Things Your System Should Deliver

Scenario #1

You’re an EMT dispatched for a 40-year-old male vomiting. He tells you he developed indigestion after eating, began to sweat and vomited. He also says he has diabetes and “just doesn’t feel right.” He denies any chest discomfort. His skin is cool and moist, and his vital signs are pulse 96, BP 154/80, RR 24 and pulse ox 96% on room air.

You’re concerned about the patient’s appearance and wish you could do more to help him, but he does not meet a protocol that requires you to request ALS. You keep him as comfortable as possible during transport to the closest hospital, with an emesis basin nearby.

Ten minutes later you arrive at a packed emergency department. The hallway is lined with patients, and more ambulance crews fill in behind you. The triage nurse quickly takes your report and directs your patient to a hallway bed. You wish him luck and wonder how long it will be before a physician sees him.

Scenario #2          

You’re a paramedic called for a patient with the same presentation. After checking the patient’s vital signs and blood sugar, you obtain a 12-lead ECG that shows ST elevation in leads II, III and aVF, with ST depression in leads V1–V3. You suspect an ST-elevation myocardial infarction (STEMI). You immediately administer aspirin and request a “heart alert” at a hospital that provides 24-hour percutaneous coronary intervention (PCI). Bypassing the nearest community hospital, you start two IVs, draw blood samples, and give fluid and ondansetron for nausea.

A resuscitation bay is ready for you at the packed ED while a catheterization suite is prepared. A cardiologist looks at the ECG you obtained and agrees with your assessment. She orders several stat blood tests, and the samples you drew are sent off. You wish the patient luck as he is wheeled away to the cath lab, and he thanks you for helping him.

Introduction

Imagine having your car break down on a long trip. You and your family and pets are stranded on the side of the road in an unfamiliar area. It doesn’t matter if your car is taken to an independently owned repair shop, a national chain or a store that offers car repair among other services; you expect the problem to be diagnosed and repaired, no matter what it is, so that your trip can continue safely. You also expect to be treated courteously and professionally, just like the service team members would expect their family members to be treated.

As stressful as that situation would be, compare it you or a family member becoming seriously ill or injured. This is also a situation you cannot handle on your own, and one that forces you to depend on a community’s EMS system. No matter who administers that system or how it is funded, you hope the people who show up are competent, compassionate and adequately equipped to care for you.

The needs of patients having cardiac arrests, heart attacks and seizures are the same wherever they occur, but if you’ve seen one EMS system in the United States, you’ve only seen one EMS system. The certification levels, experience and available procedures in one community can differ vastly from those of another system across the street. In some areas multiple paramedics are sent on every call, in others only BLS is available. Some communities send BLS ambulances to all calls and ALS only to ones believed life-threatening. There are also wide variations in the quality of care and skills available within certification levels. Some BLS services perform 12-lead ECGs, and some ALS services still do not.

The opening scenarios illustrate the differences in care patients with the same complaints may receive from different types of EMS systems, and the impact on their hospital courses and likely outcomes. Certain interventions are proven effective and widely available but in many communities do not consistently reach the patients who need them. That needs to change.

People expect a high-quality EMS system to respond to their emergency, but few know how their system works or compares to others. The most frequently reported performance measures are training standards, response times and cardiac arrest resuscitation rates. These provide only a small picture of how well a service does, and are not measured the same way by every organization. Depending on oversight practices, care in both opening scenarios could be considered adequate despite the different treatment the patients received.

It is time to draw a line in the sand. On one side will lie good clinical care; on the other excuses for bad care. The following covers what is reasonable for every community to expect from its EMS system, and how to measure it.

Response Times

People expect help to arrive quickly when they call 9-1-1, regardless of the severity of their emergency. EMS response times are the most common performance measure used by agencies, but they say nothing about how well an illness or injury is treated after help arrives. Reported response times can also be misleading. Services that use the NFPA 1710 standard report the time from when the EMS vehicle’s wheels start moving to when they stop at the call location. The standard does not measure the 9-1-1 call-processing time, the time the crew takes to start responding after being alerted, or how long it takes to reach the patient after their vehicle stops.

