Cardiac Arrest and Healthcare

Role of ALS in EMS

ALS (Advanced Life Support) represents a complex collection of rules and procedures extending beyond elementary life support, for further aiding ailing or injured individuals in clearing their windpipe, breathing and ensuring air circulates throughout their body, thus supporting blood circulation under emergency circumstances (Advanced Life Support (Definition and Explanation), 2016). The following individuals commonly need ALS transport (Lifeline: Basic and Advanced Life Support, 2016):

A surgical or medical patient with ongoing intravenous medicine but not requiring any Registered Nurse, in keeping with state regulation.

Individuals with Cardiac Monitor attached

Urgent care center patients

Patients suffering from a possible compromise of the airway

Obstetrical Patients

Patients regarded as having a possible complication in the course of transport, as indicated by a report forwarded by the sending healthcare facility.

Whiteman, C., Shaver, E., Doerr, R., Davis, S., Blum, F., Davidov, D., & Lander, O. (2014). Trauma patient access: the role of the emergency medical services system in North-Central West Virginia. The West Virginia Medical Journal.

Individuals suffering from trauma encounter a number of impediments when attempting to access North-Central West Virginia's healthcare system. Hence, the authors of this paper underline and discuss some hurdles and legislative and administrative programs which could aid in mitigating the inequalities encountered by rural patients of trauma.

The research has adopted an observational, reflective design and employed data gleaned from West Virginia University's "Medcom Database." EMS (emergency medical service) calls linked to trauma, between the years 2002 and 2011, were analyzed for ascertaining several EMS-offered care parameters in the Medcom's catchment area. A total of 54,952 trauma-linked EMS patients were studied to establish ETA (estimated arrival time) at destination healthcare center, trauma activation conditions, EMS response level, transport time and date, etc.

Observation and Conclusion:

The average emergency transport ETA, on the whole, was found to be 11.7 minutes (average emergency transport ETA in case of Pendleton County -- the most far-flung one -- was 28.4 minutes). Rudimentary life support providers took care of roughly 23% of calls, while advanced life support personnel took care of the remaining 76%. Thirty percent of emergency transports fulfilled West Virginia's trauma activation conditions. Advanced life support personnel and elementary support personnel offered transport to 78 and 19% of traumatic patients, respectively.

The State's north-central region witnesses numerous trauma patient barriers to healthcare, including lengthy transport durations, roughly half the counties lack a hospital altogether or having one whose treatment capacity when it comes to caring for trauma-related EMS patients is limited, and limited capabilities of responding EMS team (Whiteman, et al., 2014).

1. Anest, T., Ramirez, S., Balhara, K., Hodkinson, P., Wallis, L., & Hansoti, B. (2016). Defining and improving the role of emergency medical services in Cape Town, South Africa. Emergency Medical Journal.

Underdeveloped and developing nations bear an excessively heavy burden of child (under 18 years) mortality and morbidity. The developing nation, South Africa, suffers a far too high rate of mortality among kids aged below five years. Several factors contributing to children's mortality rate prove to be time-sensitive, needing competent emergency care access. Obstacles and holdups in EMS delivery cause a growth in pediatric mortality and morbidity due to time sensitive ailments.

The research is in the form of a qualitative assessment of pre-hospital care for patients aged below 18 years in a major South African city, Cape Town. A purposive healthcare worker sample, participating in or, at least, interacting with Cape Town's EMS system, was interviewed using a structured interviewing method. Every interview was both transcribed and audio recorded, and two separate reviewers carried out the transcribed interviews' blinded content examination. The journal has been cited in Grant's 2015 work.

Results and Conclusion

Study authors performed thirty-three structured coding over a span of about one month. The coding process gave rise to 8 general themes, namely communication, access, infrastructure, equipment, community education, triage, staffing, and training. Researchers utilized subcategories for identifying areas to conduct targeted intervention. A 93.36% overall agreement was found between the two coders (κ-coefficient=0.69).

Pre-hospital systems prove crucial to time-sensitive pediatric patient care delivery. In one middle-income single-facility area, obstacles to communication between dispatch workers and EMS providers or healthcare centers were identified as an area to be prioritized for interventions, ensuring care delivery improvements. Other targeted intervention areas must include training dispatch workers on basic medical lingo and widening the ALS provider base (Anest, et al., 2016).

1. Page, C., Sbat, M., Vazquez, K., & Yalcin, Z. (2013). Analysis of Emergency Medical Systems Across the World. Worcester: Worcester Polytechnic Institute.

