art of the Transfer (part 3)

Continued from part 2…

There’s another benefit of patient transfers beyond the merely educational. You get to meet the people.

Oh, you meet people on emergencies. Depending on the nature. Dead people don’t talk much. (You get a look at their houses, maybe.) And really sick people, well, you’re pretty focused on the medical stuff then. Patch this, pump that, push the magic potion. When did it start? Have you felt this way before? What Russ Reina calls the business of being a “flesh mechanic.”

But on a routine transfer, and to a lesser extent on the non-emergent “emergencies” (when you have little to do and no hurry to do it), you get to actually chat with the human being upon your stretcher. Imagine that! They don’t just have a name and date of birth — they have a trade, a family, a history, a life.

Everyone has a story. Some of them are more interesting than others on the surface, such as the retired spy or the film star, but everyone has a story, and they’re all worth hearing, if you care.

Most of these people are old. If you’re not old, you may think this means they have less to say to you, but really, it’s the opposite. You’re 25 and they’re 90; all of the problems you’ve got, all the changes in the world you think are new, every dilemma you’ve ever faced, they’ve seen it and heard it and done it. They’ve been alive for several of you. Do you think people live that long without knowing their way around?

I once heard it suggested that you don’t really grow any wiser as you age, because although you learn from your mistakes, there are still an infinite number of future mistakes to be made. You never “run out” of new errors.

Perhaps that’s true. But even if the 90-year-old benefits little from his wisdom, that doesn’t mean you can’t borrow some of it. And even if his experiences or decisions differ from yours, they were just as important to him as yours are to you, and you can bet the stories are worth hearing.

Where else can you meet such a range of people? And not just meet, but find yourself forced into spending one-on-one time with them? If you’re a misanthrope, this is not a good career for you. Multiple times a day you’ll be placed in a small box with a stranger for a period lasting minutes to hours. It’s like speed dating.

But if you like people — enjoy meeting them, appreciate their company, take pleasure in their lives — then there’s no better job to have.

Drug Families: ACE Inhibitors and ARBs

Understanding the renin-angiotensin-aldosterone system is like following one of those dotted-line Family Circus cartoons — not just long and tortuous, but seemingly designed just to be obnoxious.

Here’s the basic idea. The RAAS is the basic system your body uses to control blood pressure, as well as related values like fluid volume and sodium levels. The most important thing to understand is that the activation of this system causes an increase in blood pressure. Following the trail:

First, renin is released by the kidneys. Renin attacks circulating angiotensinogen, turning it into angiotensin I. Angiotensin I is attacked by circulating angiotensin converting enzyme (or ACE), which turns it into angiotensin II. Angiotensin II has various effects, one of which is to stimulate the release of aldosterone.

Whew.

But this isn’t as complicated as it looks. Renin has no real effect. Angiotensinogen just makes angiotensin I. Angiotensin I’s main role is to make angiotensin II. The real money here is in angiotensin II, as well as aldosterone.

Angiotensin II has the primary effect of vasoconstriction. It tightens up the vasculature, increasing blood pressure and systemic resistance. It also produces vasopressin (aka ADH, or anti-diuretic hormone) and aldosterone, which cause the kidneys to downregulate urine production — more fluid will be returned to the circulation rather than discarded into the bladder. Vasopressin also helps angiotensin II to induce further vasoconstriction.

To make a long story short, the activation of the RAAS system causes an increase in blood pressure via both vasoconstriction and a decrease in kidney output. It is always active, playing a key role in maintaining homeostasis; if you sweat out a liter of water running a marathon, or bleed out a liter from a gunshot wound, the system simply upregulates itself to maintain your blood pressure using the remaining volume. (Unlike the sympathetic and parasympathetic systems, which also play a major role in regulating blood pressure, regulation via the RAAS is captained mainly at the kidneys, where low pressure and throughput induces increased renin production.)

Cool? Cool.

Okay, so the role of ACE, or angiotensin-converting enzyme, was to transform the useless angiotensin I into the powerful angiotensin II. What do you think a drug called an ACE inhibitor would do? Indeed: it inhibits the activity of ACE, thus reducing the production of angiotensin II, which then causes reduced production of aldosterone and vasopressin.

Less angiotensin II means less vasoconstriction; the systemic circulation opens up, reducing blood pressure. Less aldosterone means less fluid is retained at the kidneys, so urine output is increased, reducing circulating volume, and again, reducing blood pressure. Handy!

A secondary role of ACE is to degrade, or break down, bradykinin. Bradykinin is basically just another vasodilator. If ACE is inhibited, then less bradykinin will be broken down, hence more bradykinin will be available. The result is more vasodilation — once again, reducing blood pressure.

Readers who can recognize patterns will probably have deduced that ACE inhibitors are used primarily to reduce blood pressure. Obviously, this includes the typical patient with primary hypertension that needs to be managed to reduce long-term morbidity. But it also means other things:

Reduced afterload — the resistance the heart has to push against when it pumps blood — means less work for the heart. This is beneficial for patients with heart failure, whose hearts aren’t pumping very well to begin with; or with coronary artery disease, whose hearts need to manage their workload to match the oxygen they’re able to bring in. It reduces “remodelling,” where the heart and the arteries thicken and change shape to better pump hypertensive volumes, with harmful results. And it reduces the damage following myocardial infarction.
Reduced preload — the amount of blood that passively fills the heart during diastole — — also means less work for the heart. Greater preload causes greater filling and hence greater contraction, which all means more work, more oxygen demand, and more remodelling. In heart failure, where the heart is unable to fully expel its contents, reduced preload also means less “extra” fluid to back up into the lungs and circulation, and therefore less edema.
Better renal function. This is a desirable effect in patients with various forms of kidney disease.

