Wrap Up From an EMT’s Point of View

Written By Chev Riley, EMT

I first met Brian Oftedal and Zach Hilton as an off duty EMT in 2013. On that particular morning, a motorist collided with a car outside my house. I stabilized C-Spine until Lieutenent Oftedal (at the time he was a Lieutenant now he’s a Captain) and Engine 16 arrived on scene. Hilton and Oftedal asked a couple questions, and thanked me for helping out. Oftedal followed up and gave me an invitation to next BAPJC dinner. I’ve been attending ever since. Whenever I attend the Bay Area Paramedic Journal Club dinners I wonder who will show up, the people I’ll meet, what topics will amaze me (because it happens every time), and most important, what we’re eating. Let’s be real here, I’m coming hungry off of work and looking forward to my three course meal. I know how these dinners work. My favorite presentation so far was the Asiana Plane Crash, but tonight’s presentation with the Field Amputation might top it. The complexity of calls that people experience is what most interests me about BAPJC. BAPJC holds a voice for EMS personnel to reflect on the trials and tribulations from experiences out on the field, and to encourage discussion and potential solutions with the best platform and audience.

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Tonight’s BAPJC included some great speakers, starting with Pat Frost discussing pediatric disaster preparedness. Early on she pointed out what trait EMS personnel all have in common which is to care for others. I agreed, my reason becoming an EMT is that I care for people. I can recall some of my experiences on the ambulance when pediatric calls had a different type adrenaline rush. Hearing a mother’s cry with her baby in her arms can stir up anxiety, but we’ve practiced this before, we know what to do. We’ve trained over and over again to prepare for this situation. Let’s keep in mind, as much as you can be ready for a call, things change so we have to prepare for that as well. Frost reiterated, that training is what makes first responders great but then asked about the training in place for a Pediatric Disaster. Recalling the various types of training I did to heighten my expertise as an EMT, it was limited and varied. I haven’t participated in a Pediatric Disaster Training, and that’s the problem. All training conducted for acute care staff or as an emergency responder should have the adult version as well as the pediatric version. Every EMT skill performed for the registry should have a pediatric version as well. The results from a pediatric disaster isn’t the time to organize training, it needs to happen now. More awareness, versatility, and retention to detail with pediatric emergency care needs to be more common place, as children’s bodies demand quick, proactive, and confident EMS workers and resources.

The second speaker was Brian Ruth a Paramedic student from Fast Response. He presented data that supported the concept of slowing the initial IO flush, which can cause fat infiltration into the blood stream. Revealing, patients complain they feel pain when a responder or caretaker pushed the saline flush to aggressively after administering a drug through an IV access. The faster they pushed the flush, the more pain the patient felt. I don’t have any experience with flushes, however this made think of the little things that count. Maybe the patient wants an extra pillow, or adjusting the patient so that they’re comfortable in the gurney. What Brian Ruth is presenting isn’t a change to a protocol, but remembering what patients go through is life changing, and anything we can do to make it easier, safer and painless for them, we should do it.

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The third speaker Captain Mitch Matlow presented Field Amputation, something I’ve never considered something possible out in the field before. But that’s what the BAPJC dinner does, creates a forum to make the unthinkable very realistic. Captain Mitch Matlow reinforced his presentation with earthquakes, specifically relating to California. All Californians are aware that a major earthquake is due any day now. Referencing back to the Loma Prieta back in ’89, easy to understand all hazards an earthquake is capable of creating; all types of rescues, fires, vehicle accidents, medical emergencies all at once. We have a highway called 980 because of Loma Prieta. Fire departments require specialties to protect its city, with those responders certified in their specialized scope; rescue, hazmat, maritime etc. For example, let’s consider a firefighter assigned to a specialty unit, who is legally allowed in the most dangerous situations, but can only stay within their scope of emergency medical practice if medical help is needed. A paramedic scope of practice is the highest any firefighter can perform. Any amputation cannot legally be performed by a paramedic. which only certifies a surgeon to perform, whom that person is not legally allowed in the most dangerous of situations given they’re not trained for it, what are we supposed to do? I believe the most difficult aspect of a field amputation is the critical thinking and stress spent over a short amount of time. Ethics to think about in this situation would be life vs limb, the golden hour, and consent. But is this something we should be prepare to endure? The Loma Prieta in ’89 created this same atmosphere where some were faced with a similar situation. What would you do? Did I mention the Good Samaritan Act?