The MIRAD Lab-focused IQP (Interactive Qualifying Project) offers a basic insight into EMS's role in particular nations across the globe. The paper presents a summary of the Franco-Germany and Anglo-American EMS systems, their functions, structure, and regulatory standards of operation. Numerous nations across the globe are utilizing these systems for delivering superior quality care within emergency or pre-hospital settings.

The Physician EMS-centered Franco-German model allows EMS personnel and a physician to assess and treat medical emergency patients, who may be transported to a healthcare facility for additional examination, if needed. Meanwhile, the other, Anglo-American EMS model involves ambulances having paramedics and EMTs (Emergency Medical Technicians) who have received training in elementary, middle-level and advanced/complex life support. These personnel offer the pre-hospital services of patient stabilization, transport to healthcare facility for additional evaluation, and intervention. The IQP analyzes both models, and studies select nations like the U.S., Germany, China, South Africa, Oman and Portugal, having diverse geographic, economic, and political backgrounds.

The IQP reveals how individual nations have applied tailored forms of both aforementioned models to suit their emergency medical competences and systems. The derived outcomes offer IQP members a chance to recognize and understand pre-hospital services' social effect and ethical problems linked to sustained, constant patient care delivery quality (Page, Sbat, Vazquez, & Yalcin, 2013).

1. Al-Shaqsi, S. (2010). Models of International Emergency Medical Service (EMS) Systems. Oman Medical Journal, 320-323.

Standard "all-ALS" systems function as one-type ambulance fleets that handle non-urgent and urgent patient care. Every vehicle has ALS-qualified staff compared to a hierarchical response system that employs advanced as well as elementary life support crew members, ensuring the former are only dispatched to highly severe events, with the latter being sent to handle scheduled and non-urgent patient transport. This hierarchical system is accompanied by the benefit of making ALS units available for severely-ailing or injured patients' acute care. Numerous researches have attempted at advocating ALS systems' effectiveness over that of elementary systems. But these research works are associated with several shortcomings like small sample size, extreme bias, and confounding. Moreover, they are largely descriptive, and not hypothesis testing, researches.

Some research scholars go on to claim that pre-hospital ALS interventions enhance patient outcomes; the finding is restricted to patients suffering trauma and hasn't been verified in case of medical emergencies. Meanwhile, other research works have depicted that swift patient transport to definitive hospitals instead of advanced interventions within ambulances greatly affect patient outcomes. Ultimately, it all boils down to attending providers' decision regarding which of the two -- swift transport or field interventions -- is the better choice for any given case.

While existing global EMS systems vary in terms of practices and components, they are all similar, in some way, to main EMS models. Global EMS systems aim at adapting models capable of fulfilling local goals and demands considering the diverse political, financial and cultural factors of individual communities. Calling for one system to suit all settings is not a wise move in today's swiftly evolving global climate. In the year 2004, the Sultanate of Oman introduced its Anglo-American EMS model-based system with ROP (Royal Oman Police) backing. The model aims at responding effectively to the rampant road accident-linked trauma cases. All-ALS trained EMTs offer pre-hospital patient care. At present, the system isn't tiered; qualified physicians oversee the teams (Al-Shaqsi, 2010).

1. Gordon, E., & Ornato, J. (2000). Emergency cardiac care: introduction. Journal of the American College of Cardiology.

Approximately 250,000 cases of unexpected pre-hospital or out-of-healthcare-facility cardiac arrests are recorded per annum, most of which result after cardiac arrhythmias. Asphyxia constitutes the cause of very few such cases. The value of timely defibrillation and onlooker CPR in survival in case of out-of-healthcare-facility cardiac arrests is well-documented. As many as nine out of ten patients may survive if they receive timely defibrillation (during the first few minutes following a cardiac arrest event). After that, however, the probability of the patient surviving to recover and get discharged from the hospital reduces by about 10% every minute; hence, the "survival link" concept emerged, comprising of the following components: timely access, timely cardiopulmonary resuscitation, timely defibrillation and timely ALS. All links are vital to improving probability of survival in cardiac arrest cases.

Population density, EMS organizations, and geographic limitations contribute to meaningful out-of-healthcare-facility cardiac arrest survival rates ranging from 0 to 44%. The standard survival rate in a large number of areas is not even 10%. Recent researches have revealed this healthcare issue's evolving demographics. Primary ventricular fibrillation incidence is declining, but an increasingly bradyasystolic initial rhythm of cardiac arrest has been observed. This corresponds to a growth in concurrent comorbid as well as age-connected heart diseases, particularly congestive heart failure, among cardiac arrest patients.