I did a fair amount of traveling and teaching in 2013 and I've been struck by the number of people who have been absolutely gobsmacked by the number of rescuers my fire department sends to a sudden cardiac arrest (1 ambulance, 2 engines, and a battalion chief).
I think there are several reasons for this. In the first place, most jurisdictions don't have the resources, or at least say they don't have the resources, to do what we we do. But I think the real issue is that people don't understand the benefit of sending 9 to 11 people to a sudden cardiac arrest. In fact, some have argued that sending that many people only encourages therapies (like drugs and tracheal intubation) that have not been proven to positively effect neurologically intact survival.
I disagree. The two issues are not related.
Aside from the fact that we identified this additional staffing on the first alarm as a best practice after speaking with some of the best EMS systems in the country (those few who can prove it), let's look at the big picture.
First, we need to consider that sudden cardiac arrest, particularly witnessed VF arrest, is a survivable event — when a process is in place to save that life. Although I don't take credit for the maxim, I have said many times that "every system is perfectly designed to achieve the results that it gets" and I certainly believe that. If the planets need to be in perfect alignment for a patient to survive in your system then it is not geared to save lives. Rather, it is geared to take patients to the hospital and generate revenue.
You might deliver excellent customer service, and you might have talented EMTs and paramedics, but no individual can save lives in a vacuum, or at least, very rarely can they manage to do that. Human performance is inexorably intertwined with system performance. Almost every young, highly intelligent, and motivated paramedic who becomes disillusioned with his or her EMS system is told, "just do the best you can in the back of your ambulance and make a difference with each and every patient you come into contact with." You can try to do that, it's true. I'll even conceded that you can find some value or solice in doing that.
But you cannot reach your potential as a medical professional within a poorly performing system.
Poorly performing systems are almost never the fault of the guys and gals on the front lines. That's true in factories, it's true in the military, it's true in hospitals, and it's certainly true in EMS systems. You can achieve compliance with a whip but you cannot achieve quality. Once we accept that it's all about the process, we can go about the task of designing processes to save lives.
The principles of the 2010 AHA ECC Guidelines are quite simple.
- Minimally interrupted chest compressions
- Controlled ventilations
- Early defibrillation and shocking in a 2-minute cycle
- Managing the peri-shock pause
- Allowing capnography to identify ROSC
- Early identification of STEMI and transport to a PCI center
- Ensuring that eligible patients receive targeted temperature management
As they say in the Resuscitation Academy in Seattle, "it isn't complicated but it's not easy." The reason it's not easy is that while no individual piece is particularly complicated, making it all happen in a highly coordinated way involves a lot of different individuals who must work together as a team, and do so over and over again, with different team configurations.
The issue is variability — the enemy of system performance.
So why send so many people to a sudden cardiac arrest? Here are the benefits.
You might have a brand new paramedic on the first arriving ambulance. But when you send multiple assets to the call you're bound to get an experienced paramedic. I can already hear the objections from some of you about "skill dilution" (which I think pales in comparison to the modern problem of "never having the skill in the first place"). But, the reality is, leaving newer paramedics alone to experience clinical misadventure teaches them nothing, except perhaps "what happens in the back of the ambulance stays in the back of the ambulance". Which brings me to the next point.
A very important, but initially unanticipated, side benefit to sending multiple crews to a cardiac arrest call is that each time we assemble our Pit Crew CPR process is an opportunity to model the correct behaviors for our personnel. We are able to reinforce our checklist-driven methodology that ensures that the appropriate leadership and communication take place, that we do not move patients in cardiac arrest prematurely, that we meet important benchmarks, and that we do so in a calm and organized fashion.
There is absolutely no reason that the first arriving crew to a sudden cardiac arrest should have to worry about locating the patient, carrying the cardiac monitor, airway bag, suction unit, drug box, a backboard, 2 liters of iced saline, and a gurney onto the scene of a cardiac arrest, which could be on the 5th floor of a hotel. When you send enough appropriately trained people to a sudden cardiac arrest you can have people holding the elevator, interact with the family, run back to the ambulance, switch out the rescuer on chest compressions, take a 30,0000 foot view and act as a "code commander", be a scribe, or just put another set of eyes on the process.
Taking command of a structure fire is considered so important that failure to do so is considered negligence in the fire service. The reason is simple. When we act as individuals (freelance) we get into trouble. There may be confusion about whether or not we are "offensive" or "defensive", vital information may not be shared, dangerous ventilation practices can threaten interior teams, or there can be a catastrophic loss of situation awareness that leads to firefighter death or injury. Have you ever been on a call with three paramedics and seen them work separately as opposed to as a team? Someone must be in charge. That doesn't mean someone reverts to Theory X and becomes unapproachable or dictatorial. It means that someone coordinates the team's activities. To do this effectively on a system-wide basis requires specific training in crew resource management which is outside the scope of this blog post.
When you send a supervisor to each and every resuscitation attempt it helps to ensure consistency from crew to crew and shift to shift. It also helps cut through any issues or problems you might have on scene. Our battalion chiefs often act as the family liaison, interact with law enforcement, nurses, or physicians on scene, make sure that policies are followed, and sometimes, even provide expert clinical care if the need arises. They are there to support the personnel who are engaged in the resuscitation, and they are there to monitor performance to identify opportunities for improvement.
In the beginning, there were plenty of paramedics who bristled at the idea of a battalion chief showing up for resuscitation attempts, and some of them thought a second engine was a ludicrous waste of time and money. No one feels that way anymore. In part, that's because we measure our outcomes and the increase in neurologically intact survival, particularly in calendar year 2012, was undeniable. When you have 9 additional survivors who walked out of the hospital (or were at least rolled out in a wheelchair) in a department the size of mine, it means that the majority of the department participated in at least one save.
That's pretty good for morale.
We have spent the last 20 or 30 years sending half the fleet to a "pot on the stove". Now, everyone understands that a sudden cardiac arrest is just as important (actually far more important) than the average "smoke in a structure". That's a change in culture. There have been other changes, too. Like the idea that we provide supportive and non-punitive feedback to the line. It turns out that when you believe in people, provide the appropriate education and training, explain the "why", give them the right tools to do the job, and support them, they rise to the occasion and do amazing things. They help build a process that saves lives and they take ownership of it. They should, because we can't do it without them. It's a human being that performs chest compressions, starts IVs, charges a defibrillator, and makes critical decisions.
A lot of people say "response times don't matter" or "it's such a small percentage of our call volume". Well, to say the least statements like that require qualification. I find it to be far more palatable from an EMS system that knows its numbers and has optimized its system performance. Otherwise, we're essentially writing off our most critical patients. I got into this business to save lives, and I'll bet you did, too. Then, somewhere along the way, we became cynical and jaded.
Saving lives makes you believe again. It feels good, too.