by Erich J. Goetz and Andrew D. Fisher
Are ambulances in LA leaving people to die?
The media has misled people to believe that due to the increased COVID-19 cases and the impact on the local healthcare system, that Emergency Medical Services (EMS) are going to leave people to die on the streets and withhold oxygen from patients.
The LA County EMS Medical Director put out a memo outlining changes to who does and does not get transported via ambulance during the pandemic and has been misconstrued by the media causing hysteria. The memo outlines new guidelines about leaving patients who are in cardiac arrest (no heartbeat or breathing) at home or on the scene after pronouncing them deceased.
What the memo really says
EMS guidelines and scope of care (what a qualified health professional is competent to perform, and permitted to undertake) in and around Los Angeles have stagnated for decades. The ability to oversee and supervise a large group of paramedics often leads to restrictive guidelines. More paramedics equal more restrictive guidelines due to span of control and typically hands-off medical directors. There’s varying competency and all paramedics within the organization use the same protocols. It is better for the medical director and EMS director to maintain protocols with tighter control rather than raise standards. There is a vast disparity in training, skill level, and proficiency within an organization, but requires a protocol that applies to everyone. Since it’s much more effort to train up the lowest level competent clinician, most protocols are written for the least capable and skilled. The current guidelines outline a modest attempt that allows paramedics to pronounce death at the scene and to work within their scope of practice as outlined by the U.S. Department of Transportation, National Highway Traffic Safety Administration (NHTSA).
What they are trying to do
Many EMS agencies across the country have stopped transporting cardiac arrests deemed futile years ago. Previous guidelines simply changed the geography, not the prognosis. These new guidelines offer a more evidence based approach for cardiac arrest. However, it hasn’t stopped the onslaught on ridiculous statements that are meant to scare readers. One comment from CNN stated, “Imagine having cardiac arrest and getting picked up by an ambulance that won’t take you to a hospital.”
Why this decision is based on sound reasoning and science
From a medical professional standpoint, those who do not achieve return of spontaneous circulation (ROSC) or a return of a heart beat and pulses after 20 minutes are usually declared dead. This is accepted as an appropriate time for an attempt to restart a heart.
Studies have shown the benefit of providing care at the scene for best outcomes. A 2020 study in JAMA demonstrated that patients who were transported by ambulance during cardiac arrest were 48% less likely to survive than those who were not transported. While studies like the Ontario Pre-hospital Advanced Life Support (OPALS) found no evidence of improved survival with advanced care (5.1% vs 5.0%, p=0.83%) or favorable neurological outcome (3.9% vs 3.4%, p=0.73), skills like CPR are interrupted and often poorly performed in the back of an ambulance.
Furthermore, in cardiac arrests due to medical reason, the emergency room doesn’t offer additional care beyond what is being provided by the paramedics. There is the rare case where someone may benefit from catheterization when they are in an abnormal heart rhythm such as ventricular fibrillation. However, to truly make this successful, you need a procedure such as extracorporeal membrane oxygenation (ECMO), which is not performed by most hospitals. There are some EMS/healthcare systems that have prehospital ECMO responses. However, it requires special training and physicians, is time-consuming, labor-intensive, and expensive.
When a patient is taken from their home, put in an ambulance, and taken to a hospital, there are significant delays and interruption of care. These delays more than likely will result in the outcome of death. By providing Advanced Cardiac Life Support (ACLS) at the scene, it provides the best chance of a neurologically intact outcome. After 20 minutes, the chances of any survival is extremely low, and abysmal for someone to be neurologically intact meaning…walking, talking, or even able to eat on their own, measured through a 1 to 5 scale called the Cerebral Performance Category Score (CPC).
Cardiac arrests from trauma have even worse outcomes than those from medical causes, with survival rates of less than 2%. This is especially true to blunt trauma, for instance, a vehicle crash. The memo states “…on-scene resuscitation and interventions to address any potential immediately reversible causes, i.e., bilateral needle thoracostomies, tourniquet placement, fluid resuscitation and defibrillation of shockable rhythm.” This approach addresses and treats any hope of survival.
Blunt trauma that causes cardiac arrests often imparts such a large amount of force onto the patient, there is multi-organ damage that cannot be corrected. If a person is brought into an emergency room in cardiac arrest from blunt trauma without signs of life and they receive a thoracotomy, it is estimated that neurologically intact survival is 0.0006%.
It is routine for much of EMS in the United States to stay on-scene of medical cardiac arrest, as EMS no longer does ‘load and go’. It stands to reason then that if these abilities are brought to you in the field with no response, you will not benefit from transport to an emergency room to receive the exact same interventions.
Transporting a patient in cardiac arrest often provides false hope to family members, this can have a substantial impact, and inappropriately delays the grieving process. It is likely of more benefit for the mental and emotional well-being of these ‘secondary patients’ to begin the grieving process in their own home, rather than provide false hope. EMS clinicians through their words, actions, and behavior can have a powerful and lasting impact on these persons’ long term mental health.
Many of these types of protocols have been in place for at least 10 years in most places and were extensively researched with decades of study, and review by numerous physicians and entities to ensure it meets the current standards of care. These protocols are essentially permanently under ongoing review and change to keep up with new evidence and studies.
In many places across the country, EMS does not speak to a physician for pronouncement of death or termination of resuscitation in certain circumstances anymore. We are given guidelines to follow that meet the most up to date evidence on survivability, if they meet these criteria, we are then given the discretion to terminate or continue our efforts for longer based on our judgment. The only newsworthy part of these articles is that LA County EMS was still operating in the 1990s in regards to pre-hospital care. Now, they are more in line with many other areas of the country. EMS will continue to show up when you call, and they will continue to treat you with their best efforts and care available. Please ignore the occasionally atrociously misleading and inflammatory articles put out by the media, and ask a healthcare professional what this actually means…wait, wait, wait, we meant ask a healthcare professional who understands and works in and around EMS, not an eye doctor who has probably never seen the back of an ambulance.
Erich is an active career paramedic and firefighter. He has been involved in the EMS and Fire fields since 2012 when he initially obtained his entry-level certifications. Erich functions currently as both a volunteer paramedic in rural jurisdictions of the state since 2018 when he obtained his initial ALS licensure, and as a part-time paid employee for a federally registered organ recovery transport organization. Erich is also currently pursuing his Bachelor’s degree in Psychology as well as certifications through the IBSC to further his education and advance his skill levels in his field.
Andrew is a 2020 graduate from Texas A&M College of Medicine after serving many years as a physician assistant with the U.S. Army. He is currently completing a general surgery internship. He is the co-creator of the Ranger O LOw (ROLO) titer whole blood program that is now utilized throughout the Department of Defense. He is a member of the Committee on Tactical Combat Casualty Care and Stop the Bleed Education Consortium. Additionally, he is the assistant director for the Resuscitation Adjuncts: Prehospital Transfusion & REBOA course and on the Board of Directors for Global Response Management.
Opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of their respective employers or any organization.