My first invitation to a BAPJC dinner started with upholding my duty to act. Helping someone who collided into a car outside my house while off duty. I always feel that BAPJC reiterates doing the best for someone who’s in need. Since, BAPJC has enhanced my professional lifestyle, challenging my critical thinking skills to address the same issues my local EMS family deals with every day. I’ve created a network of amazing people who care about their job and others from BAPJC, while preparing to keep my standard of care and local EMS strong.

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The First European EMS Conference

Written By Dr Anthony Rodigin, Sutter Delta ER

The first European EMS conference, its central moto being “it takes a system to save a life”, was held in Copenhagen, Denmark in early June of 2016. Called by many a landmark event, it united paramedics, nurses, physicians, researchers and others involved in EMS from Europe and from around the world – including the US, Korea and Japan.

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Hosted by the Copenhagen EMS and co-organized in part by the London Ambulance Service, the conference highlighted the vast differences among local EMS systems that still exist today, while at the same pointing out the fact that a single world standard of EMS care is slowly coming into recognition by all. Thus, it is hoped that the conference will become an annual platform for exchange of information among EMS agencies and organizations from various European nations and world regions. The next congress is planned for May of 2017 in the same location.

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Among many topics discussed and presented at the conference, some of the central claims advocated were the role of witnessed cardiac arrest survival rate as a key indicator for the quality of any EMS system as a whole; the paramount task of increasing CPR and AED training among laypersons, together with their willingness to initiate rescue efforts and apply such skills; the frequent discrepancy between society’s expectations and the self-perceived role of EMS providers – the latter in need of further evolution and expansion into non-traditional EMS roles such as care of the elderly, prevention and so forth.

The second Utstein meeting on implementation within EMS (the first held some 26 years ago in Norway) immediately preceded the conference and resulted in the official unveiling of the newly established Global Resuscitation Alliance – a framework aimed at improving implementation of best EMS standards globally as the key link between leading scientific theory and practical outcomes affecting morbidity and survival.

One can find out more at www.ems2016.org


A Night at The Bay Area Paramedic Journal Club

A Night at The Bay Area Paramedic Journal Club:

It is a daunting thing for a newly minted EMT Basic to walk into a event full of EMS directors, ED docs, flight nurses and paramedics who are gathered to exchange ideas and lessons. It is also an incredibly valuable one. On July 25th, just one month after completing the National Registry test I attended the Bay Area Paramedic Journal Club dinner. The dining room was filled with EMS professionals from a diverse set of backgrounds representing many different agencies. The audience included the Alameda and Contra Costa County EMS directors as well as Oakland Fire and Paramedics Plus EMS Medical directors. We were gathered to hear 3 presentations: An ER doc presented on the findings of the use of helicopter intervention in a cohort of 1,073 patients with major trauma. A paramedic presented on new immersive virtual reality simulation training for first responders in mass casualty incidents. Finally a Paramedic instructor presented along side 5 of his students on the use of pre-hospital advanced airways in patients with out-of-hospital cardiac arrest and neurological outcomes. Each talk was insightful and thought provoking and reiterated how much EMS is an ever evolving field where there is always more to learn.

A Night at The Bay Area Paramedic Journal Club Video Trailer

This dinner made clear that in EMT-B with little experience has a lot to learn. It also made clear that there are exciting career paths in the field filled with great mentors dedicated to improving the process of practicing EMS. The bi-monthly dinners hosted by The Bay Area Paramedic Journal Club are a great way for anyone in the industry to learn about new aspects of the field alongside some of the industries best leaders. New EMT’s are as welcome as anyone at these dinners where everyone seems to walk away having gleaned new insights about the industry.

Written by: Aaron Sagin EMT-B and volunteer with The Bay Area Paramedic Journal Club

This Blog Post in Sponsored by our June Premiere Sponsor First Tactical

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Come Meet First Tactical

Our Premiere Sponsor for June 23rd’s dinner is First Tactical. This is their first time sponsoring with us, and you are in treat to some great raffle prizes they are donating! John Liu a retired Fremont Police Officer will be there showing you all their latest products. Stop by his table and check out what they have to offer, and be sure to get your raffle ticket at check-in! Tickets on sale now!