Angiotensin receptor blockers (ARBs) are a closely related family of drugs. Instead of interfering with the conversion of angiotensin I to angiotensin II, they simply prevent angiotensin II from binding with its receptors. The effects are therefore largely the same: vasodilation; reduced aldosterone production, with corresponding greater urine output; and reduction in hypertension with less work for the heart.

The main difference between ACE inhibitors and ARBs goes back to bradykinin. If you remember, ACE plays two roles: converting angiotensin I to angiotensin II, and degrading bradykinin, a vasodilator. Since ARBs have no effect on ACE, bradykinin is broken down normally. This may result in slightly less vasodilation, but it also reduces the side effects of elevated bradykinin, which can include edema and a nasty cough. ARBs are most often used in patients who can’t tolerate ACE inhibitors.

Overdose on ACE inhibitors is generally unremarkable. The main effect is hypotension, but it is rarely severe.

Examples

Generic names of ACE inhibitors and ARBs are very, very easy. Trade names are harder, but do have some common elements.

ACE inhibitors

Drugs ending in -pril are invariably ACE inhibitors (enalapril, ramipril, captopril, lisinopril, etc.)
Drugs ending in -ace are often trade names of ACE inhibitors (Altace, Tritace)
Drugs ending in -tec are often trade names of ACE inhibitors (Vasotec, Renitec, Novatec)

ARBs

Drugs ending in -sartan are invariably ARBs (losartan, valsartan, candesartan, etc.)

More Drug Families: Stimulants and Depressants; Steroids and Antibiotics; Anticoagulants and Antiplatelets

Treat the Patient?

We’re taking a short break from our series on transfers to discuss a recent post on the EMT-Medical Student blog. One of the issues he brought up is the old saw, “Treat the patient, not the machine.” Rogue Medic struck on this as well.

What do people mean when they say this? They mean that if you attach a diagnostic tool like a pulse oximeter, and it gives you a result that is at odds with the rest of your assessment, then it is probably wrong, and you should not base your decisions on it. It can be broadened to the BLS level, including findings like vital signs, by saying: “Treat the patient, not the number.”

And it’s essentially true. In fact, something I frequently harp on is that diagnosis must always be based on a broad constellation of consistent findings, not on any one red flag. We like red flags, we want red flags, because they’re easy, but it never works that way. The body is an interdependent system, and if a pathology is present, then it almost always has multiple effects detectable in multiple places.

This idea can be looked at differently by asking another question: is it possible to be severely, acutely sick without showing it? I don’t mean long-term problems like cancer; you can’t look at someone and detect that. But if someone’s dying in front of you, of a proximate cause like hypoxia, is it always obvious based on their presentation?

Generally the answer is yes. That’s why it’s wrongheaded to look at a healthy patient with pink skin, normal respiratory rate, calmly denying shortness of breath, but with a low oxygen saturation, and say, “Oh no — he’s hypoxic!” If your oximeter says 72%, what’s more likely — that the number is wrong, or that the patient is somehow hypoxic without any other evidence of it?

Call this the phenomenon of the Hidden Killer. Is it common? Is it real?

It is not common. But it is real. And that’s what’s not recognized when people say, “Treat the patient…”

Why do we take 12-lead ECGs on chest pain patients? Because a clinical assessment alone cannot reliably detect ST elevation, which (simplifying the issue!) is diagnostic for a heart attack.

Why do we take CT scans of blunt head injury patients? Because a clinical assessment alone cannot reliably detect intracranial hemorrhage.

Why do we perform abdominal ultrasounds in multi-system trauma patients? Because a clinical assessment alone cannot reliably detect abdominal bleeding.

Now, some critics will say that all of these will indeed present with obvious, frank clinical findings. The major STEMI patient will eventually enter cardiogenic shock. The head bleed will become comatose and present with Cushing’s Triad and herniation. The abdominal hemorrhage will have guarding, distension, and eventually outright shock.

All true enough. But we’d like to find them earlier than that. It’s true that severe and late pathologies are usually obvious, but our job is to find them when they can still be treated, not after their effects are permanent or lethal. Heck, we could also just provide no medical care and wait until everyone died to make a diagnosis, which would extremely easy to assess, but a little pointless. It is rare that big problems do not have a big assessment footprint, but “small” problems can still be a big deal.

Consider the much-maligned pulse ox. Surely it does not replace a full assessment. But when used appropriately and its role understood, it provides valuable information. A drop from 99% to 94% saturation may not be clinically obvious, but it is potentially significant and surely worth knowing about. What about the patient who is non-verbal at his baseline? Is he going to complain if he drops from 95% to 87%? Will it be frankly obvious from his skin and breathing? Maybe, maybe not. (How about if he’s on a mechanical ventilator at a fixed rate?) If not obvious, does that mean it’s no big deal?