From the patient’s perspective, the only time that matters is from when the phone rings in the communications center to when help arrives at their side.¹ In fact, ALS response times were not associated with survival in a five-city study of cardiac arrests.² Increased survival was found, however, in systems where more arrests were managed by each paramedic.² Problems have been found in communities with higher numbers of paramedics per capita, because each paramedic in these systems has fewer opportunities to manage critical patients and perform invasive skills.³ One study showed that patients who were intubated by experienced paramedics were more likely to survive than patients intubated by medics with less experience.⁴ Adding too many paramedics with the intent of improving response times may inadvertently harm the quality of care delivered.

This is not to say response times don’t matter; only that no clinical outcomes have proven to be affected by the time it takes for paramedics arrive. In the absence of evidence supporting response time goals for anything besides cardiac arrest, goals should be based on customer service outcomes instead of expected clinical ones. Our citizens allow us the privilege of serving their medical needs. Measuring their feedback is important, and customer service should be more than an agency’s sales pitch.

Our patients deserve to know how quickly we arrive and how their EMS system measures it. From their perspective, fractile reporting provides the most accurate picture of performance.⁵ It defines expected response times, clearly states when the clock starts and stops, and states how frequently that goal is expected to be met. An example of this type of reporting for hot responses would be for first responders to arrive within 5:59, and for a paramedic ambulance to arrive within 11:59 90% of the time, based on when the phone rings at the 9-1-1 center to when vehicles stop at the residence.

Regardless of the clinical impact of response times, patients also deserve to have the closest appropriate unit sent when they call for help. This should be obvious, but it’s not widely done. In a survey of the 200 most populated U.S. cities, only 55% of EMS services reported sending the closest unit.⁵

Why do we make the sick and injured wait longer than necessary? Reasons include dispatching based on response grids, not knowing where the closest unit to the caller’s location is, or that the closest unit is from another agency. Each reason is understandable, notes author Dave Williams, but they’re just justifications for practices that aren’t in patients’ best interests—in other words, more excuses.

Response time goals must strike a balance between meeting customer expectations, maintaining adequate clinical experience for EMS practitioners, cost, and providing enough time for providers to recover between calls. It is reasonable for a community to be informed about how response times are measured and to have the closest appropriate units sent to calls.

Clinical Performance

What happens after caregivers arrive at the patient’s side? It is difficult to measure quality of care because few evidence-based clinical performance measures exist. To date, the most comprehensive clinical performance benchmark proposal was published in 2008 by the U.S. Metropolitan Municipalities EMS Medical Directors Consortium (also known as the Eagles).¹ Their paper recommends treatment bundles for cardiac arrest, ST-elevation myocardial infarction, difficulty breathing and seizures (Figure 1). Using a “number needed to treat” formula, it describes the benefit patients receive from that bundle. It can also be used to calculate the harm incurred by patients who do not receive that treatment.¹ These benchmarks are based on both the quality of supporting scientific literature and the ease of measuring their delivery.

In addition to universal response time reporting, it is reasonable to expect EMS systems to adopt universal “apples-to-apples” clinical performance measures that apply to every community and delivery model. Studies about cardiac arrest, pain management, sepsis, sedation and transport destinations can be used with the 2008 Eagles benchmark paper to measure clinical performance.

Cardiac Arrest

Cardiac arrests are high-profile responses and another popular way for services to measure performance. Survival rates vary dramatically across the country. Published survival rates of patients whose arrests were witnessed and were in ventricular fibrillation when EMS arrived are above 50% in Seattle,⁶ above 40% in Raleigh,⁷ 3% in Chicago, and less than 1% in Detroit.³ Where patients live often determines if they live.

Like response time reporting, not every system measures survival the same way. The temporary return of a pulse is much different than being discharged alive from a hospital, and the outcome of a patient who is obviously dead on EMS arrival should be measured differently than one whose collapse was witnessed.

A universal cardiac arrest reporting template was developed in 1991 among an international group of resuscitation experts at a conference in Norway. Known as the Utstein template (Figure 2), this provides common definitions of different arrest types and survival. The template includes whether the arrest was witnessed, its suspected cause and the rhythm presenting to EMS. It also tracks the outcomes of patients and assigns a cerebral performance category to measure the neurologic function of survivors.⁸

Unfortunately many communities do not track the outcomes of cardiac arrest patients, and even fewer use the Utstein template. In a more recent survey of EMS systems serving the 200 most populous cities, 52% of respondents used a local template that doesn’t allow comparison to other services.⁹

A number of system factors affect the likelihood of survival from cardiac arrest. One is how long it takes for CPR and a defibrillator to arrive after collapse. The 2008 Eagles benchmark paper recommends a five-minute response for CPR and defibrillator-equipped first responders. ¹ Another factor is the quality of care rendered after help arrives, and both can be objectively measured. Monitors now capture and archive times, compression rate, depth, recoil and duration of pauses. CPR quality can also be indirectly measured with archived heart rate and end-tidal CO₂ readings.