Who Is First Tactical?

First Tactical is dedicated to serving those who serve others. Founded by Dan Costa, a proven industry leader, First Tactical strives to meet the needs of Public Safety professionals with new, innovative ideas in apparel, footwear and accessories. Costa and his team began creating apparel for public safety over 15 years ago when asked by FBI trainers at Quantico to create purpose built apparel that didn’t exist at the time. Costa’s team learned quickly that gear is most functional when it’s designed by the people using it, which is why First Tactical works directly with Law Enforcement, Firefighters, and Emergency Medical Personnel to create durable products that meet their needs.
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This Blog Post in Sponsored by our June Premiere Sponsor First Tactical

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Tough Call

by Zachary Hilton, Firefighter/Paramedic, OFD and Gene Hern, MD, Medical Director, OFD

Raw Accounts (call from the past):

The 24 hour shift was a typical one for this time of year. I commute into work on my bike. I ride my bike 2 hours into work for some training and also ride back 2-3 hours after work. It’s a time to get some hard training in on the road for racing season, and also a time to mentally and physically relieve stress of the job.
We had a call at 1:30am this morning and got cancelled on our arrival. The patient was already loaded up in the ambulance. It’s easy to stay somewhat asleep in the back after 20 years of working 24 hour shifts. 16 years as a Firefighter/Paramedic with Oakland Fire and 4 years as an EMT with a private ambulance company.

This call came in at 6:30 am. The lights go on and the tones sound. We sleep separate from our company officer. He is on the other side of the firehouse. If the call is for a fire, he hits a long bell signaling to us that we are getting dispatched for a structure fire. In Oakland, we can usually hear the 911 call come over the loud speaker for fires but that wasn’t the case this morning. Getting woken out of a dead sleep for a fire is about one of the most adrenaline pumping calls a firefighter will actually physically and mentally feel. It’s like you just drank 4 shots of espresso from Peet’s Coffee. You have no time to think, just react. No time to go use the bathroom first either! I hear the address over the house speakers and we are first due. The address is about 1 minute from our firehouse. We practice putting on our air tanks in that time, but that doesn’t include getting fully encapsulated into all of our fire gear. I look out in the direction of the street to look for any smoke. It was that time of morning where the fog was covering the hills. This inversion layer usually means we won’t see any smoke until we turn onto the street. If it’s a true house fire the street will look like someone laid out some smoke grenades. This makes the task even tougher to give incoming units a scene size up, and report on conditions of the fire. We pull up in front of a house where people are frantically waving and pointing to the back of a 2 story home. In my experience this means there’s probably a working fire on scene. Someone also had a fire extinguisher in their hands.

This is when the locomotive I was on came to a sudden halt, and needed to be reversed! We are then told by several people that no there isn’t a fire, but someone hung themselves in the back house. My other firefighter that rides in back with me signals to me to bring the medical backpack and that it’s for a hanging. What? Huh? At this same time our radios are reporting that they are getting calls for a medical at the address and there is no fire. Our dispatch cancels us from the fire incident, and initiates a medical 9E1 MPDS call for a hanging victim. By this time neighbors are hearing the multiple fire engines, trucks and battalion chief coming with lights and sirens to the call. While fully dressed for a fire, I grabbed the medical gear and followed the neighbors to the back house where my officer and other firefighter were already. We now also needed a response from Oakland Police because we were at a crime scene. It took my Company Officer a few moments to get everyone to stop moving pots and plants for us. They were disrupting a crime scene.