Is the pulse ox always correct? No. But like all things except magic, it’s wrong in predictable ways, ways that can be accounted for, and when it is wrong, that can tell you something too. It requires adequate peripheral circulation, and poor perfusion will make it read low. How is the patient’s distal perfusion? Pink and warm? Good capillary refill? Then you’re probably okay. Carbon monoxide poisoning will make the sat read high. Has the patient been in enclosed spaces with heaters or open flames? Working around engines? Is there any potential source of CO in their history? If not, you’re probably okay. Alternately, does their sat read unusually high compared to their clinical presentation? You might then consider carbon monoxide — something you might not have otherwise have known without the oximeter. It didn’t give you a correct number, but by knowing how and when it fails, it gave us a useful answer.

Here’s a recent example. I picked up a patient with a blood pressure of 54/4. That is a ridiculous blood pressure; arguably, nobody should have it, on the theory that a pressure that low should be pretty close to unobtainable. But, there it was. We diverted to the nearest hospital and I was subsequently chewed out by the receiving nurse.

Do I think that patient truly had a central arterial pressure of 54/4? Nah. Although she wasn’t doing well, her skin was better than that, and although she was altered and combative, she wasn’t comatose. However, her pressure was undoubtedly low, and just how low? If I don’t go with this number, then I’ve got no guidance. The clinical picture was clouded. I couldn’t ask if she knew what day it was; I couldn’t ask what her complaints were; she was non-verbal. She was tachycardic and hypoxic and diaphoretic; she was certainly sick. So, treat the patient, or treat the number? The number may not have been right, but it was concerning enough that it couldn’t be ignored without an assessment that otherwise screamed “no problems here!”, which was not what we had.

Treat the patient? We always treat the patient. A hands-on physical and history is a vital, vital tool for assessment, but other tools are also useful. Some people lament the downfall of the traditional clinical assessment, from the days when doctors with fingers like pianists made diagnoses from findings like Ewart’s sign, and it is shame, but the reason that the high-tech tools like imaging and labs have become de rigueur is that they work well — they diagnose many problems with a speed, sensitivity, and reliability that is not otherwise possible. Nobody would ever say, “Treat the patient, not the unstable cervical spine fracture,” because we recognize that’s the sort of thing you may not otherwise notice until it’s too late. That’s why we spend big bucks on CT scanners.

It all matters. It’s all useful. We should neither cast aside our individual numbers nor ignore the bigger picture. Data is something that, like money and sex, you can never have too much of.

The Art of the Transfer (part 2)

Continued from part 1…

One of the best types of transfer for educating yourself is a discharge from a hospital, or in some cases from a nursing home or rehab.

It doesn’t matter where they’re going; what matters is where they’re coming from. Because your patient’s leaving a prolonged stay in skilled medical care, they should come with a whole bevy of paperwork and documentation chronicling their course of care. And you get to read it!

He presented to the ED with X symptoms. Was worked up with Y tests, and awarded Z diagnosis. Was admitted for A, B, and C treatments, and is now being discharged in Q condition.

Now if you ever get a patient with X symptoms, you have a great idea of what’s going to happen to them at the ED; you’ll know the leading diagnostic possibilities in their differential; and you can guess the types of treatment they’re going to receive. Did you learn this stuff in EMT class? I sure didn’t; for many of us, once the patient hits the door of the hospital, they’re no longer of interest. But that’s not how it works — you’re part of a sequence of care, not a one-act play, and if you don’t understand what happens later, you can’t make effective decisions now. Even something as simple as explaining to the patient what’s going to happen once they arrive at the ED is impossible if you don’t have a clue yourself. “We walk in the door… and then magic happens!”

Moreover, once you enter that patient’s room, you get to assess and communicate with that very same patient you just read about in the chart. You can say, “Ah, so this is what that disease process looks like”; you get to feel the pulse fixed at 60 by a pacemaker, listen to the lungs filled with fluid in the CHFer, and examine the scar made by a recent craniectomy. This is like getting the answer to a quiz, then learning the question. In the future, if you hear those crackling breath sounds, you’ll know what they mean, because you’ve heard the same thing in patients whose diagnosis you already knew. Remember, in the field we often never learn the answers; we make best-guesses and presumptive diagnoses, but unless we’re able to follow up later on their eventual diagnosis, we may never know if we were right. The discharge is your chance to get in at the other end of the process and put it all together.

You also get to organize your mental categories of disease. Coming out of class, you’ve learned a litany of human ailment that runs from A to Z; and whatever order you learned it in is probably the order you remember it in, except for some important, life-threatening illnesses that received special attention. But in real life, facing a real patient, the diagnosis probably isn’t the first one in the textbook, and it’s probably not the most deadly zebra; it’s probably the most common disease, because that’s what common means. Transporting a hundred patients helps you understand what’s common. You do need to remember that shortness of breath can be caused by a pulmonary embolism, but you’re coming from the wrong direction if it’s the first thing on your mind when you meet a gasping patient, because it’s just not as likely as other possibilities. Discharging a few dozen people with COPD will help rearrange this for you.

How about meds? People come out of the hospital on lots of them. Diligently reading those charts will help you learn which ones are used for which diseases, and if you make an effort, you can start to memorize their names and connect generic with trade names. And you’ll read Coumadin and then meet the elderly lady with bruises all over, complaining about how she gets cold so easily. Connecting the dots, connecting the dots.

If you’re enterprising, you can practice analyzing EKGs, interpreting labs, and reading imaging reports. It’s all in there, and it’s all part of the patient’s medical care. And no matter how distant something might be from your own scope of practice, as long is it involves the same human beings you’re treating and transporting for the same problems, then more knowledge will make you a better EMT.

