EMS and Transportation to the Most Appropriate Facility
When you review the chain of survival for a cardiac emergency or a stroke outside of the healthcare setting you’ll notice some similarities. At the start is preparedness & recognition of the emergency, followed by activation of EMS, delivery of Advanced Life Support, and transporting to the most appropriate facility. The role of EMS and transportation to the most appropriate facility is today’s Pass ACLS tip topic.
EMS Capabilities
If you don’t work in EMS, or in an area that frequently interacts with EMS, you may not be familiar with the capabilities of prehospital providers and why they make a difference in patient outcomes. There are two basic reasons why it’s important for people to call 9-1-1 for EMS when they recognize an emergency outside of the hospital setting.
The ability to make a detailed assessment and provide life-saving care within minutes of recognition is the first reason why EMS makes a difference. Depending on where you live, EMS may have Advanced Life Support (ALS) capabilities. ALS ambulances are staffed with Paramedics who have training in ACLS skills. Paramedics can perform a basic history & assessment including Vital Signs, ECG, Blood Sugar, O2 Saturation, and End-Tidal CO2. Additionally, paramedics can provide ACLS care such as obtaining IV or IO access, administration of front-line medications, insertion of an advanced airway, defibrillation, and transcutaneous pacing (TCP). Depending on local protocols, paramedics are able to perform condition-specific procedures such as pleural decompression or pericardiocentesis in the case of tension pneumothorax or cardiac tamponade respectively.
Secondly – EMS personnel are familiar with their local resources and know at which facility a patient should be seen to receive the most appropriate care. There are two ACLS-specific examples for which you should be familiar: Stroke and STEMI.
Stroke
The majority of strokes are ischemic and stroke patients have better outcomes when they receive timely therapy such as:
- Thrombolytic therapy like tPA within 3 hours of the onset of symptoms; and
- Endovascular thrombectomy (EVT) for large vessel occlusions (LVO) within 24 hours of the onset of symptoms.
EMS may help meet these clinical treatment benchmarks by transporting suspected stroke patients to a stroke center with 24/7 CT and Cath Lab or Interventional Radiology capabilities. Recent data indicates that it may be appropriate to pass up a close hospital to get stroke patients to a Comprehensive Stroke Center within 30 minutes. To decrease the time to CT, some EMS agencies bypass the ER on arrival and take their stroke patients directly to CT. In areas with ALS, the patient may arrive at CT with an IV started, the tPA checklist completed, and other causes of stroke-like symptoms such as hypoglycemia or hypoxia already evaluated & addressed.
STEMI
Patients experiencing a STEMI benefit from EMS training and knowledge of the area as well. Paramedics can obtain a 12 lead ECG and SaO2 within minutes of the onset of symptoms and administer Aspirin, Nitro, Oxygen, and Morphine as appropriate to ACS patients. If a patient’s ECG shows a ST elevation MI, transport to a facility with a 24/7 interventional cath lab would be the most appropriate to ensure the patient receives PCI within 60 minutes of first medical contact.
Summary
ALS ambulances staffed with Paramedics can obtain a medical history and perform a basic assessment including vital signs,12 lead ECG, SaO2, and blood sugar within minutes of the onset of symptoms to identify a possible stroke or heart attack. Paramedics can rule out stroke mimics, start the tPA checklist, and begin ACLS treatment of ACS before arrival at the hospital.
EMS crews are generally familiar with the hospital capabilities for their area. They know which are stroke or cardiac care centers, which have 24/7 CT, and interventional cath lab services.
Taking an extra 20-30 minutes to get a patient to “the most appropriate facility” saves time in the long run and time is brain or heart cells.