I found a 62/M prone in the doorway of a back house. Lots of people were around and two of them at the doorway holding onto the patient. One was a female inside with the patient and the other was outside trying to explain to me what had happened. We found a large knife next to the patient, bottle of beer, and something that was hanging from above the doorway. One of my firefighters was already trying to get inside up to the patients head. I took a quick look at the patient expecting to see him already deceased. Usually when we get a suicide by hanging at 6:30 am they have been deceased for a while. Not the case with this patient. Patient had agonal breathing <10 times per minute. He has a fast radial pulse, strong and regular. He is warm and dry to the touch. GCS is 3. His B/P is the following. See image of patient vitals throughout. 1

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We initiated BVM ventilations to track respirations, and I began hooking up SPO2, CO2, EKG, and BP. Ventilations via BVM were reported to me as successful. Our initial SPO2 was reading <50%. After a few minutes of BVM we brought it back up to 88%. EKG was reading sinus tachycardia. My Engineer went out to the fire engine to get a backboard and c-collar for patient extrication to gurney and ambulance. We attempted OPA and there was too much edema in airway and laryngeal to get it in. Patient respirations decreased, HR increased, and BP elevated when we attempted it. We aborted any more attempts to maintain airway with adjuncts. We attempted c-collar but neck was too swollen by this point and we were unable to maintain a good airway anymore with BVM. We aborted C-Collar and instead placed patient on backboard and used head bed to secure patients head and body for extrication. Enroute to Alameda County Highland ER we attempted a nasal airway and got a lot of resistance and aborted the attempt. We established an IO in left tibia. It was hard to keep the patients CO2 from elevating while keeping his ventilations up enough to increase his SPO2. Highland ER was approx. <5 minutes from our scene. This call was by far the most mentally challenging to overcome, and on my bike ride back home it was all I could think about. The call involves aspects of Fire, EMS, Police, and Hospital. I decided that it would be a good call to share, and write up. 3

Thoughts from the Medical Director:

This is a really tough call for a few reasons. First it sounds like a pretty emotionally charged scene. Hangings always are. The fact that it was called out as a fire and NOT a hanging makes it even tougher because you can’t mentally prepare for it. There is nothing to do but run with it once you get there. That makes it even harder.

From the medical point of view, hangings are usually asphyxiations and as such are run more like medical codes than traumas. Hangings like we see in old west movies are more like traumas because the body falls for some distance first. The body has to fall more than the height of the body to cause a lot of spinal damage. Once that height is fallen, there are usually significant bone and spinal cord injuries. Most deaths usually happen from cerebral hypoxia but usually NOT because of compression of the airway. Some theories suggest the impingement of the blood vessels causes blood backup and decreased perfusion. Whatever the cause, most agree the cerebral hypoxia ultimately is the cause of death.

There are often abrasions, lacerations or petechiae near the ligature itself. Our management in EMS will be mostly c spine and airway precautions/adjuncts. Intubation is needed in the patient with respiratory failure and can be challenging as there may also be airway edema. The odd readings of the ETCO2 detector aren’t clear. From a low reading of 9 to a high of 91, I can’t really explain the readings. I propose that the ETCO2 had been building up when ventilation wasn’t happening. Once there was ventilation, then the high readings were registered. Once there were additional full breath/adequate ventilations, the readings were falling as the CO2 left the body. Still, there was a lot of variation which is hard to account for if there was a good seal on the tubing the entire time.

In any case, this was a tough call for many reasons. The medical side is confusing, but the immediacy of the response from the EMS crews is also tough. Without time to prepare, the hanging victim requires immediate aggressive interventions (Airway management and C spine precautions) in order to survive. The challenge is that c spine precautions can make maintaining a good airway tough as well.

Tough call, and thanks for writing it up for all of us to learn from!

You can find more about Zachary Hilton at hoseman16.blogspot.com

This Blog Post in Sponsored by our April Premiere Sponsor San Francisco Police Credit Union
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The Specter of Diversion

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It seems that diversion is dead in Massachusetts, and even if it isn’t yet everywhere else in the country, it’s probably fair to say that it is fading away: diversion is falling out of favor with many in EMS and emergency medicine fields.

While the data on direct patient harm caused by diversion are inconclusive1, it is likely an ineffective strategy, at least in its “classic” form, when viewed from a system’s perspective. Diversion does nothing to increase ED throughput locally, and may in fact cause EMS offload delays2.

Thus, while it’s unclear when diversion will go away permanently on the national scale, one would be prudent to prepare for its demise. And, as dead things often do, it is leaving us with a legacy, a specter, that in all likelihood will continue to haunt for some time.

