David Lehrfeld, MD, | Ray Fowler, MD, FACEP | From the December 2011 Issue | Thursday, December 1, 2011
This is the greatest era in the history of EMS, the newest subspecialty in the house of medicine. It may be said that EMS can do more now for critically ill or injured patients in the field than ever before. Field treatments are now focused more than ever on directly approaching the now-scientifically understood pathophysiology of the conditions threatening our patients.
At this important juncture in the history of EMS, it’s a useful time to reach into the minds of some of the great resuscitation researchers in the world to find out what they’re thinking about regarding the care of critically ill patients in the prehospital arena.
Our approach to crafting a paper as a “grand rounds” on resuscitation has been to ask five prominent thinkers in EMS science to respond to three questions. We first wanted to know what they felt—in the area of greatest interest to each physician—was the greatest accomplishment in the past decade in resuscitating critically ill patients in the field. Next, we asked them what they felt is the most difficult challenge in the care of critically ill patients in the field.
Finally, we asked the panelists to look into the future and predict the best place to look to improve the outcomes from resuscitation in the field. In doing so, we wanted to tap each expert’s vision to help guide an industry that’s eager to continue its growth and improve the quality of care as a subspecialty of medicine.
These interviews pose a few questions and provide each panelists’ thoughts on that subject, moving from the past to the present and into the future.
What has been the greatest accomplishment in the past decade for EMS in the area of resuscitation science?
Ahamed Idris, MD, FACEP: We must examine every basic and fundamental thing that we do in interventions in EMS. I lump many things under this need for careful evaluation. For CPR, that includes when do we need to ventilate, and what rate of chest compressions is optimal?
One thing we discovered is that BLS is the most important thing for improving survival from cardiac arrest. Advanced cardiac life support (ACLS) doesn’t have a lot to offer. The one key thing ACLS offers is hypothermia, but most of the other interventions are not very useful. We’re in the process of examining antiarrhythmics, and it may be that placebo is the “ideal antiarrhythmic drug” because it has the best survival advantage. We may even need to examine the use of epinephrine.
Another important discovery in the past decade has been the rediscovery of whole blood as the ideal resuscitation fluid for traumatic shock. Up until 1974, whole blood was the resuscitation fluid of choice for traumatic shock. Experience in the military has revealed that whole blood is the best resuscitation fluid of anything that can be given.
Paul E. Pepe, MD, MPH, FCCM, FACEP: There are four areas that come to mind right away. One is the public recognition of the importance of AEDs. Two is the development and validation of courses that have made CPR education simpler, faster to learn, and in turn, better because we’ve simplified the training process.1–3 The third issue is the recognition by the medical community that we haven’t been doing quality CPR and that when we do focus on quality CPR, we improve survival rates. The fourth concern is now that “ventilation should match perfusion,” meaning you don’t need as many breaths in a low-flow state, particularly in the first few minutes after sudden cardiac arrest.
J. Brent Myers, MD, MPH: I think the greatest accomplishment is the recognition that the resuscitation of the out-of-hospital cardiac arrest patient is owned by EMS. It’s become a form of a philosophical thing. The notion that we’re going to do something, then take the patient to a hospital, and the in-hospital providers are going to do something else, has been totally debunked. I refer to Art Kellerman’s editorial in the October 2010Annals of Emergency Medicine, where he said that, based on his editorial analysis of the literature, the patient who suffers out-of-hospital cardiac arrest is 35-fold more likely to survive if there is return of spontaneous circulation (ROSC) in the field rather than ROSC later in the ED.
So, to me, we can talk about sequences of defibrillation and continuous compression and therapeutic hypothermia, but none of these works if EMS considers the cardiac arrest patient in a manner similar to the penetrating trauma patient. EMS is the definitive treatment for medical cardiac arrest patients in the field.
Corey Slovis, MD, FACEP, FACP: I’m delighted that I can’t pick just one. There are three. Therapeutic hypothermia; the decreased emphasis on immediate hyperventilation and intubation with the advent and increased popularity of continuous chest compressions; and the really strong focus—although not yet completely disseminated through the community—on the use of AEDs.
John Freese, MD, FACEP: I believe the greatest accomplishment is the ability to analyze the quality of CPR being delivered to the patient. The world has spent 50-plus years trying to build a model of ideal resuscitation. Now that we can look at the variables of that quality, we realize that we have been building on a variable platform.
One example would be CPR prior to defibrillation. Some research has said that it made no difference, but now that we’re controlling the variables, we may have to go back and look at that research again.