The Art of the Transfer (part 1)

One of the problems with EMS today is that it involves a bait-and-switch.

From the outside, it’s not widely understood what the work involves. There’s a vague idea about flashing lights and saving lives, but that’s about all the public knows. So, enterprising young men and women take the class, get the training, find a job, and quickly discover that EMS from day to day isn’t quite what they had in mind.

Nowhere is this more apparent than for the EMT-B. For him, in many areas, most or all of the available work involves not emergency 911 response, but non-emergent patient transfers. Patients travel from home to hemodialysis centers, from nursing homes to doctor’s offices, or from hospitals to rehab facilities. Sometimes these are patients who need oxygen therapy or airway management; sometimes they are medically unstable and need close monitoring (although these patients often travel by ALS); but most often, they’re simply people who can’t easily stand or walk. If due to age or disability you’re unable to climb into a car or shuttle, and can’t safely transfer yourself to and from a wheelchair or sit in it, then you need to travel from place to place in a bed — and ambulances are the only traveling “bedmobiles” out there. Well, ambulances and hearses.

Routine transfers can get old. Real old. Maybe you’re looking for excitement. Maybe you’re looking to make a difference. Maybe you just want to use your skills or activate some neurons. Whatever the case, it’s easy to feel like bringing an endless parade of old people to their eye appointments is neither “emergency” nor “medical” even if it is a service.

Nevertheless, for many of us it’s an unavoidable part of our day. So it’s worth making the most of it.

A Classroom in the Ambulance

Transfers might be boring. But boring’s a good way to start out. There’s no better way to learn how to be an EMT.

My first job in this business was in a system doing 911 coverage almost exclusively. This seemed like a great opportunity, especially in an area (Northern California) where EMTs in the private sector were rarely able to work emergencies.

In retrospect, though, it was the wrong way to start. I walked in the door with absolutely no idea of how to do this job, and was immediately thrown into the field with no learning curve. I was expected to assist the medic, drive the ambulance, check the equipment, manage communications, and of course handle any BLS care. This was fresh out of EMT class, where I had no idea how to do any of that, and most of what I did know is not what was needed. And guess what? Every call was an emergency. Admittedly most “emergencies” are not exactly world-ending, but there were still stakes involved, which meant that being useless was bad for the patient, bad for my medic, and bad for me — because with the pressure on, it was difficult to relax and make the necessary “learning mistakes.”

My next job was in a service where almost 100% of our work was routine transfers. Although this could be mind-numbing, I quickly realized how much of a better learning environment it was. Because in nearly every case, the patient in front of me was not having any acute problem, my assessment could be a total blind-man’s fumble and there wouldn’t be any adverse results. That’s not to say that you’ll never be in a position to take action — but it’s rare.

On a 911 response, you’re the patient’s initial point of entry for the health care system. Before today, there was no problem, at least not from this particular episode. Now there’s something new that needs to be addressed, and you’re deciding how that will happen. The answer might be easy, but it’s still being made.

On a transfer, the patient’s course of care has already been planned and initiated. Their problems are diagnosed, their treatments are underway. Your responsibility isn’t to set anything into motion, but merely to ensure that there’s no deviation from the intended path. This requires learning the patient’s current baseline — which may be very sick — so you can note any new changes, and learning what their current plan is (perhaps a discharge back to their home, which will require a stair-chair carry to get inside), so you can facilitate it as best you can.

Take some vitals. Check pupils, feel skin, listen to breath sounds. Listen to their story. You’re doing these things as a matter of course, because you’re supposed to, in the midst of friendly chit-chat — but you’re also practicing all of your foundational skills. In the off chance of anything unusual, you’ll hopefully find it. But in the mean time, you’re turning yourself into a good EMT, so in the future when you do start running emergencies, you’ll be ready. Do more than you need to, because the time to figure out the tricks of taking a thigh blood pressure is when it doesn’t matter, not when it does.

To quote the biblical if crass House of God,

Look, Roy, these gomers have a terrific talent: they teach us medicine. You and I are going down there and, with my help, Anna O. is going to teach you more useful medical procedures in one hour than you could learn from a fragile young patient in a week. . . . You learn on the gomers, so that when some young person comes into the House of God dying . . . you know what to do, you do good, and you save them. (76)

Tune in next time for more on the fine, fine art of squeezing juicy goodness out of each transfer you get.

David Hiltz on Resuscitation

In mid-May, FDNY hosted an educational conference on the topic of resuscitation. Numerous invited speakers, including medical directors from many of the country’s largest EMS systems, discussed issues like current research trends, “pit crew” models for CPR, and optimizing systems of care for communities.

I attended with David Hiltz, a longtime paramedic who now works with the AHA. A lot of valuable ideas were shared that weekend, including some material that bears upon Dave’s own work. I asked him to discuss it with me, bringing to bear his perspectives as a field provider, an educator, and a longtime “bridge builder” for Sudden Cardiac Arrest continuity of care.

A disclaimer: David’s participation here is solely personal in nature, and none of his comments or opinions should be understood as being officially endorsed or approved by the American Heart Association.

Brandon Oto: Dave, for those not familiar with you and your work, can you introduce yourself briefly?