While a nostalgic memory of being “on divert” for the select few, for everyone as a whole this legacy is a bouquet of unsolved problems:  ED overcrowding, long patient wait times (including those waiting on EMS gurneys) and no clear strategy yet discovered to effectively deal with what is typically tagged “ED surge”, just to name a few3.

In the May 2014 issue of Annals of Emergency Medicine, O’Keefe and colleagues4 present the results of interviewing ED leaders at nine teaching hospitals in Boston (all receiving 911 traffic) regarding their attitudes toward the statewide ban on ambulance diversion enacted in Massachusetts on January 1, 2009.  Prior related literature from this state includes a 2013 study showing no increases in the length of stay or ambulance turnaround times at the same EDs since the ban5, and a 2013 Western Massachusetts study claiming no significant effect of the ban on throughput at seven various EDs in that region6.

The authors report that “…the majority of key informants indicated that ambulance diversion was not considered an effective strategy for managing crowded conditions in the ED” prior to the ban. While more frequently requested by RNs than MDs, at some sites going on diversion was considered a “failure”. Diversion was noted to potentiate conflicts, “particularly between EMS providers and ED staff”. Importantly, diversion’s seemingly positive effects were frequently described as “mostly psychological” – reassuring “stressed staff that everything had been done to try to ameliorate the situation [crowded conditions]”.

Among the perceived benefits of a no-diversion policy, the paper reports improved hospital ownership of flow, less distraction of staff with regards to planning for diversion instead of “focusing on what’s happening in the moment” and improved working relationships with EMS.

While the authors do not address the issue of patient satisfaction in depth, some respondents described better outcomes here as well – likely due to the reduction of animosities between EMS and ER personnel witnessed by patients, and as fewer patients were brought to hospitals where they were not followed prior.  Most importantly, none of the 18 survey recipients confirmed any “fears” of the pre-ban period as coming true:  neither from the patient safety perspective, nor from the ED volume perspective.

In the grand scheme of things, diversion is passing on, and likely we should not attempt a resuscitation – at least not of the usual practice that took place since its inception7. But recognizing the futility of doing CPR on diversion should not be confused with giving up the search for new and innovative approaches for dealing with the issues at hand (while anticipating new ones on the horizon).

Community paramedicine, “directed destination” and “alternative destination” EMS policies, ED-Urgent Care physical coupling, hospital-wide “Code Help” protocols based on ED surge criteria, EMR integration among non-affiliated hospital networks are just a few examples of strategies being trialed to various degrees (and with variable success rates) across the country’s EMS districts.

The editorial8 entitled “Two Cheers for Regulation” in the same issue as the O’Keefe article concludes: “[the] Boston experience demonstrates that regulation judiciously used is valuable and essential in a variety of circumstances.”  Translation – the gavel has to come down sometimes.

Time will tell.

For now, we should only note that as past experience has shown time and again, collaborative work based on empathy, mutual respect and finding common motivation is always preferred to harsh and abrupt unilateral decisions of the “top to bottom” variety.

References:

  1. Pham JC, et al. The effects of ambulance diversion:  a comprehensive review.  Acad Emerg Med. 2006 Nov.
  2. Position statement by the National Association of EMS Physicians: “Ambulance Diversion and Emergency Department Offload Delay”.  www.naemsp.org/pages/position-statements.aspx (Accessed 8/20/14).
  3. Cooney, et al. “Ambulance Diversion and Emergency Department Offload Delay:  Resource Document for the National Association of EMS Physicians Position Statement”. Prehospital Emergency Care.  October/December 2001.
  4. SD O’Keefe, et al. “No Diversion: A Qualitative Study of Emergency Medicine Leaders in Boston, MA, and the Effects of a Statewide Diversion Ban Policy.” Ann Emerg Med, May 2014.
  5. Burke LG, et al. “The effect of an ambulance diversion ban on emergency department length of stay and ambulance turnaround time.”  Ann Emerg Med, 2013.
  6. Rathlev NK, et al. “No diversion in Western Massachusetts.” J Emerg Med, 2013.
  7. Lagoe RJ, Jastremski MS.  “Relieving overcrowded emergency departments through ambulance diversion.” Hosp Top. 1990.
  8. Wears, RL. “Two Cheers for Regulation”. Ann Emerg Med, May 2014.

