Home EMS/Medical News A Matter of Time
A Matter of Time
By Art HsiehLet's face it: For many of our calls, time is not an issue when it comes to clinical importance. Sure, the public expects that EMS will respond in a timely manner, and we configure our systems so that performance standards can be met. But from the perspective of improving patient outcomes, there's not a lot of data to support the notion that time is critical.
Take an example: In a recent study published in the Annals of Emergency Medicine, researchers with the Resuscitation Outcomes Consortium (ROC), noted that for seriously injured patients, response time, on scene time, or transport time did not impact the their overall outcome.(1) In another words, the "Golden Hour" really isn't. 
Now, I'm not suggesting that EMS suddenly turns off it lights and sirens and stop responding promptly to trauma calls; the study did not look at the techniques of airway. breathing and bleeding control that may have been applied once trained personnel arrived. However, we should wonder if the need to rapidly transport to an appropriate receiving center at risk to patient and crew may be more risky than beneficial to the patient.
Another example is the notion of early defibrillation. In early studies of the use of the AED, it appeared that the sooner the cardiac arrest patient was defibrillated, the better the outcome. Seems to make sense; after all, ventricular fibrillation has a certain "life expectancy" and becomes asystolic as the heart cells run out of oxygen. EMS systems in the 90s adopted "shock early and often" approach, equipping basic ambulances, engines and police cars with AEDs so that early defibrillation can take place. Subsequent studies show that it's probable that severe electrolyte imbalances exist at the cardiac cell level, prohibiting successful countershock from occurring. Researchers have found that in many cardiac arrests require a "priming of the pump" through fast, hard chest compressions before defibrillation has a chance of being successful. We've seen this development in the change of protocols where for unwitnessed cardiac arrests, CPR is now performed first and for at least two minutes before defibrillation is attempted.
I cite these two examples among many, to emphasize that things that sound like they make sense, sometimes don't play out. It's why we do research, to find out what should work, what does work, and as importantly, what doesn't work. It's easy to become complacent and allow theory to become reality, rather than asking for proof. Much of our industry was founded in theories, and for most of its existence, those theories were allowed to become gospel. We should continue to question, study and review what we believe to be true.
Now, you might think I am beating up our business. No way! I know we provide a service and protect the public. I've seen too many patients feel better and safer because of what I or my colleagues provided during their time of need. As an EMS professional, I would be interested in knowing if being compassionate, professional and competent makes a difference in the patient's outcome, physically or psychologically. I'm also interested in knowing how reliable we are with our skills and the accuracy of our clinical judgment. As an educator, I'd like to know how much of the information we provide in the class translates to quality patient care. I am just not that interested in how fast we run through a call.
(1) Newgaurd CD et al. "Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort." Annals of Emergency Medicine 55:3. March 2010.
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