STRENGTHENING THE LINKS
IN THE CHAIN OF SURVIVAL:
LOUISVILLE METRO EMS TAKES ON
CARDIAC ARREST.
Neal J. Richmond, MD, Ben Neal, EMT-P, Michael Tully, EMT, Kristen Miller
E
ach year, approximately 350,000 people
in the United States suffer out-of-hospital cardiac arrest (OOHCA). Survival
rates for the majority of them have traditionally been dismal, even though tremendous
resources have been dedicated to their management. This situation has been attributed
to weak links at every step in the chain of
survival for OOHCA, including delays to
immediate recognition and activation of the 911 system, initiation
of early CPR, rapid defibrillation, effective application of advanced
life support and integrated post-arrest care.
In May of 2013, Louisville Metro EMS (LMEMS) implemented
new evidence-based medical protocols to address what is largely a
public health emergency in our own community. One of the most
notable innovations was to introduce a high-efficiency resuscitation
sequence to the management of OOHCA - pit-crew CPR - which
brings to the patient’s side the kind of tightly choreographed roles
and responsibilities that race crews bring to their cars at the track.
These protocols place a sharp focus on quality chest compressions
14
LOUISVILLE MEDICINE
without pauses for ventilations, coupled with the somewhat counter-intuitive use of passive oxygenation during the early phases of
resuscitation. In addition, crews are provided with a real-time
monitoring modality, wave-form capnometry or end-tidal carbon
dioxide measurement (etCO2), to verify both successful airway
management and overall resuscitation performance.
The CPR analytic software that we use measures the amount of
electrical impedance or resistance to the patient’s chest each time a
compression is performed and then calculates the chest compression
fraction - the percent of time that the chest is actually being compressed – as well as the rate or average compressions per minute,
both critical evidence-based measures for survival outcome. This
analytic feedback then is shared with our EMTs and paramedics,
including a minute-by-minute review of their performance during
the entire resuscitation. In this way, we are able to provide meaningful and almost real-time feedback to each of our providers,
individually, thereby continuously upgrading their knowledge base
and repertoire of critical management skills.
Along with this direct feedback loop, we also incorporate a robust