Thursday, November 29, 2012

EMS Notes: Maine medics triple cardiac arrest survival rate

 Paramedics have started treating patients on the scene instead on en route

Seth Koenig
Bangor Daily News

PORTLAND, Maine -- Portland paramedics have nearly tripled their success rate in the past year of saving patients who have suffered cardiac arrest, in large part by providing emergency services on the scene and avoiding time-consuming ambulance rides to local hospitals.
The latest data, shared with city first responders Tuesday during a regular monthly review of best practices, provide statistical reinforcement to a new wave of emergency medical protocols being implemented statewide. The trend of treating patients on-site -- instead of en route -- has become the latest standard in Maine, but until now, there was only anecdotal evidence of its effectiveness widely available.
"Everybody's situation is different, but if [emergency medical responders] can produce these results, that's great," Lt. John Kooistra, paramedic and head of quality assurance for the Portland Fire and Rescue Department, said Tuesday.
The shift in procedure also means that Portland paramedics are declaring about three times as many more patients dead on scene as well, forcing the medical responders into unfamiliar territory as the ones who must break bad news to family members who may be nearby.
"That's something that's brand new to paramedics," said Portland paramedic David Pratt. "In 20 years as a paramedic, this is the first year I've had to do that. In the past, you'd be in the emergency room and the doctor would be the one to say, 'I'm sorry, there's nothing more we can do.' Now we have to have those conversations at the scene."
Kooistra said that, in addition to conducting more of the treatment on-site, more responders are being sent to each call, oftentimes freeing up a paramedic to explain to the patient's family members what's going on. The extra level of communication throughout the process can help soften the news when the patient has died, he said.
But by keeping the treatment on scene, Kooistra said, responders have much better odds of avoiding those difficult conversations. Since December 2011, Portland paramedics have handled 47 cardiac arrest cases. Using the new procedures -- administering CPR at the location and increasing the numbers of responders from six to nine -- they were able to fully revive eight of those patients, a success rate of 17 percent.
Over the previous two years, Fire Department Medical Director Dr. Matthew Scholl said, responders were able to save about 6 percent of their cardiac arrest patients. In the past 11 months, resuscitation efforts were terminated by paramedics -- meaning that the patient was declared dead on scene after treatment, but without having been taken to a hospital -- 21 times, or 44.6 percent of the time.
That's up from between 15 percent and 16 percent in previous years, when patients died more often but were declared deceased at hospitals the majority of time.
"Historically, the two of us in [a standard ambulance crew at the time] would get to the scene, we'd begin resuscitation, then roll them onto a stretcher, bring them to the ambulance and rush off to the hospital," said Deputy Fire Chief Terry Walsh. "We started over the years to add another truck to each scene, but our success rates weren't getting any better. We now know that if we get extra bodies on the scene and apply medical care on the scene, we greatly increase our success rate. There's no more blazing lights and sirens and flying down the road to the hospital."
In Portland, the previous standard response team included two paramedics with the initial ambulance, a three-person team on a following fire engine and a deputy chief. Over the past year, the department has added a second three-person follow-up contingent, allowing responders to work in fast-paced rotations administering CPR and other procedures.
By cutting out the placement of patients on stretchers and transporting them in an ambulance, responders also are cutting out 30- and 40-second gaps of time in which nobody is administering CPR or other treatments, Kooistra said. Those extra seconds, when the heart needs consistent and regular compressions to restart, are making the difference between life and death, he said.
New cardiac monitors the department has begun carrying provide instant feedback on how effective the paramedics are when administering CPR -- they should be thrusting down onto the patient's heart with both hands at a depth of 2 inches, and with a frequency of between 100 and 120 compressions per minute -- and so responders can tell when a paramedic is getting tired and a fresh set of hands is necessary.
Kooistra said the American Heart Association suggests that a responder providing CPR should administer the treatment for about two minutes before handing the duties off to somebody fresh. He said the Portland department's new "pit crew" approach, in which every responder is assigned a specialty at each scenario, at least two at each scene are dedicated chest compressors, who can rotate in and out as needed.
Scholl said the top determiners for success in a cardiac arrest case is how quickly resuscitation efforts begin and how consistently they continue. To that end, the doctor said it is important that members of the public are empowered to recognize symptoms of cardiac arrest and begin "hands only" CPR immediately, while waiting for paramedics to arrive.
"In almost every success story we see, the public is involved in that success, either with early activation of 911 or bystander CPR," Scholl said. "We have case after case after case this year of the public beginning resuscitation and giving us great success."
Scholl said members of the public should keep an eye out for individuals who are experiencing irregular breathing. He said dispatchers can talk bystanders through the correct way to administer CPR, thrusting both hands rhythmically down on the heart of the patient.
"It doesn't need to be 'no breaths at all'; it needs to be irregular breaths," he said. "Subjects may continue to gasp for seconds, if not minutes, after cardiac arrest."
While not every fire and rescue department in Maine has the same manpower or technology as Portland, which is the largest city in the state, Kooistra said the underlying method of treating cardiac arrest patients on-site can be implemented anywhere.
Indeed, Maine Emergency Medical Services, a statewide agency, saw the rate at which paramedics took patients to hospitals drop from 83 percent of the time in 2010 and 76 percent of the time in 2011 to just 50 percent of the time over the first six months of 2012, according to a July report by the Sun Journal.
Maine EMS officials told the newspaper at the time that there weren't enough data to confirm that the new protocols are saving lives. In Portland, such data have begun to come to light.
"This is a great way to broker our experience and help patients throughout the state, by getting the word out about these successes we're having," Scholl said.

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