EMS Mythbusters Myths, Facts & Realities

1. EMS MythbustersMyths, Facts & Realities Amy Gutman MD prehospitalmd@gmail.com

2. Prehospital diuresis fixes CHF TASERS kill patients EMT-initiated refusals are safe Paramedics save lives in OOHCA Spinal immobilization is beneficial The “Golden Hour: & “Platinum 10 Minutes” are standards of care Corollary: Lights & Sirens Save Lives If you know one EMS system, you know EMS The Dead Will Rise Overview It is better to not understand something true, than to understand something false. Neils Bohr

3. Myth: Prehospital Diuresis Fixes CHF • For years prehospital CHF treatment was: O2, MSO4, diuretic • Many EMS have SOPs that include giving furosemide for respiratory distress despite few studies on effectiveness • Anecdotal evidence cited by medics that treatment “works” • Rationale: utilize rapidly acting medication to decrease work of breathing

4. Myth: Prehospital DiuresisFixes CHF • Retrospective of 144 pts receiving prehospital furosemide matched to hospital records • Furosemide “inappropriate” if discharge dx did not include CHF, BNP <200, IVF given. Furosemide “potentially harmful” if diagnosed with sepsis, IVVD, pneumonia, or BNP <400 • Results: • 59% CHF; furosemide “appropriate” • 42% no respiratory dx; “inappropriate” • 17% sepsis, dehydration or pneumonia; “harmful” • Conclusions: • Prehospital furosemide frequently inappropriately administered & potentially harmful Jaronik. Evaluation of prehospital use of furosemide in patients with respiratory distress. PEC 2006.

5. Reality: No Data Prehospital Diuresis Effective or Safe • Prehospital MSO4 + furosemide to pts with CHF resulted in increased mechanical ventilation / ICU admissions, longer hospitalizations, higher mortality • Many CHF pts routinely taking furosemide; boluses appear to have little acute effect Peacock WF. Morphine and outcomes in ADHF: an ADHERE analysis. EMJ Cotter G. Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary edema. Lancet. 1998 Hoffman JR. Comparison of NTG, MSO4 & furosemide in treatment of presumed prehospital pulmonary edema. Chest. 1987

6. Reality: Other Modalities Have Greater Immediate Benefit With Less Risk • CPAP vs standard meds for prehospital pulmonary edema • Nonrandomized: all pts presenting to ED via EMS in 1 year with impression of “pulmonary edema” • Control: O2, nitrates, furosemide, MSO4, +/- ETI • Intervention: CPAP at 10 cm H2O +/- standard therapy • Resuts: • Pts receiving standard Rx more likely to be intubated/die than those receiving standard therapy w/CPAP (OR 4.04) • Intubation: 8.9% CPAP, 25.3% ontrols (p=0.003) • Mortality: 5.4% CPAP, 23.2% control (p=0.001) • Conclusion: • Prehospital CPAP decreases ETI & mortality Hubble. Effectiveness of prehospital CPAP in the management of acute pulmonary edema. PEC 2006

7. Myth: Tasers Kill Patients • Weapon utilizing electrical current disrupting voluntary muscle function causing “neuromuscular incapacitation” via involuntary muscle contractions • High-voltage, short-pulse • 3 microsec pulse followed by 100 microsec pulses • Low-impedance current pathway across propelled barbs • Multiple animal studies demonstrated relative safety, with “clinically irrelevant” arrhythmia, QT prolongation or acidosis • Tasers attract media attention for “contributing” to deaths of violent individuals by police

8. Reality: A Taser is a “Less Lethal” Not a “Non-Lethal” Weapon • Increased VF / VT vulnerability: • Underlying cardiac disease, long QT syndrome, pre-excitation syndromes • Increased adrenergic tone (cocaine / stimulants) • Electrolyte disturbances, acidosis • Multiple shocks

9. Reality: Tasers Can Kill Patients • Effects increase with duration of application • Inhibits skeletal muscle voluntary function x 5-15 mins • Post-taser • Metabolic acidosis • QT prolongation • VT/VF secondary to R on T phenomenon • Additive risk of death from excited delirium