Mechanical vs. Manual CPR

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Mechanical Chest Compressions and Simultaneous Defibrillation vs Conventional Cardiopulmonary Resuscitation in Out of Hospital CA: The LINC Randomized Trial.

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AED use on commercial flights

In-flight automated external defibrillator use and consultation patterns.

AM Brown, et al.  Prehosp Emerg Care, 2010.

This 2010 article speaks to the issue of in-flight emergencies on commercial aircrafts, but also raises two broader themes:   AED use and availability in public, and lack of uniform standards in many narrow subsets of emergency care.

The study is a retrospective descriptive look upon in-flight AED use, as reported by three major airlines during various periods between 2004 and 2009 to an airline consultation service ran in connection with University of Pittsburgh.  169 cases of AED use, including 40 cases of cardiac arrest were reported and examined.  Mean patient age was 58 and 63, respectively, 64% male.

Out of 40 arrest cases, 10 presented with V-fib/Vtach (7+3), and 9 were defibrillated.  5 additional patients were shocked after initial PEA or asystole converted to a shockable rhythm.  There were 2 human failures to shock when advised by the AED: 1 initial Vfib and 1 PEA conversion (1 shock out of 3 advised given, an MD present).  6 patients had survived to hospital admission:  5 out of 9 with initial Vfib/Vtach who were shocked, and 1 person with ROSC after 7 min CPR without a shockable rhythm.

An AED was applied for monitoring in an additional 129 patients with various complaints but not in cardiac arrest.   There were no inappropriate shocks given.

Survival was 100% to the hospital, with only 2 deaths prior to discharge.  Sinus rhythm or tachycardia was seen in 89%, as well as Afib/flutter, SVT and complete heart block.

The authors report that available ground medical consultation was obtained in only 40% of the 129 patients above, and for only 35% of the cardiac arrests.  Diversion was recommended twice, zero times for cardiac arrest cases.  The service was accessed for only half non-sinus rhythms, including only 2 out of 4 complete heart blocks.  The study presents no information regarding number and type of medical personnel from among the passengers who gave assistance, except in 1 CPR case.  All flight crew were BLS and AED certified.

The study supports prior literature indicating poor to no survival in cases of out-of-hospital cardiac arrest who do not present nor develop shockable rhythms, or are not shocked early in such rhythms.  Only one person out of 40 survived to the hospital after no shock, with ROSC after an initial junctional rhythm and CPR alone.  However, 5 out of 9 shocked Vfib/Vtach cases surviving is important to note, while no statistical significance can be derived from the study.

Bigger picture items are as follows:

  • There is poor awareness among medical professionals regarding equipment available on board commercial aircraft and flight crew training.  Reliance on passenger expertise is both historic and accidental, subject to luck of the draw

  • There is no standard of care for in-flight emergencies.  On-line control or ground consultation services, when available, are poorly utilized

  • While any aircraft diversion decisions are complex, and pose real and unique risks to the rest of the passengers and crew, little exists regarding streamlining such decision processes.  Any medical professionals present on board are likely to lack training to be able to interact with the pilots and ground control concisely and effectively

  • There is a lack of mandatory reporting of in-flight medical events

  • Overall, medical care on board domestic and international flights represents a medical frontier that is only beginning to resurface in EM and EMS literature, with ample opportunities for study and intervention

Anthony Rodigin, MD, FAAEM, FACEP


Kids and Young Adults with SCA

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Warning Symptoms and Family History in Children and Young Adults with Sudden Cardiac Arrest

Jonathan A. Drezner, MD, Jessie Fudge, MD, Kimberly G. Harmon, MD,
Stuart Berger, MD, Robert M. Campbell, MD, and Victoria L. Vetter, MD

JABFM July–August 2012 Vol. 25 No. 4 http://www.jabfm.org

LINK TO ABSTRACT

Identifying medical conditions in their dormant or early stages and preventing subsequent illness is one of the main goals of medicine.  This is especially true for conditions harboring lethal outcomes if left untreated.   Within the fields of EMS and EM we are often faced with the latter, so it is useful to occasionally expand our scope and review the latest on prevention.  Rest assured – we will still get plenty of business.

