Kittens with AEDs

There is a big shift in some circles to limit the number of advanced care givers available to a community.

The belief supporting this concept is that areas with less Paramedics have better OHCA survival rates, so less medics=more survival.  The data, at least the data cited by supporters of this concept, seem to support the conclusion.

It is, of course, a complicated system to address and controlling for multiple variables, including the population's age, lifestyle, co-morbid factors, EMS system capabilities and deployment model is a challenge.

It is easy to grab one metric and one system and claim it as successful.  This argument of limiting advanced responders is supported in multiple communities when addressing cardiac arrest.

I have a problem with the model if it focuses on 0.5% of the population.

While less medics does mean more opportunities for advanced interventions for those medics it also means patients are waiting longer for those advanced interventions.  How much longer?

Not many seem to be tracking that.

We can all agree dead people are easier to intubate than a crashing CHF patient staring past you into the afterlife as they slump over in the chair.

Medics delayed by a thinned out system will have better ETT first pass success rates.  A nice side effect, however, is that now your BLS teams will get more experience dealing with critical patients.  Before some of you get too far into that comment about how I'm anti-BLS, please remember, I am not.

I just believe your model to be upside down.

Yes, I am a card carrying union thug and proud second generation knuckle dragging hose monkey.  I also completed my BS in EMS with a paper titled "Shortening the Chain of Survival" which called for, among other things, massive PAD programs, CPR to graduate high school and a focus on rapid delivery of ALS.

Data appear to show that patients treated with only BLS procedures do well, however many of those communities focused on the things I mentioned above.  Could it be that the first 3 chains are more important than the last 2?

If ALS can be delayed, can hospital transport be delayed as well?

The data say yes, possibly.

At the same time we are "helping" a cardiac arrest patient with fewer medics, a complicated patient elsewhere suffers while BLS stands ready with an NRB, gauze roll, stethoscope and radio.

That last tool possibly being the most important.

If you are going to thin your medic herd in search of a 95%+ first pass ETT score and maybe a 5 point bump in your OHCA survivability in tact, please make sure your BLS crews are trained far above the BLS level.

Their assessment skills must be almost on par with their ALS counterparts and have a thorough understanding of how the system can help each and every patient.  A robust BLS fleet of first responders backed up with a smaller ALS cadre could be very successful in many patient populations.

As I said, the data support that in certain sections of the patient population.

Response times have little impact in patient outcome in most cases.  Those cases were BLS to begin with and a first in BLS fleet well trained to handle the assessment and determination of needs can save a system a lot of money.

Imagine for me if law enforcement adopted this model.

All calls for service receive a police service aide, unarmed, to respond until an armed officer is available.

Insane?  Perhaps.

But most of the calls for PD probably only need a service aide.

On the other side of the coin, if presented with a heavily armed suspect, PD will send SWAT, but also an armed officer to assess the situation until SWAT can arrive with their special skills and training and deal with the situation.

Both scenarios are believable.

My rambling point is that limiting the level of care available to your system needs to be based on your community's needs, not what your manager brought back from the bar at the conference.

A lot of smart folks use this model and are able to produce good data to support it.

Make sure your community is similar enough in demographics, geography, capability, training and equipment before cutting your medic numbers and rerunning your CARES data every morning.

If you don't you might as well just give kittens AEDs.  A tool in the wrong hands is not a tool, it's a hazard.


Anonymous said…
This idea comes from the Seattle Fire Department, who have been rightly praised for increasing survival rates for cardiac arrests. You can see the advantages that their EMT-heavy model has in that field. If you trade paramedics for EMTs, you have more responders overall, so the vital basic but early response is more likely. And the paramedics spend more time responding to cardiac arrests, so can build up their skills in providing the advanced, later response. It's also encouraging to see someone looking at the wider picture of patient outcomes, instead of the misleading focus on response times.

At the very least, I think it reveals some ideas worth trialling, like training specialist paramedics. But the EMS can't just be designed just to treat cardiac arrests, which are less than 1% of callouts, and are probably the most hopeless. How does the EMT-heavy model work for heart attacks, strokes and sepsis? Or for callouts that aren't life-threatening (i.e. the majority)?

It's also worth noting that there are other reasons for Seattle's success. SFD have worked with other agencies and the public to make sure that AEDs are widely available and that the wider public can be trained in CPR and using a defib. If anything the SFD does needs to be copied, it is surely this.