10. Case study series of taser-related deaths 37 males, 18-50 yrs 54% cardiac disease 84% illicit drugs 76% deaths attributed to “excited delirium” 27% TASER “potential” or “contributory” COD Vilke: No cardiac effects, arrythmias or “clinically relevant ECG changes” in 32 healthy males after 5 sec taser shock QT interval shortened / widened “insignificantly” in 50% Lower pH immediately post shock Levine: QT shortened / widened, tachycardia in 105 healthy police volunteers after a 5 sec taser shock Reality: Taser Human Studies Strote. PEC. 2006 Vilke. AJEM. 2008 Levine. JEM. 2007

11. Reality: Tasers Less Lethal Than Gunfire • 218 individuals subdued by police with firearms vs TASERs • 1.4% mortality (TASER group) • 50% mortality (firearm group) Ordog GJ. AEM 1987; 16:73-78.

12. Myth: EMT-Initiated Refusals Are A Safe Idea • Public Utility Model (PUM) based on EMS economic & clinical characteristics required for optimal pt care • “Care best for the patient, not necessarily the system” • PUMs ideally produce a “guarantee of uninterrupted service” by transporting everyone” • Allows for patient-initiated refusals • Non-PUMs allow EMT-initiated refusals • Risk of error when dispatchers / EMTs attempt to determine which pts can safely be denied transport. • Medico-legal conclusion: eliminate risk by providing every patient requested care Overton. High Performance and EMS: Market Study. NAEMSP 2002 Cone. Can BLS personnel safely determine that ALS is not needed? PEC 2001

13. Reality: Even With SOPs, EMT- Initiated Refusals Often Unsafe • Can EMTs apply SOPs to assign patient transport options? • Results • 1,300 study pts EMTs categorized as: • 79% required ambulance transport • 15% told to go to ED via alternative means • 5% told to contact PCP, no transport offered • 1% treated & released • In reality: • 30 / 277 (11%) pts not offered transport had a critical event • 7 (3%) required resuscitation prior to EMS recall • 95% sensitivity for identifying pts requiring transport • Conclusion • 11% pts determined to not require ambulance transport had a critical event leading to an unacceptable level of under-triage Schmidt T. Evaluation of protocols allowing EMTs to determine need for treatment and transport. AEM. 2000

14. Reality: Even With SOPs, EMT-Initiated Refusals Often Unsafe • Retrospective: • 85 cases medics felt transport unnecessary • 27 (32%) met criteria for ED Rx • 15 (18%) admitted hospital • 5 (6%) admitted ICU • Cone evaluated “ALS call-offs: • In 87% cases where BLS crew cancelled ALS, patient required ALS upon ED arrival • Data do not support practice of medics’ determining whether patients require ambulance transport Brown LH. Paramedic determinations of medical necessity: A meta-analysis. PEC. 2009

15. Reality: Underfunded & Overworked EMS Services Cannot Transport Everyone • Prospective: Can experienced medics (10 yrs+) using transport guidelines identify pts with minor problems who can be safely alternatively transported (taxi) • Results: • 93 subjects given a taxi voucher • Average time from taxi dispatch to ED triage 43 mins • 10% transported by taxi admitted to hospital • No subjects required transfusions, emergent procedures or had significant adverse events • Conclusion: • Ability to triage pts to alternative transport unproven & limited by underestimation of illness severity Knappab. Prospective Evaluation of an EMS-Administered Alternative Transport Protocol . PEC 2009

16. Myth: Paramedics Save Lives in OOHCA • Ontario Prehospital Advanced Life Support Study (OPALS) • 5,638 patients • 3 phases • 7 years • Results: • Prehospital ALS interventions more expensive with no better outcomes than BLS + AED • OOHCA ~1% EMS run volumes • US / Canadian survival ~5% • Of cities with higher survival, almost all improvement attributed to BLS