The authors of this paper focused on 146 families of children and young adults who had unexpectedly collapsed via sudden cardiac arrest (SCA).  A survey was distributed through Parent Heart Watch database asking for retrospectively recalled information, with the objective of determining “the prevalence of warning symptoms and family history” in this cohort.  With a 60% survey return rate and after excluding 9 patients, 8 of which had known cardiovascular disease prior to SCA, the authors analyzed the resulting N of 79 responses.  There were only 9 survivors, totaling 11%.

The final cause of death was unknown in up to one third of all patients even after autopsy, and an additional 9 (11%) had never received one.  However, cardiac-related disease was found in virtually everyone else, and an additional 5 cases of it were found via molecular biopsy (post-mortem genetic testing) in 11 of the unknowns (45%).  Not unexpectedly, hypertrophic cardiomyopathy and prolonged QT interval led the list of identified causes, otherwise ranging from SVT and MVP to anomalous coronary artery and myocarditis.  Nearly 70% of victims were male, of ages between 5 and 29.  It is especially important to note that 48% of SCAs are reported to have occurred during or within 1 hour of exercise.

According to the findings, 72% of victims had at least one cardiovascular symptom (fatigue leading ahead of chest pain or palpitations and shortness of breath) prior to their SCA, and 24% had at least one event (seizure or syncope), with a 2.6 episode average.  Of note, the time scale reported for subjective symptoms ranged from 19 to 71 months prior to SCA.  Nearly two-thirds of study subjects had been screened prior via either a well-child check or a sports pre-participation physical.  27% of families reported a person who has died of a heart condition before age 50.

Unfortunately, because of severe design limitations, most of which to their credit the authors acknowledge themselves, this study does not truly allow for accurate estimation of prevalence of any pre-SCA symptoms or events.  It is unknown whether the PHW database provides a fair representation of all SCA cases in children and young adults.  Possibility of a significant recall bias puts into question any data received, and the overall response rate of 60% is low.  Finally, the symptoms put into question such as fatigue and palpitations are so common and non-specific, even when they occur in the young, they hardly provide any practical guidance for practitioners attempting screening for SCA risks.

Thus, the main value of the paper is in the important issues it raises rather than in the results it reports.  As the authors point out, even as fairly recent AHA guidelines for screening of young athletes exist, they are rarely utilized consistently by the wide variety of physician (and non-physician) workers conducting such evaluations.  There are no guidelines for screening of normal healthy children and young adults.  In addition, no outcome-based studies have been published regarding which screening programs or other interventions used even in just athletes are actually effective.  Clearly, a more focused research effort is in order and long overdue.

There are a few clues and pointers, however, that the paper does provide.  The importance of a thorough cardiovascular family history is emphasized.  We should pay more attention to new onset seizures in older children and young adults, many of which are believed to be cardiogenic – related to brain hypoperfusion and hypoxia occurring secondarily.  Recurrent syncope, syncope on exertion and syncope is the setting of non-specific or vague chest symptoms at other times should perhaps trigger a prompt advice or referral for a cardiology evaluation.  Should a heart echo be a routine standard for preprogram screening in young athletes?

Until a sufficient body of research in this area accumulates and routine practices are changed, what does all of this entail for EMS?

One thing is taking extra measures for accurate information gathering at scene and emphasizing it appropriately to the receiving MD provider.  As the authors allude, there may be a vast difference between convulsions originating while the person is upright and convulsions following loss of consciousness after a brief delay.  Paying attention to pulses and the rhythm strip during the seizure is important. Other clues may come from family members who will not be accompanying the patient to the ED.

The second has to do with public advocacy about actual interventions when nothing else can be done.  For arrhythmias without a perfusing pulse, this means quality CPR and early defibrillation.

A great number of articles have been published in the last decade on bystander CPR and AED use by non-professionals: an adequate analysis of this literature is beyond this limited review.  It is hard to debate the benefit of AEDs and their general safety for individual victims [1,2].  Still, much is yet to be learned about their appropriate and cost-effective distribution – even among professional rescuers.  Earlier select studies did not show a survival benefit when AEDs were widely adapted to PD or EMT units [3,4].  Most recently, authors continue to focus on appropriate AED placement for general public access [5,6].

