R. Darrell Nelson, MD, FACEP, FAAEM, assistant professor of Emergency Medicine at Wake Forest School of Medicine, presents the history of modern trauma care and how it has influenced EMS care of patients with STEMI (ST segment elevation myocardial infarction). He also discusses new developments in EMS cardiovascular care that have improved outcomes.
DARRELL NELSON: Thanks, I'm glad to be here today. I'm pretty excited to talk to you about this topic. Bad news for you, I could talk about this all day long. Good new for you, Amy only gave me 30 minutes. So never fear. So I have no conflicts of interest, no industry bias. I'm not going to talk about anything off label today. Well, maybe. I'm going to mention therapeutic hypothermia, which is actually not FDA approved. I do not have any financial conflicts, looking for some if anybody has any out there. Just let me know after this talk. So I'm going to just do a little bit of back and forth. So can you tell me five critical illnesses where EMS can make a difference in patient outcome? Just shout them out. Trauma, yes. Stroke, MI, cardiac arrest. I heard four. That's good. Cerebral bleed, absolutely with stroke, absolutely. So that's true, absolutely. Airway, respiratory emergencies, trauma, stroke STEMI, and out-of-hospital cardiac arrest. So I'm going to talk about a few of those things toward the end. It will be a good segue into Dr. Zhao, what he was going to talk about. So how do we achieve the greatest impact on these illnesses? Well, the best way is what we call regionalization or really moving care forward. So there's a lot of things we can do in the emergency department. There's a lot of things that we do in the hospital that are applicable to the field. So that's what really has been happening over the last 10 to 20 years. We've been taking a lot of proven therapies that occur in the hospital every day and just moving those things forward in care out to the pre-hospital environment. And then regionalization. So what is regionalization? So it's the formation of a coordinated system of care, crosses geographical boundaries. And it crosses competing health care systems. So ouch. So as we know, we have competing health care systems here in Winston-Salem. I can tell you I was in the Charlotte market for many years. And the competitions there is a lot worse than it is here. So we actually have it pretty well. Our health care systems do compete. But they actually work together on many issues, particularly when it comes to EMS. As a matter of fact, just before this talk, I received an email from Doctor Don Heck who's one of the neurointerventionalists at Novant. And we are working on a study to try to get folks with large vessel occlusion strokes to either Novant or Wake Forest where we can do mechanical intervention for those folks who are going to benefit much better than TPA. So we do work closely together with our health care systems when it comes the EMS. So regionalization more is combining all the necessary components to optimize patient outcomes. It involves public health, kind of, not as much as we probably could incorporate. But definitely out of hospital component and the in hospital component. It's commonplace now. But it hasn't always been commonplace. And it is complex. And it's really complex when you put the politics in. So even though we do work together, we still have our feuds. But luckily we really do work together. So I have been fortunate. I actually worked at Novant as a nurse for many years. I was a paramedic before I became a nurse and worked at Novant and then went on to medical school and now a physician at Wake Forest. So I've worked in both of our competing health care systems here in our area. And we really do work well together. Here's the biggest problem when it comes to EMS and also in the hospital is silos. So you think you see these things only on the farm. But health care is inundated with silos. Everybody works in their own silo. You see this every day at work. We can't do this because our paperwork says we've got to do it this way in the PACU. We can't do it this way in the ICU. We can't do it this way in the ED. So we all have these different silos. And EMS has really being carved literally almost outside the health care system as its own huge silo. It's taken years to really incorporating EMS into the health care system. Even though when you talk about an EMS system, the EMS system starts from the moment an injury or illness occurs. And it ends when the patient is completely rehabilitated. But most of us don't consider that the definition of EMS. But that is actually the definition of EMS. So the key is to try to bring EMS into the fold of the health care system and break down these silos in order to move care forward. We don't want to give this medicine outside the hospital. Because we want to hang onto that medicine inside the hospital. So the goals of regionalization are to facilitate the provision of quality care, assure overall economy of the system, and then appropriate utilization of resources within a region. So hopefully we'll improve outcomes and save money at the same time. Some of the ways we could do that though is performing tasks earlier in the sequence, activation of trauma teams, STEMI teams, CVA teams. And it results in significant time savings. So how did we get here? So for those of you who don't like guns, unfortunately, that's where most of our modern medicine has come from is ware. We've learned more about the care of trauma and emergency medicine from military conflicts than