17. Myth: Two Paramedics Are Better Than One in OOHCA • Maintenance & performance of medic-specific skills linked to patient outcomes • Cities with more paramedics have worse patient outcomes • Boston 10:100,000; OOHCA survival to admission 40% • Omaha 44:100,000; OOHCA 3% survival • Paramedics with OOHCA 4.68 cases / yr = 27% survival • Paramedics with OOHCA 1.63 cases / yr = 4% survival • Comparison of 2 cities served by same EMS system, identical demographics, response times & run volumes; only difference being ALS vs BLS 1st response • 100% pts BLS 1st response successfully intubated, 38% ROSC • 78% pts ALS 1st response successfully intubated (47% 1st attempt success), 13% ROSC Sayre. AEM 2006 Dunn. EMS Today 2007

18. Reality: ALS Improves Outcomes For Some Patients • ALS has clinically & statistically better outcomes for respiratory distress, chest pain & hypoglycemia vs BLS ONLY if the intervention is ability to initiate IV therapy

19. Myth: Spinal Immobilization Beneficial & Necessary • No randomized prospective trials in peer-reviewed journal demonstrate ANY aspects of immobilization prevent or lessen morbidity of spinal injuries • Questionnaire answered by 1,500 EMTs listed beliefs: • Spinal immobilization prevents spinal cord injury • Manual neck stabilization required until C collar applied • C collars alone inadequate to prevent cervical movement • KEDs reduce paraplegia if thoracic or lumbar fxs • Cloth tape acceptable method to secure pt to backboard • Prehospital skin breakdown does not occur Gutman. Neck and Back Pain. EMS: Clinical Practices & Systems Oversight. 2009. Baez. "Is Routine Spinal Immobilization an Effective Intervention for Trauma Patients?" AEM 2006

20. Malayan C-Spine Study 5 yr retrospective chart review 454 pts with SCI 0/120 Malayan pts immobilized 334/334 New Mexico pts immobilized Neurological disability less for Malayan subjects (11% vs 21%) Conclusion: immobilization has little effect on neurologic outcome 2002 Maine implemented EMS spinal clearance protocol 16,019 trauma transports 7,014 immobilized 86 (0.01%) spinal fractures 12/86 not immobilized 11 stable fxs, 1 unstable T-spine fx Unstable fxpt had no neurological deficits Conclusion: immobilization has little effect on neurologic outcome Myth: Spinal Immobilization Beneficial & Necessary

21. NEXUS (National Emergency X-Radiography Study) clinical criteria designed to minimize unnecessary x-rays Validated on 34,069 pts 818 cervical fxs, all but 8 identified with physical exam criteria Accurate in ruling out cervical spine fractures Nexus accuracy 99% Radiography accuracy 97% NEXUS Exam Criteria: No midline C-spine tenderness No intoxication Normal alertness No focal neurological deficit No distracting injuries Fact: Prehospital Providers Can Safely Clear C Spines

22. Reality: Prehospital Providers Can Safely Clear C Spines • Canadian C-Spine Study (Off-shoot of OPALS) • 8,924 patients • Same results as NEXUS, except: • >65 yo at greater risk • Clearer MOI definitions • Injury above clavicles greatest determining factor in whether to x-ray in high MOI cases

23. Reality: Spinal Immobilization Has Serious Consequences • Pain / Anxiety • Increased ICP • Risk of aspiration • Respiratory decompensation • Decubitus ulcers can begin within 20 mins • Occiput • Sacrum • Heels

24. Myth: “Golden Hour” is Proven Standard of Care • R Adams Cowley father of trauma care & developer of Golden Hour concept • PR tool promoting importance of rapid surgical intervention in trauma pts at newly opened U Maryland “Shock Trauma” • “Pts must arrive at a trauma center within 1 hour of their injury in order to have their best chance of survival.” • R Cowley, MD • “Golden Hour” repeated so often that it has “willed” into truth; Does data back it up?