Since better outcomes have been shown in patients treated by experienced paramedics, it is also useful to know how many arrests each paramedic has the opportunity to manage. Some services have adjusted response patterns to add experienced paramedics to cardiac arrests.

While it is not reasonable to expect every patient in cardiac arrest to be saved, don’t members of each community deserve to know how well their EMS service performs compared to others? Don’t people in Detroit deserve the same chance of surviving as those in Raleigh? It is time for us to be transparent about how well we do, stop making excuses and spread the best practices of communities with high survival rates.

Cardiac arrests constitute about 1% of EMS calls, but improving cardiac arrest management will also improve care for patients with other complaints. Better tracking of cardiac arrest data opens the door to tracking other objective clinical performance measures.

STEMI

Treating heart attack patients was one of the foundations of early paramedic systems, and there is a proven benefit for such patients from EMS care. According to the 2008 Eagles benchmark paper, one death, a second heart attack or a stroke is prevented for every 15 STEMI patients who receive 12-lead ECG, aspirin, direct transport to a PCI center and activation of the PCI center before arrival.¹

In a study of more than 40,000 STEMI patients, mortality increased with every 30-minute delay from reaching the hospital to receiving balloon angioplasty. This was true even if it was done within the current 90-minute goal.¹⁰ Prehospital ECGs and early hospital notification have been shown to reduce time to reperfusion in the hospital.¹¹ Serial ECGs are also important. A study from Toronto showed that only 85% of STEMIs were detected with the first ECG, and 15% were detected after the patient was moved to the ambulance or during transport.¹² Perform ECGs early and often on any patient with a suspected acute coronary syndrome (ACS).

ACS does not always present with chest pain. In a study of more than 430,000 MI patients, 33% did not complain of it. These patients were more likely to be older, female and diabetic. It took significantly longer to recognize and treat their MI than with patients who complained of chest pain, and their mortality rate was twice as high.¹³ Another study showed that 28% of STEMIs would have been missed by EMS if ECGs were only done on patients with chest pain.¹⁴ Atypical symptoms of MI include nausea, vomiting, weakness, dizziness, syncope and sweating.

In many systems, however, a BLS-only response is indicated for patients who complain of these vague symptoms. Newer monitors are designed for BLS providers to transmit ECGs, and some education programs teach ECG interpretation at the BLS level, but it is still primarily an ALS function. A wide net must be cast to catch these patients, and 12-lead ECGs should be done on any patient with symptoms that could be caused by ACS.

Twelve-lead ECGs have become the cornerstone of prehospital cardiac care, and lives are saved when they are incorporated into regional STEMI systems. Not only that, but EMS care has been shown to prevent second heart attacks and strokes long after patients are delivered to hospitals.¹ STEMI patients deserve this treatment bundle from their EMS system, no matter what their complaint is when they call 9-1-1.

Difficulty Breathing

EMS treatment has also been shown to have a significant impact on patients who are short of breath.¹ For patients with pulmonary edema caused by congestive heart failure, the 2008 Eagles benchmark paper recommends noninvasive positive-pressure ventilation (usually provided with CPAP) and nitroglycerin. For every six CHF patients who receive this bundle, the need for one intubation is avoided.¹ This saves patients the trauma of being intubated, the risk of infection from a mechanical ventilator and possibly admission to an ICU.

For bronchospasm, the Eagles recommend that a nebulized beta-agonist, such as albuterol, be administered by the earliest-arriving trained and qualified responder. This has been shown to provide immediate relief of symptoms and improve respiratory status.¹ Another study showed that patients with moderate to severe asthma attacks benefit from having IV steroids given before they reach the hospital. In a system with an average transport time of 10–20 minutes, a group of patients who received IV steroids by EMS got them one hour earlier than another group who received them at the hospital. The EMS-steroid group also had a lower hospital admission rate.¹⁵ Even if the benefits of this are not seen while EMS has contact with patients, its impact on their hospital course is significant.