David Hiltz: I have been in the healthcare industry since 1984, and over time, working in hospital emergency departments and with EMS agencies, I developed an interest in resuscitation. I have been on staff with the American Heart Association’s Emergency Cardiovascular Care Programs for over 13 years and during that time, I have had the good fortune of meeting some really brilliant and committed people from whom I have learned so much.

BO: You’re involved with the AHA’s HEARTSafe Communities initiative. Can you tell us about that? What are you and the AHA trying to do?

DH: To be correct, the HEARTSafe program does not really “belong” to anyone. Rather, it’s a concept for communities to use in improving recognition, response, care, and outcomes for cardiac arrest patients.

The HEARTSafe program is a population and criteria-based incentive program designed to advance systems change in accordance with the American Heart Association’s Chain of Survival. Individuals, businesses, public officials, and emergency responder agencies are asked to establish a cardiac arrest response system geared toward these criteria.

The primary goal of the HEARTSafe Communities program is to increase survival rates from out-of-hospital cardiac arrest. Individual communities are asked to develop and implement lifesaving strategies that focus on coordinating local resources to prevent sudden cardiac arrest from becoming sudden cardiac death.

Half the men and women with serious coronary artery disease first learn about it in a dramatic way: sudden cardiac arrest.

Outcomes at this point depend on whether the collapse is witnessed, whether the bystanders are trained and willing to perform CPR, and whether the arrest has occurred in a system set up to allow the early arrival of needed resources and the timely execution of evidence-based interventions.

Many have recognized the need to improve community systems of emergency cardiovascular care in order to optimize patient survival. The “Chain of Survival” represents the current approach to improving recognition, response, and care.

Decades after its creation, this same systematic and coordinated approach remains the strongest recommendation the resuscitation community can make to save more people in out-of-hospital cardiac arrest. (Not that I have any business being a “representative of the collective opinion” of the resuscitation community!) The idea is simply to maximize each community’s resources by implementing appropriate measures and strategies to achieve the greatest attainable patient survival.

There are numerous systems around the world where the implementation of community-based measures has lead to improved outcomes for critical out-of-hospital patients. I believe that programs such as Heart Rescue and HEARTSafe Communities are valuable frameworks for any group looking to explore related strategies for improving survival and quality of life.

BO: This past May, you and I were able to attend a conference on Randall’s Island, hosted by FDNY and focusing on topics surrounding resuscitation. The main theme was a continuing reinforcement of the basic fundamentals of resuscitation by laypeople and BLS responders, especially the importance of early, ongoing, and high-quality CPR.

Several speakers made the particular point that improving bystander CPR rates is one of the most important and highest-value steps we can take to improve our survival rates; Dr. Chris Colwell described it as the low-hanging fruit of the Chain of Survival. Overall, Dr. Paul Hinchey suggested that we need to shift our priorities away from the clinical practices of professional rescuers and clinical centers, and towards the recruitment of the general population.

Based on your experience with HEARTSafe, what are the principal challenges to improving bystander CPR rates? Why haven’t we been able to accomplish this important and seemingly simple task in all of our communities?

DH: Let me first say how much I enjoyed attending the conference and spending time with old and new friends there.

Your questions are significant ones. This statement from the Executive Summary of the 2010 American Heart Association Guidelines for CPR and ECC Science articulates the core issue at hand:

Although technology, such as that incorporated in automated external defibrillators (AEDs), has contributed to increased survival from cardiac arrest, no initial intervention can be delivered to the victim of cardiac arrest unless bystanders are ready, willing, and able to act.

Bystander CPR can dramatically improve survival from cardiac arrest, yet far less than half of victims receive this potentially lifesaving therapy. CPR is inexpensive, readily available, and can save lives. Based on what we know, increasing the rates of bystander-initiated CPR is critical to improving outcomes.

There are a number of theories regarding the hesitation of bystanders to perform CPR, even when adequately trained. Mouth-to-mouth breathing and concern about the transmission of infectious disease may explain reluctance among some. Another potential barrier to learning and performing bystander CPR has been the complexity of past resuscitation guidelines. This complexity may affect a citizen’s willingness to learn CPR skills, contribute to a failure of recall, or negatively impact confidence in their ability to perform during an emergency.

While “fear of failure” is often cited as a major barrier, some bystanders may also decline to perform CPR because of legal concerns, and are often not aware of their protections under Good Samaritan statutes. Many educators and clinicians continue to hear concerns such as, “What if I break a rib?”, “What if the person dies?”, and “Can’t I hurt someone with CPR?” Fears like these should not get in the way of helping another person in their ultimate time of need. Knowing and performing CPR should be thought of as a moral obligation and civic duty.

Widespread access to CPR education is another potential barrier. In many cases, citizens need to make a concerted effort to identify and enroll in a CPR program. For instance, many sources for CPR education focus their efforts on training healthcare providers and do not routinely offer appropriate courses for the general population. This should change.

The marketing surrounding CPR are also important. My experience has been that despite our best intentions, CPR “advertisements” are often poorly conceived and send the wrong message. Make no mistake, regardless of whether you are a hospital, an EMS agency, or a lone instructor, you are marketing and promoting CPR education. If your “message” is not effective, people will not be interested. Consider the following commonly seen messages promoting CPR. Which do you think would be most effective in enlisting the public?