25. Reality: No Data Shows the Golden Hour Saves Lives • 2001 AEM detailed literature & historical records search for data supporting ‘Golden Hour’ • NONE identified • “Nobody wants to talk about the false notion of a ‘Golden Hour’ because it shakes the roots of EMS & trauma care.”B Bledsoe MD • There is also little evidence that faster response times lead to better outcomes • Number of pts benefiting from a rapid response small; benefit in this group projected upon larger group who do not need a rapid response Lerner. “The Golden Hour: Scientific Fact or Medical ‘Urban Legend’?” AEM 2001 Turner J. The Costs & Benefits of Changing Ambulance Response Time Performance Standards. Medical Care Research Unit School of Health and Related Research, University of Sheffield. 2006

26. Myth: The Platinum 10 Minutes Is Also A Proven Standard of Care • Applies only in setting of hemodynamically unstable trauma pts in which EMS should “be on scene <10 mins” before transporting patient to ED for surgical intervention • Often results in shoddy assessment, care & packaging • Not part of original “Golden Hour” concept • Benefit of rapid surgical intervention for trauma pts is intuitively obvious, however no data identifies optimum time frame

27. Myth Corollary: Lights & Sirens Save Lives • North Carolina • 43.5 sec savings with lights & siren compared to without lights & siren • Syracuse • “L&S reduce response by an average of 1 min, 46 secs • Though statistically significant, time saving unlikely clinically relevant • Philadelphia • Evaluated pt outcomes when EMS strictly limiting use of lights & sirens • “No adverse outcomes were identified as related to non-lights & siren transport” Hunt. Is ambulance transport time with lights and siren faster than that without? Annals of EM 1995 Brown. Do warning lights and sirens reduce ambulance response times? PEC 2000 Kupas. Patient outcome using medical protocol to limit “lights and siren transport. PDM 1994

28. Reality: EMS Response Time Recommendations Based on Conjecture not Science • EMS visionaries set 8 minutes as goal for 90% of responses to “save the most persons in need” • Time it takes to travel between 2 points determined by speed. Speed affected by: • Traffic • Road conditions • Vehicle conditions • Operator experience • Shorter response intervals are not without safety & monetary costs for EMS & the public • Data demonstrate that neither mortality or frequency of critical procedural interventions performed in the field vary based upon “goal” ALS response time Blackwell. Lack of association between prehospital response times and patient outcomes. PEC 2007 Bailey. Considerations in establishing EMS response time goals. PEC 2003

29. 4 min response associated with increased survival in OOHCA IF: No witnessed arrest No bystander CPR No AED Rapid response less important than appropriate scene care & destination facility in major trauma 9,273 OOHCA pts (OPALS) 4.2% survival if <6.2 min to defibrillation “Steep decrease in the 1st 5 mins of survival curve, beyond which slope gradually leveled off” Medic response time of 8 mins not associated with improved survival Response time of 4 mins did improve survival in patients with high mortality risk Fact: Sometimes Faster is Better De Maio. Optimal defibrillation response intervals for maximum OOHCA survival rates.” AEM 2003 Pons. 8 minutes or less: Does ambulance response time guideline impact trauma patient outcome?” JEM 2002

30. Myth: If You Know One EMS System, You Know EMS • What defines a quality EMS system rooted in local experience • Who provides EMS & how EMS provided vary significantly • There is no one "ideal" system model, rather local factors that determine right delivery method for a community • Quality Benchmarks • Effective EMS Communications • Coordinated Medical Response • Safe Medical Transportation • Customer / Community Accountability and CQI • Illness / Injury Prevention & Community Education • Optimal System Value • Efficient Organizational Structure & Leadership

31. Reality: There are “Common” EMS Systems, But All Are Different • Private-For Profit • Public Utility Models (PUMs) • Third Service • Hospital-Based • Fire Service • Dual / Single role; Profit / Not-For-Profit