Intubation is another example. I have been wary of continuing intubation for the cardiac arrest patient. If we could control the interruptions to less than 10 seconds and ensure the quality of CPR being delivered during the intubation, what, then, is the effect of intubation on outcomes?
What is the greatest current challenge in the resuscitation of critical EMS patients in the field?
Dr. Idris: I think one of the biggest challenges is identifying who the critically ill patient is. With people who are really sick, it’s pretty obvious. People who are in traumatic shock may have a normal blood pressure, but they’re still in shock. Identification of critically ill patients is a challenge in EMS.
For example, we know that at least 20% of patients in traumatic shock have a normal blood pressure. These patients are even misidentified in the ED, and it probably does result in a delay of care for patients who look too good to be sick.
Dr. Pepe: Airway management choices: Although endotracheal intubation (ETI) has been considered the “gold standard” for airway control and is immediately used in the hospital, concerns exist in the way EMS systems are organized today. Paramedics may not be as skilled as would be preferred in ETI. Because of infrequent opportunities for individual paramedics to perform ETI, it is less likely to be performed in as facile a manner as one would like.
However, in systems that maintain a smaller cadre of medics through tiered dispatch systems and an intensive focus on controlling respiratory rates in low-flow states, outcomes can be improved. Nevertheless, the majority of EMS systems are not set up that way, and this has made ETI a less reliable tool and one that can actually be harmful without all the right factors in place.
Dr. Meyers: I think the biggest challenge now is probably the one that has been there all along: I know that this may be politically insensitive, but my biggest concern is changing the paradigm of bystander education. This notion that we need cards and four-hour courses as opposed to a 20-minute YouTube video to teach somebody how to do CPR. We’ve got to cross that threshold. It’s OK for a bystander to pull out his iPhone and use an app to learn CPR on the spot. All of the card courses are equally guilty; it’s everybody.
Dr. Slovis: The great variability of bystander response and EMS response, where some communities have many of their citizens trained in CPR and others have few; where some communities have a tiered response and other communities have response times that don’t allow for survival.
Dr. Freese: I believe it’s the coordination of the care—both in the field and with the transfer to hospital care. We put an enormous pressure on our providers to do a great number of things in a short amount of time, and I think that leads to some degree of frustration that we expect them to accomplish “A to Z” in such a short amount a time; yet, they may not have providers who have sufficient skill and knowledge in the importance of what they’re doing and why they’re doing it to assist them.
Where is the best place to look for the next few years to improve resuscitation outcomes for EMS?
Dr. Idris: The challenge, which goes to my second point, is that we can’t very well measure the effect of what we’re doing, the effect of our interventions. For the patient in cardiac arrest, we can’t measure blood flow during CPR. So we don’t know what we need to do to improve the patient’s condition or what we need to change to improve the way we are doing it. Outcome is our only guide right now.
There’s no intermediate measurement that can give us feedback on blood flow while we are doing CPR. The same thing applies to trauma. Blood pressure is a crude measurement of traumatic shock: It’s a metabolic derangement. If we could measure what is happening at the tissue level, we could resuscitate patients more effectively. My whole thinking about improving outcomes from cardiac arrest is “saving life through metrics.” We could save many more lives by better measuring what we are doing.
Dr. Pepe: The best place to look is having the political clout to make our cities safer by ensuring that every man, woman and child—at least of age 12 or above—knows how to perform CPR and is ready to do so in a timely manner. This includes the use of AEDs and perhaps, with cheaper AEDs, they might even be sold as an automobile accessory to be sure one is always available. (JEMS then asked Dr. Pepe if he ever imagines a smartphone app that will somehow serve as an AED, and he replied, “Yes, or something similar.”)
Dr. Meyers: Hmmm … that’s the most challenging of the questions. For the first time in EMS, we’re generating our own data in a robust fashion. Thanks to the Resuscitation Outcomes Consortium, EMS as a subspecialty, and Prehospital Emergency Care as a world-class journal, we can now objectively look at each other. I think we look to each other to do this. We have to give kudos to the AHA for the past set of Guidelines, the 2010 AHA Guidelines for CPR and ECC; they were truly multidisciplinary, a really practical document.
Previously, when we had to look at someone’s ejection fraction before we gave certain drugs, clearly this did not have prehospital resuscitation in mind. We are at such a different place. For the first time, we have quality data from EMS systems and national bodies acknowledging that data, and we are seeing a measureable and quantifiable change in outcome.