Get certified in CPR
Instruction in BLS for Healthcare Providers, CPR, First Aid, Bloodborne Pathogens, AED use, Emergency Oxygen Administration, Fire Safety, and Child & Babysitting Safety to the public and private sector
BLS every Wed or Sat
One quarter of Americans say they’ve been in a situation where someone needed CPR. If you were one of them, would you know what to do?
Is learning CPR important? Just ask these people… she learned and he lived
There are 300,000 cases of cardiac arrest each year with 80% occurring in and around the home. Only 5% survive. Learn CPR.
The time to learn CPR was yesterday… tomorrow could be too late.

I highly recommend reading the book Made to Stick, by Chip and Dan Heath. We all want our ideas to be understood, remembered, and have a lasting impact; this book may help you to make your ideas more effective. They also discuss the concept of “The Curse of Knowledge,” which is described as “knowing something too well, so that this knowledge actually inhibits our ability to communicate the essence of it to the audience.” This curse of knowledge can be seen in how we promote CPR to the public as well as in how we often deliver it! I believe that the “curse of knowledge” is a villainous and self-defeating phenomenon that often shows up in our CPR training.

All of us in public safety should remain focused on broadening CPR education for the general public, and there are a number of new programs to help support this, such as the AHA’s “CPR Anytime for Family and Friends” kit and the advent of Hands Only CPR. The CPR Anytime kit makes it possible to deliver hands-on training to large groups of people in a matter of 20-30 minutes. I am particularly supportive of this system, due to studies that demonstrated the effectiveness of the kit being as good as the traditional three- to four-hour courses — 93% of trainees could still perform adequate chest compressions and successfully use an AED six months after learning it.

BO: It sounds like the answers to many of the current problems in addressing Sudden Cardiac Arrest are not medical in nature, but psychological. We’re moving away from questions like “what’s the ideal antiarrhythmic?” and towards questions like “how can we market CPR so people will learn it, teach it so they’ll remember it, and contextualize it so they’ll be willing to do it?”

The reason this shift is both possible and necessary is that there’s a tentative agreement in the literature that, to put it briefly, what works is the simple stuff. As Dr. Chris Colwell laid it out, when it comes to the good old ABCs, compressions are definitely important in arrest — but Airway and Breathing perhaps not so much, and the jury’s still out on exactly what role they should play. But we do know that early, consistent, deep chest compressions, at an appropriate rate, with minimal interruptions do make a difference, and it’s fortunate that this dovetails well with the “human interface” problem, where people have been telling us that bystander CPR was too complicated and scary. So the main goal now is to see how many people we can tag with this meme of “when someone looks dead, push on their chest” — and simpler memes work better.

But what about the role of EMS in this picture? On the one hand, we are trained professionals who have less room to complain about “scary complexity” in our care. On the other hand, we’re human beings too, and we seem to face some of the same problems as laymen — for instance, we bag too fast, we don’t push deep enough, and (as Dr. Paul Hinchey described) we have a nasty habit of interrupting our compressions for all sorts of reasons. Some people were predicting the 2010 AHA Guidelines would see a wholesale switch to compressions-only, even for healthcare providers. That didn’t happen, but is that the general direction we should be going? The clinical picture here isn’t clear — the literature has some support for minimally-interrupted compressions by EMS, but it seems unwise to start demanding that the BVM always stays in the cabinet when there’s no pulse. Respiratory etiologies of arrest — like drowning — make this clear enough. Still, as Dr. Paul Pepe said, would we rather have more oxygenated blood circulating less, or less oxygenated blood circulating more (with fewer interruptions to compressions to allow for breaths)? How far do you think we should take this trend of simplification in the professional setting? Does the “human element” mean that we need to cut things down on the professional side as well?

DH: I think that categorizing citizen CPR “issues” as psychological, psycho-social or as one of behavioral change is correct.

Existing education research suggests that attitudes and behaviors are different from cognitive knowledge and skills, and cannot be adequately addressed through discussion that is simply added or dropped into courses. Perhaps future course design could better address these emotional perceptions. Ideally, the average citizen should want to know how to perform CPR and should feel comfortable about the idea of doing it in a real emergency, perhaps even before they ever give serious consideration to learning the skill itself. Increasing the number of people who are trained and willing to act is essential to improving the likelihood of survival.

EMS providers should be doing whatever is necessary to improve the quality of the resuscitation we provide. This will not be accomplished through initial training and education alone. Examining and optimizing our actual performance in the field is needed: improving resuscitation quality will require regular practice, real-world data collection, and an iterative process of measuring and improving.

Adding more sophisticated gadgets and more complex therapies may not yield the desired results, particularly if the fundamental problems have not been addressed. This would support the general idea of simplification — but because of the diversity among EMS providers and agencies, it is difficult to make any broad statements. Before adding “something else,” it may make sense to first ensure that we are doing the essentials well and consistently.

In addition to improving the quality of our own resuscitation, we as providers also have a unique opportunity to play a role in citizen CPR education. I would even suggest that other public safety agencies, such as fire and police, share this responsibility as well. If we truly believe that EMS is where public health and public safety intersect, then we should be making citizen engagement one of our priorities. There are a wide variety of “off the shelf” programs, products, and strategies that we can put into practice at the local level. Concepts like HEARTSafe Communities, HeartRescue, and other similar models for improving community response to cardiac arrest can provide guidance for implementation.

Desire and intellectualization alone are not enough to save lives. Full implementation of the AHA recommendations will improve outcomes, but it requires the involvement of each provider, agency, and system to make resuscitation quality a priority and lead the effort to save lives.