almost anything else. This began in antiquity. The Egyptians were the first to treat soldiers on the battlefield and extricate them. More modern times, with Napoleon. His chief surgeon Dominique Jean Larrey developed these things he called the ambulance volantes which are these two or four-wheeled horse carriages that extricated the wounded off the battlefield to a casualty collection point. And then they were moved to the rear to be cared for there. Those same principles of evacuation in medical care are in our military today. And we incorporate many of those military aspects into the EMS system and our trauma systems now. So you can see these pictures. So if you're as old as I am, you grew up watching MASH. And you see that bubble face helicopter there with the two side stretchers off the skids. So that's how we extricated people out of the Korean War. We put the injured on the side of a helicopter and we flew them out into a primary receiving station, then onto a secondary casualty collecting point, and then maybe out to sea to a surgical hospital. But there was no care. They just were on the sides of the skid and flown to definitive care. Still worked though. The picture below that is the time I was born is when the Vietnam conflict was starting. So you see those pictures at the bottom with the big Bell Huey. And the only difference there is they were actually giving care during the transports. So soldiers were being treated at the point of injury, then extricated to a primary casualty point, and then on to a secondary casualty point. About that same time though in the American streets, we had tremendous amount of crime. Gunshot wounds, penetrating trauma, and automobile accidents were all occurring. And then in 1966, a major white paper came out from the National Council of Research that kind of really set into motion our modern EMS systems today. Before that though, in 1961, Maryland had really developed the first shock trauma. And the Maryland state was actually one of the first to incorporate kind of a regionalized approach to trauma care. So a lot of our regionalization came out of initial trauma care where we learned those basic principles from the military. And those principles work. The mortality since World War I down to our modern conflicts have just plummeted. So if the soldier survives the initial injury, their chance of survival is much improved by a factorial number for modern conflicts. And 1973 is when the federal government kind of got involved and passed a bill called the EMS Services Act. And in North Carolina, we passed a very similar act to use some of that block grant research money that was offered by the federal government. That also kind of started regionalization, categorization, and designation of trauma centers and emergency departments. So here you can see the trauma regionalization in North Carolina. You see each color represents a RAC, so a trauma regional advisory council. We are purple at the top. And you can see it works pretty well in the state til you get toward the Raleigh-Durham area. And then there's a little bit of health care competing things that go on there. But you know, it's Duke. So what can you say about Duke? But that's really how our trauma regionalization happens in North Carolina. So trauma outcomes are one of the first things that we're really studying. And we've kind of use that information and built on other aspects of pre-hospital care. We know that if you recognize an injury, rapid transport to a trauma center, mortality and morbidity plummet when that happens. One of the first studies to look at this though looked at San Francisco and Orange County. They found that in San Francisco, who did have a systematic trauma care system, 1 out of 92 preventable deaths were found in San Francisco. At the same time, 11 of 30 preventable deaths in Orange County. They looked at this later when Orange County instituted a trauma system and saw that their mortality had kind of plummeted by over half. So moving care forward, let's talk about STEMI. Because I know this is a cardiovascular conference. We're not interested in trauma. But many of the same principles we use in trauma we can put forward as some of our medical illnesses. So just to kind of go through a step fashion, in the past, when EMS was involved with an ST Elevation MI, symptoms were recognized. Somebody called 911. EMS arrived. First responder is EMS. EKG was done. So over the past 20 years, we've gone from three leads to six leads, to now we can actually do 12 lead EKGs. And then they were transported to a hospital of choice. So that's the way a STEMI has worked historically. So now STEMI version 1.0, symptom onset, 911, EMS comes, EMS gives an aspirin now. So aspirin is pretty effective. So some of you nurses out there that has given thrombolytics before, when I was a nurse we were given streptokinase. It bubbled up. Pumps would never work right. And I gave Retavase one time as a resident when I was at Carolina's Medical Center. So we don't give thrombolytics much anymore. But aspirin is just as effective as streptokinase. If you give both together, you get better outcomes. But if you just compare both, aspirin is almost as effective as streptokinase. And you only need to treat about four people to have a good outcome. So it's pretty cheap therapy. EKG transmission, maybe. So if they've got the capability, they can transmit an EKG. Transport to the hospital of choice. And care was delivered there. So now let's look at what really moving care forward means. So you take that kind of