Who Needs Paramedics?

Paramedics John Moody and Rick Gillespie recently attended the wedding of Sandra Casper. There is nothing unusual about a couple of paramedics attending a wedding. Maybe Sandra was a fellow employee or a nurse from one of the local hospitals where they transported patients. Possibly Sandra was a relative or a close friend of one of the paramedics.

But it was none of these circumstances. Eighteen years earlier, Sandra was a patient of John and Rick.

At the age of 5, Sandra darted into the street after seeing a friend who lived across the street return home. She ran before her Mom had a chance to even realize what was happening. Sandra ran between two parked cars, never looking either way, into the path of an oncoming vehicle. The car struck her and threw her about 15 feet.

John and Rick were dispatched to the scene and arrived to find Sandra unconscious and near death. Her blood pressure was 70 systolic, her skin color was terrible and she was fading fast. Among many other basic life support procedures, they intubated her and put in two IVs to get her blood pressure back up. After intubation and the IVs were established, they transported her to the local trauma center. During the 17-minute transport, Sandra’s skin color improved and her blood pressure started rising. Within 30 minutes of the incident, Sandra was in an emergency room receiving definitive treatment for her injuries. Shortly thereafter, she was having surgery for a ruptured spleen and other injuries. Sandra fully recovered to live a normal life.

This single event changed Sandra’s life forever. Very few doubted that if it had not been for the quick, rapid and aggressive intervention of John and Rick, Sandra might not have survived. But she did, and she wanted to thank those who made her wedding day so special – John and Rick.

However, you would think paramedics don’t make a difference after some media outlets jumped on several studies published in the New England Journal of Medicine. One study titled “Ontario Prehospital Advanced Life Support Study (OPALS): Rationale and Methodology for Cardiac Arrest Patients.” This study looked at over 5,600 patients who suffered out-of-hospital cardiac arrest in 17 Ontario urban centers. Of those patients, 1,391 had a cardiac arrest when the Ontario area only had a rapid-defibrillation program. Another 4,247 patients were studied after a full advanced life support program was instituted. The researchers concluded that CPR and rapid defibrillation increase cardiac arrest survival, but advanced life support (ALS) intervention does not.

Another article in the same New England Journal of Medicine, titled, “Public-Access Defibrillation and Survival After Out-of-Hospital Cardiac Arrest,” concluded that “training and equipping volunteers to provide early defibrillation with an AED in public places doubled the number of survivors to hospital discharged after out-of-hospital cardiac arrest.”

Some consumer publications and professional journals appear to have taken what they wanted out of both these studies and used it to create sensational headlines. For example, USA Today published a front-page story titled, “CPR, Defibrillators as Effective as Paramedics, Study Says.” The article ended with a quote from National Association of EMS Physicians President-Elect Robert O’Connor, MD, MPH: “These two studies will change way we think of EMS. This changes the playing field.”

Just like its multi-story series on EMS systems last year, USA Today missed the mark again and seemed more focused on selling newspapers with sensational headlines. Reporter Robert Davis, a paramedic who previously worked in Denver, wrote in the article, “Bystanders performing CPR and using automated external defibrillators save as many cardiac arrest victims as highly trained paramedics – and send more of them home with normal brain function.”

In all fairness, other professional journals and media outlets also jumped on the study. Journal Watch Cardiology published an article called “Advanced Life Support by Paramedics: No Added Benefit.” Journal Watch Emergency Medicine published a commentary, “Defibrillation for Out-of-Hospital Cardiac Arrest – Shocking Results.”

These professional publications ignored statements in the studies that were disclaimers. The OPALS study said, “Our study does not address the value of ALS programs in urban communities that have high rates of CPR by bystanders or very rapid ALS responders.” The study went on to disclaim, “Also unknown is the benefit of ALS in rural communities, where transport times to a hospital are longer.”

The second study in the New England Journal of Medicine also said, “The results of the trial pertain only to the implementation of a layperson-based defibrillation system in public settings with an organized emergency response system in place.” Additionally, researchers who conducted the OPALS study said they plan further studies of the benefits of various interventions, including ALS, on patients with breathing difficulties and trauma.

Every few years, these studies pop up and advocate that we get rid of paramedics, get rid of ambulances, don’t use lights and sirens, just do basic life support – don’t do ALS, just throw and go, and – my favorite – patients survive better if they go to hospital by car. Usually, these studies are done by researchers who never rode in the back of an ambulance, never tried maintaining an airway on an unconscious patient who is trapped in an automobile, or tried moving a large, obese patient who is having trouble breathing down three flights of stairs. They crunch numbers and generate statistics, and the news media spin their own view of the studies.

These studies fail to realize that cardiac arrest victims make up only 2% or 3% of an EMS system’s total call volume. How many patients never went into cardiac arrest because of definitive and rapid advanced life support intervention by paramedics?

Having data is the key to proving the value of an EMS system. The police have the Uniformed Crime Reporting (UCR) system where all criminal activity is reported to the FBI. This is mandatory. Fire agencies report fire activity to the U.S. Fire Administration (USFA) through the National Fire Incident Reporting System (NFIRS) and the EMS component of NFIRS 5.0 is not that comprehensive. This is voluntary unless you receive FIRE Act grant money.

EMS is starting to move forward on data collection. Standardization of data collection is being coordinated by the National Emergency Medical Service Information System (NEMSIS). On Oct. 26, 2004, all 50 state and territorial EMS offices signed an agreement to promote the new National Highway Traffic and Safety Administration (NHTSA) data set and its implementation.

Once there is 100% compliance among EMS providers with the national data set, the second challenge is to link the EMS data with hospitals’ data to determine the final patient outcome. In other words, did the patient walk out of the hospital and return to a life of normalcy after EMS delivery to the hospital?

Without the final patient outcome, EMS systems will never be able to justify that they make a difference with advanced life support. Does ALS intervention make a difference? I have seen it make a difference and I am sure you have also. It certainly made a difference to Sandra and her new husband –and they did not have to see the data to know it.