BO: Paul Hinchey talked about CPR devices and adjuncts like the LUCAS and the Zoll AutoPulse. The current evidence seems to indicate that these devices are no more effective at increasing survival to discharge than perfect-quality manual CPR. However, when perfect-quality manual CPR is not possible, a mechanical device may have a role. In particular, Dr. Hinchey pointed out that if we begin to routinely accept codes directly into the cath lab for intra-arrest PCI, then transports prior to ROSC would become a valuable option in some situations, and due to the challenges of continuing CPR while packaging and transporting, mechanical devices might then come into their own.

This idea seems to mirror another idea involving “code drugs” like epinephrine and amiodarone. Currently there is no evidence that any of these drugs improve survival to hospital discharge — the only outcome that really matters. However, they may improve survival to hospital admission, and one argument for their continued use is that if we can keep people “alive” (neurologically intact and with a salvagable myocardium) until they get into the hospital, then perhaps later advanced care (such as catheterization, ECMO, therapeutic hypothermia, or other future remedies) might be able to get them back out again. In such cases, even an intervention that only supports part of the Chain of Survival might have ultimate value if something else can provide the last few links.

In any case, do you believe devices that “replace” the rescuer in providing the major components of CPR can have a role? Assume that, as have tentatively found, they do the job no better than an ideal human, but also no worse. With all the challenges we’re encountering in getting really consistent performance from our rescuers, are there some situations where we should simply cut our losses and turn the job over to a machine? Obviously this won’t always be possible — unless every citizen carries their own Thumper — but we could move towards a point where every EMS and first response unit carried such a device and made attaching it a priority.

DH: A variety of devices have been developed and promoted in an effort to enhance perfusion during cardiac arrest. Generally speaking, these devices require more personnel, training, and equipment, or apply only to specific settings. Although the idea of using technology to improve perfusion during arrest is indeed intriguing, I think it is important to remember that the application and use of these devices also has a potential to delay or interrupt CPR. Since we do know that delays and interruptions negatively impact survival, agencies and rescuers choosing to use these devices need to be acutely aware of this downside, and take steps (such as appropriate training) to minimize potential interruptions in chest compressions and/or defibrillation.

To quote the current AHA-ECC and CPR Guidelines: “To date, no adjunct has consistently been shown to be superior to standard conventional (manual) CPR for out-of-hospital basic life support, and no device other than a defibrillator has consistently improved long-term survival from out-of-hospital cardiac arrest.” Also, “Class IIb recommendations are identified by terms such as “can be considered” or “may be useful” or “usefulness/effectiveness is unknown or unclear or not well established.”

High-quality CPR is fundamental to the success of any “ACLS” type of intervention. We should place the highest priority on performing good chest compressions with adequate rate, depth and complete recoil. Interruptions in chest compressions and unintentional hyperventilation must be avoided. In particular, for patients with shockable rhythms, defibrillation should be delivered with minimal interruption in chest compressions.

To date, increased rates of ROSC associated with ACLS drug therapy have not translated into long-term survival benefit… but perhaps improved quality of CPR, combined with advances in post-resuscitation care, will provide additional insight regarding the role of drugs in optimizing outcomes.

I think it is also appropriate to consider the process of organ and tissue procurement in an effort to minimize waiting time and alleviate suffering for patients qualifying for organ transplant. In my opinion, there is room to improve efforts relating to the ethical procurement of organ and tissue donations.

Based on what I know, and in my opinion, mechanical devices can’t replace a rescuer in providing the major components of CPR. They may have a role in certain circumstances and settings, but there is a clear and continued need for human hands on the chest. Adding a mechanical device will not, by itself, solve CPR quality issues. Additionally, without careful implementation, these devices could potentially hinder rather than help the CPR process. Incorporating them is fine and could be very appropriate in certain settings, but caution and careful implementation is needed.

BO: Thanks for bringing that up; we often don’t think about CPR’s role in maintaining viable organs and tissue for transplant.

You mentioned post-resuscitation care. One of the points Dr. John Freese made is that, when it comes to practical implementation of post-ROSC therapeutic hypothermia protocols, we’ve found that starting hypothermia prior to ED arrival can be beneficial. This isn’t necessarily for clinical reasons, but instead because hypothermic therapy already initiated when the patient arrives at the hospital is very likely to be continued in the hospital — whereas if it is not yet initiated, the patient may or may not end up being cooled, depending on how aggressively and consistently that facility is applying a hypothermia protocol. In other words, field treatment in this case is playing an economic or policy role, by letting the EMS side say to the hospital side: “We’ve already started this beneficial therapy — you’re not going to terminate it, are you?” And in fact, if they’re still reluctant to get on board, it becomes reasonable for us to divert these patients to other facilities instead, applying further economic pressure.

This is an example of a change in the standard of care being pushed through by a “grassroots” type of influence, as opposed to a top-down fiat which may take much longer to occur (due to institutional inertia or financial concerns). Many of our readers may have experienced frustration with the slow pace of change in their own systems. You’ve done a lot of work with implementing large-scale adoption of new training and procedures in different communities; in your experience, what’s the best way to approach this? Is it top-down, by seeking buy-in from administrators and medical directors at the highest level, or is it from the trenches, by finding broad support for the initiative from clinical staff or even from the public?