compartmentalized, step-wise fashion, almost different silos. And you sequence that in a much closer. So symptom onset, someone calls 911. So that PAI stands for pre-arrival instructions. So 70 of our 100 counties in North Carolina have the ability to interrogate callers, come to an impression basically, not really a diagnosis, and then can offer pre-arrival instructions from CPR with cardiac arrest to birthing of a child to giving rescue breathing and also giving an aspirin. So now the dispatchers can recognize that a potential MI is occurring and actually direct that caller to give an aspirin. So EMS arrives. And now when EMS arrives, now it's much different. So now we kind of put all these things into simultaneously processing instead of stretching it out in sequence. So now paramedics get an EKG, give an aspirin, transmit that EKG, and now we notify the cath lab. So in the daytime, probably don't save a lot of time. But at 7 o'clock at night on Saturday and Sunday when cath labs aren't operating during normal business hours, this can decrease time. So that's what we talked about earlier, saving time. Because if I've got a medic in Stokes County on the other side of the Sauratown Mountains who's given an aspirin, transmit an EKG which shows an ST elevation MI, they've got 30 to 40 minutes before we're going to get to definitive care. That way the cath lab team has ample time to come in, get the cath lab suite set up, and can be waiting to receive that patient on arrival. Whereas before, they would have lingered in the emergency department until the cath lab is ready to receive them. So now, simultaneously transportation. So we've got EMS transporting. And we've got cath lab teams en route to the hospital. And now we go to the definitive care where PTI center is located. So look at STEMI version 2.1. So now same thing, symptom onsets recognized, 911, pre-arrival instructions, give an aspirin, EKG, aspirin if it hasn't already been given, EKG transmission, and cath lab notification. So now thrombolytics. Does anyone know that we have EMS systems in North Carolina that actually provide thrombolytics? Good. So we don't have many. But we do have one in Wilkes county. Doctor Henderson McGinnis, one of my partners in the emergency department is medical director there. They've been giving thrombolytics for over a decade with no bad outcomes. So simply because they can't get to a cath lab within 90 minutes, and if they go to a primary hospital, there's no way they can get to a cath lab within 120 minutes which are standard minutes. So we do have EMS systems in North Carolina that do give thrombolytics and have given thrombolytics with great success. So now we can give thrombolytics and still transport to the primary transcutaneous site as we had before. So now, what about thrombolytics? So I was kind of coming, I was a nurse in a residency when thrombolytics had kind of peaked and then kind of moved off to the face simply because PTCI came on board. And thrombolytics kind of took a second seat because we had a mechanical intervention. So I don't think we ever completely teased out the effectiveness of thrombolytics, even though we've kind of gone back to that a little bit now. In those centers where we can't make those door times to 120 minutes for cath lab, we still have an opportunity to give thrombolytics. So how have we done with STEMI outcomes? So RACE project, regional approach to cardiovascular emergencies in North Carolina, we got a lot of national press about our RACE project. This started in 2002 at Duke University. They just looked at their quality metrics with the folks that were coming in with a myocardial infarction and found that they could do a lot better. So most of these people weren't able to get intervention because they didn't get there in time. So that's really where this project was born out. They got a grant. And we started to do regionalization across the entire spectrum of North Carolina. So STEMI centers were identified. Primary cathing sites were identified. And then depending on where you were in your region, you started to filter those patients into the primary cath sites. And this has gone on for years. And it still is in play now. So we also got some negative press a few years ago. A nice editorial was written about the RACE project. And the title was "Race to Where?" So their argument was there wasn't really any mortality benefit that was shown. And that's probably true. A similar program that was launched in Dallas, Texas did show a decrease of about 3% mortality. There's a lot of confounders. I still think the main success of the RACE program was the fact that we identified those primary cathing sites and actually effected regionalization, which now helps with a cardiac arrest and also stroke. So I think even though maybe we didn't show a huge benefit in mortality, more patients were eligible for therapy because of this program. And it's actually helped us launch into other regionalization projects with stroke and out-of-hospital cardiac arrest. So let's talk about stroke. So previously, symptom onset recognized, call 911, EMS arrives, and then basically that was it. So we didn't have a lot to offer the stroke patient years ago. We just transported to the hospital, went to your hospital of choice. And many times they were transferred somewhere else later. So more modern version is symptom onset, 911. So in some places in the United States, they give aspirin to strokes. That's about an 85% chance you're going to have a non-ischemic stroke. So if you're rolling