32. Reality: The Fire-EMS Dual Service Model Neither Cheap Nor Efficient, But Often Necessary • Average Annual Salaries • Firefighter 35 – 60K • EMT-B 30 - 40K • EMT-I 35 – 45K • EMT-P 60 – 80K • Cost per Response Engine / Pumper (2 hour call) • Fuel: (15 gal / hr / 4$ gallon) = 120$ • Personnel: 4 FF/ truck (55k / 1800 hrs per yr ~30$/hr x 4 x 2 hrs) = 240$ • Cost per Ambulance (2 hour call) • Fuel: (4 gal / hr / 4$ gallon) = 36$ • Personnel: 3 EMTs / truck: (60k / 1800 hrs per yr ~33$/hr x 3 x 2 hrs) = 198$ • Cost Per Chase Car (2 hour call) • Fuel: (1 gal / hr / 4$ gallon) = 8$ • Personnel: 1 EMT / truck (60K / 1800 hrs per yr ~33$/hr x 1 x 2 hrs) = 66$ • Vehicle Costs: • Pumper: $250K +$100K equipment • Engine: $500K + $100K equipment • Ambulance: $100,000 + 100K equipment • Chase vehicle: 35$ + 50K equipment US Bureau of Labor Statistics, 2009

33. Reality: If you Know 1 EMS System, You Know 1 EMS System • Think Cinci…in Hamilton County, Indiana & Kentucky, there are >50 different Departments • Despite AOM Guidelines, there are nearly as many SOPs & operational configurations as there are Departments • All rely on the same performance Standards of Care, but delivered in very different manners

34. Myth: The Dead Will Rise • Researchers watched 2 yrs of ER,Chicago Hope & Rescue 911 • 65% OOHCA occurred in children or young adults • 75% survived arrest • 67% survived to discharge • Los Angeles: • 2,021 consecutive OOHCA pts • Results: • 1.4% survived neurologically intact • 6.1% survival bystander-witnessed VF • 2.1% survival bystander CPR • 3.2% survival witnessed arrest & bystander CPR • 1% survival without bystander CPR Diem SJ, Lantos JD, Tulsky JA: “CPR on television. Miracles and misinformation.” NEJM 1996 Eckstein M, Stratton SJ, Chan LS: “Cardiac Arrest Resuscitation in Los Angeles: CARE- LA.” Annals of EM 2005

35. Fact: Despite 30+ years of EMS & Expenditure of Billions of Dollars, the Majority of Dead People Remain Dead • No change in traumatic arrest survival since the Crimean war • Some improvements in medical OOHCA • Bystander CPR • Witnessed arrest • Early AED usage • Effective compressions • What is the benefit saving the very very few vs the safety risk to EMS, the public & the financial expenditure “Trauma.” Scientific American. 249:220–227, 1993.

36. Prehospital diuresis fixes CHF TASERS kill patients EMT-initiated refusals safe Paramedics save lives in OOHCA Spinal immobilization beneficial The “Golden Hour: & “Platinum 10 Minutes” are Proven Standards of Care Corollary: Lights & Sirens Save Lives If you know 1 EMS system, you know them all The Dead Will Rise Prehospital diuresis worsens outcomes Tasers sometimes kill patients, but less often than bullets EMT-initiated refusals are often unsafe Fewer Medics = Better Outcomes Appropriate patient packaging improves outcomes with less sequella Rapid but safe responses with appropriate transport triage improves outcomes If you know 1 EMS system, you know 1 EMS system Dead is dead Myth vs Reality Summary

37. References • Bryan E. Bledsoe, DO, FACEP George Washington University Medical Center • EMS Responder Magazine “EMS Myths” • Zian Tseng MD, Assistant Professor of Medicine, Cardiac Physiology Section UC San Francisco • Mark Eckstein MD. Medical Director Los Angelos County EMS • Garza. One city’s miraculous EMS transformation. www.jems.com. August 2006 • David Jaslow MD Chief EMS, Director of the Center for Special Operations • Patricia Gabow MD • Fitch and Associates Survey Group

38. Summaryprehospitalmd@gmail.com • We routinely perform & promote EMS practices without considering risk:benefit ratios • What we know & do in EMS is often based upon anecdotal evidence, politics, medical director mindset & available resources • Despite this, every day the job is performed well by overworked, underpaid & underappreciated members of your community