HCMC_P_049062 - Hennepin County Medical Center

EMS Perspectives
Eugene Nagel, MD demonstrated that non-physicians
could be trained to provide advanced cardiac care in
the field under a combination of standing orders and
consultations with physicians by radio. Dr. Nagel and
Jim Hirschman, MD developed the original telemetry
device to send ECG data to a radio receiver in a
hospital, allowing physicians to hear what the
paramedic on scene had to say about a patient’s
condition while reading the ECG waveform in real
time and directing advanced care.
Meanwhile, the Seattle Fire Department created the
breakthrough Medic-1 program, which combined
community CPR education with advanced life support
by paramedics. Seattle’s early survival rates
of up to 50% were much better than the low singledigit
survival in much of the nation. This program
showed that pre-hospital cardiac resuscitation
required a coordinated approach combining the
efforts of the bystander, the professional rescuer,
and the hospital.
By the later 1970s, a patient living in a major city
who experienced cardiac arrest might receive CPR
from a bystander or from a rescuer, such as a police
officer or firefighter. By then, paramedics could
initiate care at the scene, control the airway, establish
IV access and attach ECG electrodes while calling a
physician for orders. Patients often received
epinephrine, sodium bicarbonate and Isuprel (a strong
beta agonist). Patients in ventricular fibrillation were
often given lidocaine and defibrillated under the radio
direction of a physician, often with the aid of ECG
telemetry. Once initial care was established, the
patient was transported with CPR in progress.
Unfortunately, most patients who required CPR
during transport still did not survive to admission.
The 1980s and 1990s
The ‘80s and ‘90s brought more gradual change, and
the scope of the paramedic’s practice increased in
most communities, allowing for more seamless
resuscitation efforts under standing orders without
continuous calls to a physician for orders. Telemetry
for ECG rhythm analysis fell by the wayside as
paramedic education increased. However, community
involvement in CPR continued in fits and starts.
Attempts to mitigate the lack of bystander action in
cardiac arrest included the Medical Priority Dispatch
System (MPDS), developed by Dr. Jeff Clawson.
MPDS used standard questions to allow the emergency
dispatcher to send the correct emergency resources
to the scene while providing bystander care
instructions to the caller, to assist in childbirth, help
someone who is choking, or administer CPR 5 .
Early defibrillation remained a key factor in resuscitation.
The advent of the Automatic External Defibrillator in
the ‘80s was expected to greatly increase survival
because this device did not require a paramedic to
determine a shockable rhythm. CPR took a back seat
in many training programs, with the idea of “buying a
little time” while waiting for a defibrillator.
By the 90s, many EMS systems had established first
responder programs using local police or nontransporting
fire services to bring an AED to the
patient’s side. These first responders would arrive
and attach the AED and deliver defibrillation.
Advanced life support was performed by paramedics
on scene. Unlike the ‘60s and ‘70s, transportation of
patients in cardiac arrest decreased dramatically.
Patients who had a return of spontaneous circulation
received continued advanced life support and
transport. Those patients who did not have a return
of pulse were often pronounced dead at the scene.
National survival rates still hovered around 20%, so
researchers began to examine why surviving sudden
cardiac arrest was so elusive. Drugs came and went,
often based on anecdote or animal studies. Human
resuscitation research was fraught with ethical
obstacles, such as the lack of informed consent from
a patient in cardiac arrest. These efforts to study
cardiac arrest finally led to the Utstein Template,
which provided specific definitions to help researchers
and providers better understand one another’s
successes and roadblocks 6 . It allowed EMS systems
to report and reflect on their success. Nevertheless,
even in high-performing EMS systems, successful
resuscitation remained less than 30% for patients in
ventricular fibrillation.
Today’s Rapid Access
Today’s more rapid access to basic life support
improves survival in cardiac arrest 7 and CPR for the
lay rescuer has become even easier. Disco has
returned, at least for resuscitation. “Fast and hard”
compressions on the center of the chest, to the beat
of the Bee Gee’s “Stayin’ Alive” and “Call 9-1-1”
simplify what a layperson needs to know to initiate
resuscitation. Pulse checks and rescue breathing
have become a thing of the past for lay rescuers.
Researchers found that Safar was right—exhaled
breaths provide sufficient oxygen to preserve life –
and it is more important to provide circulation
because sufficient oxygen is already in the sudden
cardiac arrest patient. The old approach to “ABC”;
Airway, Breathing and Circulation has been replaced
by “CAB”, where circulation comes first, then airway
and breathing.
14 | Approaches in Critical Care | January 2013