Until more can be said, it is the mutual duty of the EMS and EM communities to continue to steer future research efforts in this area, while continuously examining without bias new data that becomes available.

References

  1. Sana T, et al.  Cardiopulmonary resuscitation alone vs. cardiopulmonary resuscitation plus automated external defibrillator use by non-healthcare professionals: a meta-analysis on 1583 cases of out-of-hospital cardiac arrest.  Resuscitation. 2008 Feb;76(2):226-32. Epub 2007 Sep 17.
  2. Lim SH, et al.  Results of the first five years of the prehospital automatic external defibrillation project in Singapore in the “Utstein style”.  Resuscitation. 2005 Jan;64(1):49-57.
  3. Sweeney TA, et al.  EMT defibrillation does not increase survival from sudden cardiac death in a two-tiered urban-suburban EMS system.  Ann Emerg Med. 1998 Feb;31(2):234-40.
  4. Groh WJ, et al.  Limited response to cardiac arrest by police equipped with automated external defibrillators: lack of survival benefit in suburban and rural Indiana–the police as responder automated defibrillation evaluation (PARADE).  Acad Emerg Med. 2001 Apr;8(4):324-30.
  5. Winkle RA.  The effectiveness and cost effectiveness of public-access defibrillation.  Clin Cardiol. 2010 Jul;33(7):396-9. doi: 10.1002/clc.20790.
  6. Brooks, SC, et al.  Determining Risk for Out-of-Hospital Cardiac Arrest by Location Type in a Canadian Urban Setting to Guide Future Public Access Defibrillator Placement.  Annals of EM, May 2013.

Efficacy of Early TPA in the ED

stroke_tpa

Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke.

Saver JL, Fonarow GC, Smith EE, Reeves MJ, Grau-Sepulveda MV, Pan W, Olson DM, Hernandez AF, Peterson ED, Schwamm LH.
JAMA. 2013 Jun 19;309(23):2480-8. doi: 10.1001/jama.2013.6959

LINK TO ABSTRACT

There has been some resistance among emergency physicians to adopt the aggressive use of TPA in the acute ischemic stroke patients over these last two decades. This real world study sheds some new light in its efficacy and highlights that even earlier administration is better for the patient’s outcome.

This study examines the outcomes of over 50,000 acute ischemic stroke patients who received TPA.
This comes from the “Get with the Guidelines Stroke Program”, a Quality Improvement program used by many stroke centers.

50,000 acute ischemic stroke patients who received TPA

Measurements

  • Stroke Onset to Treatment Time (OTT)

  • Mortality

  • Rate of Intracranial Hemorrhage

  • Functional Level

Faster Onset to Treatment was associated with

  • Reduced mortality (OR, 0.96; 95% CI, 0.95-0.98; P<.001)

  • Reduced rate of intracranial hemorrhage (OR, 0.96; 95% CI, 0.95-0.98; P<.001)

  • Increased rates of independent ambulation (OR, 1.04; 95% CI, 1.03-1.05; P<.001)

  • Increased rate of discharge to home (OR, 1.03; 95% CI, 1.02-1.04; P<.001)

brain_scan

For every 100 patients treated, for every 10-minute delay in patients treated within 4.5 hours of onset, 1.2 fewer had better ambulation at discharge and 0.8 fewer had a more independent discharge destination.

Patient factors most strongly associated with shorter OTT

  • Greater Stroke Severity (OR 2.8)

  • Arrival by Ambulance (OR 5.9)

  • Arrival during regular hours (OR 4.6)

Comment

Demonstrates that earlier TPA treatment leads to better outcomes.

Stroke Centers need to improve their afterhours care.

Unspoken Secret

In this real world study, only 5.8% of all stroke patients received TPA. Most are excluded for a hemorrhagic stroke, onset of greater than 4.5 hours, and a variety of relative contraindications (hypertension control, bleeding problem, or recent surgery).

This rate varies from 7% to 30% in our local stroke centers depending on the interpretation of the relative contraindications by our stroke centers. This study has demonstrated some room for improvement for our stroke centers.