Initial Emergency Care

     There was a time that, without a coordinated network of public-safety and healthcare entities, as well as the knowledge and skills of competent, well-prepared EMS providers, victims of life-threatening illnesses or injuries usually didn't survive.

     They're far more likely to do so today, but despite the development of better EMS systems, the outcomes of medical emergencies—especially cardiac arrests outside hospitals—are still often determined not by paramedics or cardiologists, but by coworkers, family members and other bystanders who first detect and react to them. Recognizing that a problem exists, calling for help and the subsequent initial-care actions of these "first detectors" are as essential to reducing the number of premature deaths and preventable disabilities as are the proficiencies of the professionals in the various links of the EMS system.

     Unfortunately, the incidence of CPR or other life-sustaining actions being delivered by average citizens (many with a CPR card in their wallets) is appallingly low. Combine this with the sad and growing number of reported incidences of newly installed AEDs being available but not used, and it is obvious that we have much to do if we're going to ensure that everyone in need gains the full benefit of our EMS systems.

     Well over a billion dollars a year is spent to provide first aid and CPR/AED training and related materials to folks who don't normally deal with medical emergencies. In addition, nearly a million AEDs are now in service across the country. But in terms of actual attempts by "infrequent" responders to support life when needed, the return on this hefty investment isn't good. While the numbers of books, training materials and AEDs sold continue to rise, the percentage of patients actually benefiting has been stagnant for years. In the U.S., with few exceptions, consistent and effective onsite care continues to be elusive. Obviously, there's a problem with the way we're training and equipping these "first responders."

Preparation Is Key
     Those who are first to detect and care for serious medical emergencies need to possess much more than just a first aid kit, AED and minimal training to use them. To be ready to act, infrequent—and often reluctant—responders must be prepared physically, emotionally and logistically. Knowing what to do and how to do it is of little value if people aren't willing and able to support life when needed. Whether the initial care provider is required to act as part of his job, a concerned family member or just a Good Samaritan passing by, preparation is an ongoing process. How well infrequent responders have been prepared will greatly influence the success of their efforts and even whether they will act at all.

     Recognizing this, a number of EMS professionals and other clinicians, have developed basic emergency care curricula and materials and the tools to manage on-site care programs. Thousands of these individuals now operate private training enterprises comprising a growing industry, but with little consistency, quality control or accountability.

White Paper
     A key part of the solution must be leadership from, and the direct involvement of, the major professional emergency-care organizations in developing a more patient-centric approach. In much the way we defined and corrected deficiencies in prehospital care in the 1970s, it will again take strong and committed leadership to frame the problem and structure a national solution to achieve the needed improvements in pre-EMS care.

     There is a pressing need—and, some might argue, a significant responsibility—for leading EMS and other emergency-care organizations to craft a national agenda to address and correct the glaring deficiencies in immediate onsite emergency care. A "white paper" calling attention to this problem is long overdue and would be an important first step to fixing this weakest link in EMS systems everywhere.

     Such a document could define the role local EMS services can play in resolving this long-standing problem; provide guidance and direction for accomplishing needed improvements; and promote an independent accreditation process for programs working to prepare people to act in the event of life-threatening medical emergencies.

     We don't have to start from scratch. There are significant training, technical, data and human resources already available, as well as a well-established structure in place, to identify and work to resolve pre-EMS deficiencies. If we're going to achieve our ultimate mission to "save hearts and brains too good to die," it's time for a new direction and leadership in shaping pre-EMS care. A new white paper—Initial Emergency Care: The Neglected Disease of the New Millennium—would be a good place to start.

Frank J. Poliafico, RN, is Executive Director of the Initial Life Support Foundation (ILSF). He is a veteran ER nurse and paramedic, as well as the former director of EMS services for New York City.