Dr. Slovis: EMS has to become one of the leaders in preventive medicine in regard to blood pressure control, smoking cessation and lipids management. Who better to lead our nation in preventive healthcare practices than the very people who save lives on a daily basis? Our fire halls have to become community outreach health centers for specific diseases as they relate to stroke and heart attack: BP checks and referrals for treatment, smoking cessation and referrals to places to get care for this, easy lipid profile testing and firefighter- and EMS-led exercise classes offered free to the public.
Dr. Freese: I think the next big leap is going to come with the further integration of technology into our resuscitation technology that’s able to communicate from one device to another. I think proprietary technology is a hurdle.
An applied mechanical CPR device, which easily improves resuscitation outcomes, is necessary. But if it’s not talking to the monitor and isn’t able to analyze underlying rhythms appropriately, then time defibrillation efforts at the proper time in the upstroke, and the appropriate time with respect to ventricular fibrillation quality—if all that doesn’t happen, we’ve missed the boat.
I think what you end up with today with some technology is like we have with people—they don’t understand what each other is doing. We also need to be able to transfer the information to medical oversight. Dr. Myers tells his crews “if you don’t have a pulse after 10 minutes, give him a call.” And he includes the receiving facility, so they can see the progress of the patient prior to resuscitation. Then, they can see what has happened in real time rather than having someone explain to them what has been going on for the past 30 minutes.
The technology piece has to come along for us to be able to improve outcome. We are transfixed on the depth of compression: We need technology to assess the efficacy of our compressions, to guide us as to how we make compressions effective for this patient.
The diversity of the responses from these great leaders in our field demonstrates the breadth of both the responsibility and the opportunity that we have in EMS. The science is clear: Good BLS works; it’s an essential partner in the successes that we’ve had to date and lies at the heart of the potential for the greatest decrease in morbidity and mortality in our work.
From these great leaders we hear that simple, quick training programs in performing citizen CPR, for example, might improve survival from out-of-hospital cardiac arrest of thousands of people each year, a public health imperative that cries out for prompt attention.
It is clear, then, that we must use all our experience to optimize training, because lives truly hang in the balance. Concepts as simple as immediate citizen response, de-emphasized early ventilation, appropriate rate of compressions and seeking out EMS response are key factors that will save thousands in our country alone.
The opportunity to tease out of the minds of great thinkers the essence of their experiences can help us set our sights on the future. Such leadership will allow us to optimize our care and simultaneously guide an industry to partner with medical providers. Thus, we may together set our paths for developing technologies and maximizing patient outcomes. JEMS
1. Roppolo LP, Heymann R, Pepe P, et al. A randomized controlled trial comparing traditional training in cardiopulmonary resuscitation (CPR) to self-directed CPR learning in first year medical students: The two-person CPR study. Resuscitation. 2011;82(3):319–325.
2. Roppolo LP, Saunders T, Pepe PE, et al. Layperson training for cardiopulmonary resuscitation: When less is better. Curr Opin Crit Care. 2007; 13(3):256–260.
3. Roppolo LP, Pepe PE, Campbell L, et al. Prospective, randomized trial of the effectiveness and retention of 30-min layperson training for cardiopulmonary resuscitation and automated external defibrillators: The American Airlines Study. Resuscitation. 2007;74(2):276–285.
Ahamed Idris, MD, FACEP, is professor of emergency medicine and chief of the section on resuscitation research. He’s the principal investigator for the National Institutes of Health Dallas Resuscitation Outcomes Consortium, University of Texas Southwestern Medical Center. He can be reached at
Paul E. Pepe, MD, MPH, FCCM, FACEP, is a professor of surgery, medicine, pediatrics and public health and is Chairman of emergency medicine at the UT Southwestern Medical Center in Dallas. He’s also the director of the City of Dallas Medical Emergency Services for Public Safety, Public Health and Homeland Security. He can be reached through his administrative assistant at
J. Brent Myers, MD, MPH, is director of the Raleigh/Wake County EMS System in Raleigh N.C., and is an adjunct assistant professor of emergency medicine at the University of North Carolina, Chapel Hill, N.C. He can be reached at
Corey Slovis, MD, FACEP, FACP, is professor and Chairman of emergency medicine at Vanderbilt University School of Medicine, and he’s the medical director of the Nashville, Tenn. Fire Department and Nashville International Airport. He can be contacted at
John Freese, MD, FACEP, is the medical director and director of prehospital research at the Fire Department of New York, and he’s the principal investigator for NYC Project Hypothermia.
This article originally appeared in December 2011 JEMS as “Resuscitation Round Table: Five EMS experts offer views on key topic.”