If someone feels like they are breathing through a straw, supplemental oxygen alone does not make it easier. Nebulized bronchodilators and/or CPAP are needed for this. Knowing how common respiratory distress is, and how much of an impact early EMS care has on its outcome, patients deserve an EMS system that can deliver those treatments when needed.

Seizures

Seizures are another common problem encountered by EMS. Status epilepticus, which is a seizure lasting more than 30 minutes or multiple seizures without a lucid interval in between, has been shown to cause permanent brain damage and increased mortality. There has been a recent push to change that definition to any seizure lasting longer than five minutes.¹⁶ Up to one third of these patients are either actively seizing on EMS arrival or have a seizure in the presence of EMS.¹ In addition to checking seizing patients’ blood sugar, the 2008 Eagles benchmark paper recommends giving them a benzodiazepine medication. Of every four patients given lorazepam or diazepam, one will have their seizure terminated.¹ Since that report, midazolam delivered with an intramuscular auto-injector has also been shown to be effective at stopping seizures.¹⁷ This may make seizure medication available to more responder levels.

Although most seizure patients do not require medication from EMS, the Medical Priority Dispatch System has not been shown to reliably determine which ones do. Under the telephone triage system, a BLS response is indicated for patients whose seizure has stopped and breathing is verified.¹⁸ In one study, this group of patients received an ALS medication just as often as others who were believed to have prolonged seizures. Based on this data, and with seizure medication only available from ALS units, the authors recommended that ALS be sent on all seizure calls.¹⁸

Knowing how dangerous prolonged seizures are and how effective EMS treatment is for them, shouldn’t at least one person on scene be capable of delivering medication to stop them on every seizure call? If a patient remains actively seizing during transport and does not receive medication, no matter how close the hospital is, his or her EMS system has failed.

Sedation

For a variety of reasons, some patients encountered by EMS are combative. They present a threat to themselves, bystanders and the people who respond to help them. Causes include drug overdoses, alcohol intoxication and psychiatric conditions. Sometimes combativeness is caused by excited delirium, a life-threatening condition in which agitated patients are irrational, violent and immune to pain. Patients who do not respond to verbal de-escalation techniques or whose combativeness is not caused by a correctable medical condition need to be restrained before transport.

A number of problems have been found with physical restraint. It can worsen agitation, and patients risk injury from fighting against it. In cases of excited delirium, sudden death can occur during physical control measures. To reduce the risk of sudden death, a white paper published by the American College of Emergency Physicians recommends that physical restraint from law enforcement be combined with immediate sedative medical interventions by EMS.¹⁹ Agitated patients may also display unusual physical strength and be immune to pain, so providers risk being injured if they break free.

Chemical restraint, used with or instead of physical restraint, can mitigate these problems. The same benzodiazepines used for seizures can be used for chemical restraint, along with antipsychotic medications such as haloperidol (Haldol), droperidol (Inapsine) and ziprasidone (Geodon). The dissociative agent ketamine is also effective for agitated patients, has a faster onset than other agents when given intramuscularly, and has the fewest side effects.¹⁹

Why do we fight with people when safe chemicals are so readily available to sedate them? Soft restraints can be found on every ambulance, but medications for sedation are restricted to ALS units. Why do we place ourselves in enclosed spaces with violent patients who resist physical restraints? Since any patient has the potential to become combative, shouldn’t at least one provider be capable of administering these medications on every call? When something bad happens with a combative patient, to us or to them, is there any excuse for not having sedatives available? For everyone’s safety, medications for sedation should be given to any patient who requires physical restraint.

Pain Management

Pain is one of the most common reasons people seek medical attention. It is often undertreated by EMS, even though acute pain is associated with significant morbidity and mortality.²⁰ Pain is described as “physiologically bad” in a 2008 Journal of Emergency Medicine article; it is “destructive to the body. Untreated, it damages the immune system, hinders wound healing, rewires the neurological system and can lead to chronic pain.”²¹ According to a 2000 article in the Journal of the Royal Army Medical Corps, “The effective management of pain in the prehospital environment may be the most important contribution to the survival and well-being of a casualty that we can make. The prehospital practitioner has the first and perhaps only opportunity to break the pain cascade.”²²