DH: An interesting perspective and suggestion, Brandon. I think you did an excellent job of framing up the subject. Improving systems of care for stroke, STEMI, and cardiac arrest patients can be very complex, to say the least. Increasingly I am finding that EMS can play an essential role in developing an integrated systems approach to optimizing response, care, and outcomes.

Yes, Dr. Freese made a compelling suggestion concerning the implementation of EMS therapeutic hypothermia protocols, and his point about continuity of hypothermic therapy is one that I have also observed. This is a great example of a practice being “imported” from the out-of-hospital environment to the hospital setting.

It is difficult if not impossible to make a single recommendation that will hold true everywhere. However, EMS providers, leaders, and agencies will be integral components of any localized strategies of care.

Multi-party coalitions involving EMS field providers, representatives from local prehospital and hospital agencies, and emergency physicians as well as cardiologists can help coordinate strategies for improving cardiac arrest outcomes within a region. This can involve not only therapeutic hypothermia, but the entire spectrum of issues associated with a comprehensive system of care for these patients.

In order to effectively address the issues, such coalitions need a thorough and honest understanding of what is working and what is not. This requires an examination of all system components and how they interact. Each member’s input can help in defining and framing the overall issues, as well as in the development of strategies to yield life-saving results.

Unless a system is hopelessly obstinate, changing and improving standards of care through a combination of “grassroots” influence as well as a top-down approach may yield the most desirable results. Indeed, in my experience, this has been the most effective means of implementing change. Programs like Mission: Lifeline, HEARTSafe, and Heart Rescue can also offer good frameworks for developing this type of process.

BO: Dave, it’s been a pleasure; I hope we can chat again soon. One of the best things the internet has done for EMS is to bring together widespread people with different ideas from different places, but with many of the same problems. My thanks to FDNY for hosting a great (and affordable!) conference, and to yourself for taking some time to discuss it.

Any parting words?

DH: The pleasure has been all mine!

Additional remarks:

An agency or system’s ability to resuscitate VF cardiac arrest can be an excellent indicator of its overall clinical quality.
There is no single change that will dramatically improve cardiac arrest survival. A combination of approaches, including improved recognition, willingness of citizens to perform CPR, telephone CPR (via EMD), rapid defibrillation strategies, really good BLS, and effective post-resuscitation care are all needed to truly move the “survival needle.”
Data collection and an iterative process of measurement and improvement is important in every system.
Desire alone is not enough to yield results. Real effort is required to improve recognition and response. Public safety agencies, EMS included, are well positioned to take the lead in this drive for improvement.
Increased probability of citizen CPR, implementation of AHA guideline recommendations, and improved quality of resuscitation from all rescuers is what is needed in order to save lives.

Experience: Sweating the Small Stuff

Dr. Weingart at Emcrit gave a brief but excellent podcast about “Logistics vs. Strategy.” Go have a listen and then report back.

His point was that it’s not enough to decide what the best course of action for a patient may be. Most of our training and planning is focused on this — what’s the diagnosis? The plan? The treatment? But this is only half the battle. In a war, this would amount to our strategy, and wars aren’t won by strategy alone. You have to implement your strategy through sound execution of the basic fundamentals of logistics and tactics — keeping everyone fueled and fed, maintaining the vehicles, setting up supply lines, and so on.

In medicine, the same problem applies. It’s one thing to say, “I’ll C-spine, assist with ventilations, and transport.” That’s your plan. But can you make it work? It may be easy, but it may be hard. All three of those items — immobilize, bag, and hoof it — are potentially difficult skills, and how they occur will depend on details like the patient, the environment, and the circumstances. I know you can say “assist with ventilations,” but if I hand you a BVM and a mannequin, can you do it? Now, can you do it an a real human? How about this human who’s tied to a board and being maneuvered through a house? Oh, you haven’t tried that before? Well, go ahead and figure it out. But wouldn’t it be nice if you’d done that before the sick patient needed it?

Experience is where we learn this. We talked about how experience involves learning how textbook clinical events actually present in real patients; experience also involves learning how textbook skills are performed in real patients. You may be able to articulate how to apply a cervical collar — in fact, it’s a very simple process, so I hope you can. But until you’ve actually tried to do it, can you flip up all the right plastic bits, and insert Tab A into Slot B? Can you hold it in the right hand while securing it with the other? Can you do it from the other side? How about from behind? While standing and kneeling? Heck, do you know where the collars are?

You might get all of it right the first time you do it. Or you might fumble, but it’s easy enough, so you figure it out and the second time, you’ll have mastered it. Or maybe it takes a few times. Or maybe it’s a difficult skill like intubation, and you’ll need dozens of attempts before you’ve made all the mistakes. This is the process of developing experience. Even if you do get it the first time, until that happens, you won’t know whether you can do it or not.

But you can speed up your experience by doing the right kind of learning. Hopefully you know the basic functioning of your equipment, but how often are our situations in the field straightforward? How many times have you seen a veteran provider pull off some trick that you never imagined was possible, just because he understood some subtlety of the equipment or of pathophysiology? Have you ever used towels to modify a carseat for a small infant? Is it safe to do so? What’s the exact maximum load weight of your stretcher, and how dangerous is it to exceed that? If you trim the length of the prongs on a nasal cannula, will it compromise its effectiveness? If I took away or broke half of your equipment, could you make do with the other half? Is your portable radio waterproof? Do bloodstains come out of your uniform beanie?

You’ll learn it all eventually. But asking the questions ahead of time will make you a better provider sooner.