the dice, the chances are good that the aspirin is not going to cause any harm. And it probably is not going to cause any harm if you do have intracerebral bleed. So many systems do advocate giving aspirin up front to a stroke victim. EMS arrives. And then we do that sequential processing again. Do a stroke exam. There's many stroke exams that are out there. Not the NIH, that's way too complicated for us in pre-hospital medicine. So we have much more curtailed stroke exams to accomplish. So we recognize a stroke has occurred. Then we notify the center. And that can be a primary stroke hospital or a specialty stroke center. It just really depends on your region. Because many of our stroke-capable hospitals now have under teleneurology. And they can make a decision to give tPA. So in some of those locales where we couldn't get to a stroke center and be able to deliver tPA, we can get to a primary stroke-capable hospital, have that patient seen by a stroke robot and a teleneurologist, and make a decision on giving tPA. So again, we can move care forward. Then once that is given, then many times they can be transferred to a higher level of care, or many times can remain at that hospital depending on the stroke programs there. So stroke outcomes. This is new. So we're really entering new territory. And we're starting to look at this in North Carolina to see how well we've done in regionalizing our approach to strokes. Still a lot to be learned. Because this is also kind of cool politically complex. It's not as politically complex with STEMI because not everybody can do catheterization. But almost anybody can get a stroke robot. And almost anybody can get tPA. The problem is downstream from that. So this is a little bit more political in terms of folks trying to hang on to their patients at local hospitals, which is great as long as they've got the capability. Because so taking tPA, taking mechanical intervention, does anyone know the single thing that improves stroke outcomes more than anything else? Skilled nursing. Skilled nursing care. That's the one thing that's proven to be more beneficial than anything else in stroke. Nurses who know exactly how to take care of a stroke patient, physical therapy, and occupational therapy. Because with tPA, 12% get better, 6% get worse, and 82% there's no change. So skilled nursing is still the single best reason folks get better from strokes. So early identification, we use all sorts of tools. In North Carolina, we use a Cincinnati scale and a Los Angeles scale. Most folks use Cincinnati. There's others-- Miami and Melbourne. And one of the things we're working on now, what I mentioned earlier with Dr. Don Heck and Doctor Stacey Wolfe, one of our neurointerventionalists here at Wake Forest is coming up with a better exam to figure out those patients who have a large vessel occlusion stroke. Because those folks have a much bigger window of time, anywhere from six to eight hours. So in many cases, those folks-- it's a small percentage-- but if we can identify those folks who have a large vessel occlusion, we could bypass a primary or stroke-capable hospital and go onto a center where they can get a mechanical intervention. So this is probably the newest thing in stroke that we'll be teasing out over the next 10 to 15 years trying to identify those folks who would be best suited for mechanical intervention. The studies so far have shown that they all get tPA. And they all do better if they get tPA before the mechanical intervention. But we're trying to identify those folks who are going to be most benefited by mechanical intervention. All right, so let's talk about out-of-hospital cardiac arrest. This is the part I could talk about all day. So in the past-- symptom recognized, call 911, first responders and EMS arrive, and then we put a body in the back of an ambulance, and we race quickly to the hospital with lights and sirens, putting the public in danger, putting our crews at danger, and then doing pretty poor CPR to the hospital of choice. So I don't know if you think that I was very sarcastic about or negative about that, but that's not the approach that I think we should be doing. So in many cases now, we've changed our approach to out-of-hospital cardiac arrest. So now-- symptom onset, dial 911, one of the most important things we have now, especially in our rural areas, is the dispatcher. A dispatcher who's trained to recognize that someone's in cardiac arrest and quickly move to compression-only CPR. We don't advocate mouth to mouth. I don't want to do mouth to mouth. Most folks don't want to do mouth to mouth. So we just advocate hands-only CPR. And that's been proven to be just as effective as conventional CPR. So that's the key. Because there's only two things that improve outcomes in cardiac arrest. What are they? Circulation by compressions and defibrillation, right. Those are the only two things that are proven to be beneficial-- hands and defibrillation. So hands and electricity, those are the two main things that improve outcomes in cardiac arrest. So now what we advocate is when EMS arrives on scene, we don't leave. We stay there and we focus on high quality CPR with attention to great compressions. We don't worry so much about the airway in the adult patient for the first 10 to 15 minutes. And we don't worry so much about drugs. Because there's no real studies that have ever shown that all the drugs that we like to give make any difference whatsoever. We know that a little bit of epi probably helps and a whole lot of epi means you're never