Even in systems with short transport times, patients often wait several hours in the hospital for relief they could have received before being moved. In a study of patients with extremity fractures who were medicated for pain, only 12% received it from EMS. When pain medication was administered by EMS, the average time from arrival to delivery was 23 minutes. The other 88% received pain medication an average of 75 minutes after arrival at the hospital.²³ Another study of patients with leg or hip fractures showed that 8% received pain medication by EMS and 91% received it in the emergency department. The patients whose pain was medicated by EMS in that study received it an average of two hours earlier than those first medicated in the hospital.²⁴

Paramedic administration of fentanyl has been shown to safely reduce pain.²⁵ Morphine and nitrous oxide are also used in the prehospital setting. Analgesic medication is restricted to ALS units, but a BLS response is indicated for many patients in pain.¹⁸ Very few patients need EMS to save their life, but many can be helped to feel better. Most of our patients are in some type of pain. That pain is often made worse during movement to the ambulance and transport over bumpy roads, especially when strapped to a hard board. Many of these patients then get pain medication in the hospital, but wait more than an hour for it. Delays in the treatment of acute pain can lead to a longer recovery and chronic pain.

Why isn’t this a bigger priority for us? Knowing how detrimental untreated pain is and how safe chemicals are available to treat it, is there any excuse not to make them available for patients in pain? For any system to say it is patient-centered, at least one person should be capable of administering pain medication on every call.

Detecting Life Threats

Patients receive one-on-one care while they are with EMS. Diagnostic equipment is brought to their side, and vital sign trends can be monitored during transport. It is much different in the hospital, where each staff member is responsible for multiple patients and the sickest must be treated first. Objective EMS assessment findings in patients with vague symptoms can identify critical illnesses before patients decompensate, and move them ahead in line.

Early critics of 12-lead ECGs argued they did not change the treatment rendered by EMS and thus were unnecessary. We now know that many patients have symptoms that may be caused by an acute coronary syndrome, but the few with STEMIs need immediate reperfusion. A similar approach is taken with identifying major trauma and stroke patients who need immediate treatment. Alerting hospitals allows them to prepare before those patients arrive.

Early recognition and treatment of sepsis is an emerging role for EMS. Patients with severe sepsis often present with vague symptoms and stable vital signs, but 30%–35% of them die if not treated before shock symptoms develop. Early goal-directed therapy (EGDT) for sepsis reduces this mortality rate; it includes diagnosis by lactate measurement, aggressive fluid resuscitation and antibiotics.²⁶

Emerging technology will allow even more life-threatening illnesses to be detected by EMS. Soon portable ultrasound machines may be used to diagnose internal bleeding, cardiac tamponade, pneumothorax and stroke.²⁷ Point-of-care tests for electrolyte imbalances and cardiac enzymes may come to ambulances. Paramedics can use this information to make better treatment decisions, and hospitals can use it to better triage patients. The sickest ones benefit from our finding this information long after we turn them over to the hospital.

Appropriate Hospitals

While shorter ALS response times have not been associated with improved patient outcomes, getting patients to the most appropriate facilities has.^{1, 28–30} In 2006 the Institute of Medicine called for regionalized, coordinated systems of care for high-risk medical patients. Such systems direct the sickest patients to hospitals with the greatest expertise in caring for their critical illnesses.²⁸ The most appropriate hospital may not be the one closest or the patient’s first choice, so it is important for EMS to understand what resources are available in its region.

A regional approach was first taken with trauma care. Based on injury severity score, the 2008 Eagles benchmark paper states that one death is prevented for every 11 seriously injured patients transported directly to trauma centers. For patients over 65, one death is prevented for every three patients taken to trauma centers.¹

Based on the model of trauma systems, regionalized care has been developed for other conditions. For STEMI care the Eagles paper recommends patients be transported to medium- to high-volume interventional cardiac facilities.¹ Improved stroke care has also been found at primary stroke centers, and the American Heart Association now recommends EMS direct patients to those centers.²⁹ Improved survival has been found at hospitals that treat higher numbers of patients resuscitated from cardiac arrest. The AHA recommends that this group be transported to hospitals capable of inducing hypothermia and comprehensive critical care, even if they are not the closest.³⁰

Rare situations such as an upper airway obstruction require rapid transport to the closest hospital. More often, however, sick patients are best served at regional specialty centers. This means paramedics in many areas will spend even more time treating the sickest patients they encounter. Patients deserve to have systems in place that direct them to the most appropriate hospitals and paramedics capable of managing them during transport.

