Blurring the line between pre-hospital and hospital care

CarolinaFireJournal - David S Bowen, RN
David S Bowen, RN
04/29/2011 -
In the early 1970s, Wake County had a total of two ambulances, both of which were owned by a funeral home — a common practice at the time. When an injured or sick person needed to get to the hospital, it could be a while before one of those ambulances could be on the scene. It would be even longer before any sort of medical assistance could be issued since the ambulance driver was little more than just that — someone with a driver’s license and little, if any, medical training. Further complicating matters was the fact that 911 was in its infancy and available only on a spotty basis. Simply getting word that an ambulance was needed could take time. image

The motto for what passed as pre-hospital care at the time: You call, we haul.

That began to change after a Cary teen was seriously injured in a car crash and the slow response resulted in a bad outcome. Volunteer ambulance services began to pop up around the county, and while the response time improved, it still wasn’t good enough: By the time a call came in, the volunteer was summoned from work and drove to get the ambulance, then responded to the scene, precious minutes were lost. It was a culture of, “Do the best you can.”

But a rapidly growing population — Wake County had just 228,000 residents in 1970 compared to more than 900,000 today — demanded more. That demand, aided in part by increasingly sophisticated technology, has resulted in one of the leading counties in the nation for pre-hospital care. A county where the notion of “Doing the best we can,” has been replaced by, “What more can we do?”

Wake County’s preh-ospital resuscitation rate — the rate at which people are successfully revived after having no heart beat — is more than twice the national average. And by successfully revived, I don’t mean on a respirator with the heart beating and no brain function. I mean walk-out-the-door living. The American Heart Association/American College of Cardiology recommend a door-to-balloon time of no more than 90 minutes. Wake County has been able to shave 22 minutes off that amount thanks to treatment that now starts on the scene. The pre-hospital use of continuous positive airway pressure (CPAP) masks keeps about 50 patients a year off ventilators in the ICU.

According to Brent Myers, medical director for Wake County EMS, “The notion that there is an EMS portion of patient care and a hospital portion of patient care is over. That line is blurred.”

The beneficiary of this melding of pre-hospital and hospital care: The patient.

I started in what was then called the emergency “room” at the then, Wake County Hospital in 1989 as a nurse tech, three years after earning my EMT training at Appalachian State University. The ER had 25 beds set up in a horseshoe. EMTs would call in with a general description of the patient’s situation and we’d assign them a room. The EMTs took the patient directly to that room, and while we knew they were coming, we didn’t always know when they had arrived. We also had only a general idea of what we were dealing with; it wasn’t until the patient was here, in the emergency room, that we were able to get a clear picture, mobilize and begin treatment. There simply wasn’t a lot of treatment in the field. We tried to get them stabilized and that was about it. If we wanted to start an IV, we had to call in by radio to the mobile intensive care nurse and get permission. It was a new profession, this business of being an EMT as opposed to simply driving the ambulance. There was a lot of trust-building going on. You were operating on someone else’s license.

That fledgling trust blossomed and has helped create a model system for emergency care that starts when EMS arrives and continues through the emergency department and subsequent treatment.

A car crash provides a good example. Twenty years ago, we might know only that a car crash victim was coming in and likely to arrive in, say, eight or 10 minutes. Precious time was lost in those eight to 10 minutes not knowing what kinds of injuries we should be preparing for. Today, when an EMT arrives on the scene there is an immediate patient assessment, including administration of the Glasgow Coma Scale, which helps us determine what level of trauma we’re dealing with. The EMT examines the vehicle and searches for mechanisms of injury. Is the steering wheel deformed? Did the air bag deploy? Did the victim hit his head on the windshield? All this information is relayed back to us immediately. We can even get pictures from the scene, and if the vehicle involved has OnStar, we can get the speed at impact.

All of this helps us understand what happened and better prepare for the crash victim. We can mobilize the appropriate personnel: an ED nurse, a secondary backup nurse, a nurse to record what’s happening, a nurse tech, an ED physician and usually a resident, a respiratory therapist, a surgical attendant, a surgical resident, a mid-level surgical physician’s assistant, two x-ray techs with a portable x-ray machine, a chaplain — everyone pertinent to this particular patient’s care. We can have a patient in the OR within 10 minutes from the time they come in, greatly increasing the odds of a positive outcome. All because the process now starts in the field, with EMS.

One of the purposes of a trauma center is to work within that “golden hour,” that period between incident and intervention in which action is critical.

Perhaps nowhere is that action more critical than with cardiac patients.

A new technology embraced by Wake County EMS with the support of the county’s three hospital systems is helping cardiac patients even more.