going to walk out of the hospital. So those are the only two things we know about epinephrine. So that's why now we really advocate that we concentrate on good effective CPR and stay put and do great CPR on scene. And then if we get return of spontaneous circulation, then obviously, we transport to a primary receiving hospital hopefully. The goal is to go to a STEMI receiving center, again regionalization, where we've got MICU, CCU, neurologists, and critical care interventionalists who know how to take care of this very complex post-cardiac arrest patient. So that's kind of where we are with cardiac arrest. Over the last five years, we've added RACE CARS to our project. And that's RACE plus cardiac resuscitation system. So our goal was to the double survival in North Carolina over the previous five years. And luckily, we've done that. Does anybody know what your chance of surviving cardiac arrest in general in North Carolina is? Well , it was 6%. So about 5% when we started in 2010. That means we had a 95% kill rate unfortunately. So about 5% survived. We're now at about 11.8%. So we've a little bit more than doubled. Now, that really still depends on where you live. And this is the horrific thing about cardiac arrest in the United States. It really makes a huge difference about where you live. If you're in Alabama, you've got a 9% chance of surviving. If you're in Seattle, Washington, you've got a 40% survival chance because they've got CPR instructions on the back of every Starbucks cup there. Not really, but you have to know CPR. You guys believed me when I said that. So you have to know CPR before you can even get your driver's license in Washington state. So that's how dedicated-- Seattle's been the leader in out-of-hospital cardiac arrest since the 1970s. But we can do that too. We've got systems here in North Carolina that mirror Seattle-- Mecklenburg County, Wake County, they approach about 40% to 45% walking out of the hospital. Again, we don't count just getting a pulse back. You have to walk out of the hospital with the cerebral performance score of one or two. So hopefully all of us in here are a one or pretty close to a one. Maybe a two or something. My wife would tell you I'm a two. Or at least back to that cerebral performance score that you had before the cardiac arrest. And lots of our rule agencies have done tremendous with this as well over the past few years. So the results have been great statewide. But they still are really variable depending on where you live. And that just shouldn't happen. So it shouldn't matter where you live as to your chance of survival from cardiac arrest. So to summarize some of the things we talked about, EMS is definitely capable of moving care forward in time, especially in critical cardiovascular disease. One of the things we've just been talking about the last few weeks is open fracture care. So it's very hard sometimes to get antibiotics in within 60 minutes, even at a level one trauma center where we work, to get that antibiotic in within 60 minutes. So we're thinking about moving antibiotics out to the EMS to have them give them before they get there. That way, the time is zero. They've already had the antibiotics before they arrive at the hospital. You just can't beat a metric better than that. So that's one of the things we're talking about now moving care forward. But regionalization is extremely important, especially with cardiovascular care. And I think we're lucky, we're very fortunate to live in a city that has two great medical centers that partner together, especially with EMS, when it comes to regionalization. Because the key is improving our outcomes and decreasing duplication of services and then overall decreasing our costs, which we're going to be held to more and more as time goes on. It's not an easy process though. It requires continual assessment of the system in quality and improvement initiatives and oversight. And one of the ways we do that is through our peer review committees. So each county is responsible-- each county in North Carolina is mandated by law to perform quality assurance or peer review. We have to meet at least quarterly. Some meet monthly. Most meet quarterly. But at our peer review meetings in agencies where I'm medical director, I have representatives from Forsyth, from Baptist, Moses Cone, depending on what system I'm in that day and where we transport our patients to. We've got our stroke coordinators, our STEMI coordinators. And we go through all this data. We look at our times to folks to get to the cath lab. We look at our cardiac arrest survival. We look at our stroke initiatives. Did we get blood draws? How well were we at deciding if this person actually had a stroke? But more importantly, how many folks were recognized to have stroke that we didn't recognize? That's the number that I'm more interested in than anything else. So we do this continually. And some of folks in this room are actually involved in some of those processes. But it's an ongoing process. You just can't start it and then expect it to move forward. It has to be continually nurtured. So QI process is extremely important with data collection and benchmarking. So you want to benchmark against yourself and benchmark against agencies outside yours. And this also helps us identify silos so that we can acknowledge those and then break them down. Because silos are everywhere in medicine. And they should be cut down like Don Quixote. Anytime you get a chance to do that.
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