Conclusion

In his book Resuscitate!: How Your Community Can Improve Survival from Sudden Cardiac Arrest, Dr. Mickey Eisenberg says brutal self-assessment is an EMS system’s first step toward improvement. “The simple fact is that nothing will change if the status quo is to be tolerated,” Eisenberg writes. “And the status quo in virtually every community is indifference combined with insufficient data—a powerful duo on the side of inaction.”³ These performance measures are a start but certainly not all that is needed for a system to be successful. The authors of the 2008 Eagles benchmark paper said they hoped more benchmarks would be researched and published.¹

From the patient’s perspective, it doesn’t matter if the people who show up when they need help are called EMTs or paramedics. It doesn’t matter if they volunteer or get paid. It doesn’t matter if their service is funded by donations, transport revenue or taxes. They expect their heart attack to be detected and to be taken to the hospital best equipped to manage it. They expect to receive medication to open their constricted airway. And they expect their pain to be treated before being moved. When they don’t get these things, their EMS system has failed.

How does your EMS system stack up? How does your cardiac arrest survival rate compare to other communities’? Do patients get transported to hospitals without CPAP or seizure medication? Do they continue to fight against cloth restraints without chemical sedation? When they arrive at the hospital, are they in more or less pain than when you arrived?    

The time for excuses is over. It is time to look past the way EMS has always been delivered and toward getting every patient the interventions they need.

References

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2. Sayre, M, Hallstrom A, Rea, T, et al. Cardiac arrest survival rates depend on paramedic experience. Acad Emerg Med, 2006; 3(5)(Suppl): S55–6.

3. Eisenberg MS. Resuscitate!: How Your Community Can Improve Survival From Sudden Cardiac Arrest. Seattle: University of Washington Press, 2009.

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12. Verbeek PR, Ryan D, Craig AM. Serial prehospital 12-lead electrocardiograms increase identification of ST-segment elevation myocardial infarction. Prehosp Emerg Care, 2012; 16(1): 109–14.

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15. Knapp B, Wood C. The prehospital administration of intravenous methylprednisolone lowers hospital admission rates for moderate to severe asthma. Prehosp Emerg Care, 2003; 7(4): 423–6.

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17. Silbergleit R, Durkalski V, Lowenstein D, et al. Intramuscular versus intravenous therapy for prehospital status epilepticus. N Engl J Med, 2012; 366(7): 591–600.

18. Sporer KA, Youngblood GM, Rodriguez RM. The ability of emergency medical dispatch codes of medical complaints to predict ALS prehospital interventions. Prehosp Emerg Care, 2007; 11(2): 192–8.

19. ACEP Excited Delirium Task Force. White paper report on excited delirium syndrome, 2009.

20. McLean SA, Maio RF, Domeier RM. The epidemiology of pain in the prehospital setting. Prehosp Emerg Care, 2002; 6: 402–5.

21. Thomas SH, Shewakramani S. Prehospital trauma analgesia. J Emerg Med 2008; 35(1): 45–57. Retrieved from: Canning P. Time to Pain Management. Street Watch: Notes of a Paramedic, https://medicscribe.com/2012/10/time-to-pain-management/.

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23. Abbuhl FB, Reed DB. Time to analgesia for patients with painful extremity injuries transported to the emergency department by ambulance. Prehosp Emerg Care, 2003; 7(4): 445–7.

24. McEachin CC, McDermott JT, Swor R. Few emergency medical services patients with lower extremity fractures receive prehospital analgesia. Prehosp Emerg Care, 2002; 6(4): 406–10.

25. Krauss WC, Shah S, Thomas SH. Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia. J Emerg Med, 2011; 40(2): 182–7.

26. Whitehead S. Sepsis alert: recognition and treatment of a common killer. EMS World, www.emsworld.com/print/EMS-World/Sepsis-Alert/1$13434.

27. Bowman, J. Ultrasound application in EMS. J Emerg Med Serv, https://www.jems.com/ultrasound.

28. Institute of Medicine Committee on the Future of Emergency Care in the United States Health System. Hospital Based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press, 2007.

29. Jauch EC, Cucchiara B, Adeoye O, et al. Part 11: Adult Stroke. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 2010; 122: S818–28.

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Bob Sullivan, BA, NREMT-P, is a paramedic with New Castle County EMS in Delaware. The views expressed in this article are his only and do not represent those of New Castle County EMS. Reach Bob through his blog, The EMS Patient Perspective, at emspatientperspective.com.