In February of 2006, an EMS fellow who had just completed his residency approached Wake County EMS Medical Director Dr. Brent Myers about a new approach to treating cardiac arrest: therapeutic hypothermia. By cooling a cardiac patient’s body temperature by about seven degrees to 91 degrees F through injection of an ice-cold saline solution, the damaging effects of reduced blood flow to the brain and other organs could be greatly reduced. The patient is kept in this state for 24 hours, then gradually re-warmed, by no more than one degree an hour. The procedure — which the American Heart Association issued guidelines for in 2005 — was being administered in hospitals, but not by many EMTs in the field. Convinced of the need, Myers approached Wake County’s three hospital groups, and WakeMed and Rex immediately signed on. Together, they were able to go from concept to practice in just seven months. Even Dr. Myers was surprised by the speed at which the procedure was approved and enacted. While the hospitals do compete for business, this was not a matter of competition, he said. It was a matter of what’s right for the patient and how can we make this happen.

This is one of the few places in the nation where EMS and hospitals are working together on therapeutic hypothermia treatments. Eventually, our goal for cardiac patients is for them to bypass the emergency room completely and have the EMTs take them directly to the catheterization lab.



Photo by Julie Macie/WakeMed Health and Hospitals

What’s right for the patient is also getting to the right hospital. It used to be that the nearest hospital was the right hospital, but no more. Let’s say a paramedic administers a 12-lead EKG and detects Acute Coronary Syndrome or Acute Myocardial Infarction. He wouldn’t want to take them to our Apex facility simply because it was the closest facility, Apex doesn’t have a cath lab. The patient would need to be transported again, wasting critical time. Our EMTs have a solid knowledge of the county’s facilities and what each one can do.

A special nod goes to EMS providers in outlying counties on this count. A lot of the rural hospitals don’t have the services we have here at WakeMed. They may not have an advanced trauma center, for instance. Instead of taking a car crash victim to the nearest hospital, the EMTs will make that extra 15- or 20-minute drive and bring them to WakeMed. In the case of someone bleeding to death who can only take so much IV fluid before needing blood, in the case of someone who may be combative and fighting from a head injury and may be battling an EMT’s efforts to keep a cervical collar on — well, doing all that while traveling 70 miles an hour on a bumpy road in order to get the patient the right care as quickly as possible, that’s admirable to me.

Admirable as well is the dedication of EMTs and paramedics, who are continually updating their skills to keep pace with the latest in treatment and technology. They are out there almost every month, taking continuing education classes and refreshing their skills. We’re well aware of their extra effort here in the emergency department, well aware that they know their stuff. That, too makes trusting their judgment all the easier.

That brings up a traditional shortcoming of emergency care: the lack of feedback on patient outcomes. Too often, the EMS brings in a patient and that’s the last she sees — or hears — of him. It’s especially frustrating to not know what kind of impact your treatment may have had. Or to know if another route may have been more effective. In the long term, you don’t know what happened.

This feedback loop is already in place on some levels. For instance, the WakeMed Stroke Center, will provide EMTs with patient outcomes. That’s especially important with stroke victims who generally have a three-hour window before the effects of a blood clot can become devastating. Did the patient get thrombolytics and were they effective at thinning the blood? EMTs can also request information on their patients from the hospital, in accordance with HIPAA guidelines, of course.

Wake County’s hospitals and its EMS system are working to further that flow of patient information. Dr. Myers says we’re now very close to establishing a true patient outcome assessment of how their treatment did. If it worked, great. If it didn’t, how can we change it?

“It used to be that we did things to patients,” says Dr. Myers. “Now it’s, ‘We do things for patients.’”

Wake County EMS helps us in small ways you might not expect. They have a select group of Advanced Practice Paramedics who are trained for high-risk procedures such as intubation, but who also perform a variety of other functions. Say a diabetic comes into the Emergency Department unresponsive. We give them dextrose and they come back, but they don’t want to be admitted to the hospital. The Advanced Practice Paramedics will drop by their house three hours later to check up on them, to make sure they’re eating and taking their medication. They also do a lot of work with the mental health community. In general, they do a lot of follow-up for us. Their work is preventive in nature, but it’s helping to not tie up resources in the emergency department.

It’s that two-way mutual respect — and trust that began building more than two decades ago — that continues to blur the line between pre-hospital and hospital care says Dr. Myers, who is himself a practicing emergency department physician regularly staffing in the WakeMed Raleigh Campus emergency department. Because of Dr. Myers, we have a model EMS system.

Dr. Myers is equally quick to praise Wake County’s hospitals. “There’s no resistance,” he says to EMS proposals that promise to help the patient. “That’s the beauty of it. As soon as we can get the technology we need, they’ll help us facilitate implementation.”

We are lucky to have a model system for EMS/Emergency Department relations and the reason is simple. It’s not about us, it’s not about them. It’s about the patient.

Bowen is EMS Liaison - Raleigh Campus Emergency Department WakeMed Health and Hospitals
Comments & Ratings