On EMS Office Hours a few nights ago, Tim Rogue Medic Noonan, Jim Hoffman, Josh Knapp, and I had a great discussion about the pit crew approach to managing cardiac arrests. Here are a few points I took away from the discussion.
1. Josh mentioned that he frequently works arrests with only his partner, and that backup is not available. I ask why. Would it ever be acceptable for a fire department to only have one engine available for a working house fire? For a police department to have one patrol car available for a shooting? Arrests make up less than 1% of EMS calls and are a true matter of life and death. They also happen to be the most labor intensive calls we go one, so why don’t communities demand that more resources be available for them? Can’t lower priority calls wait a little longer?
2. Training and preparedness also came up, specifically AHA CPR and ACLS classes. If they were effective, there would not be such a wide variation in survival rates across the country. I pointed out that most groups I have been affiliated with in the past do not take CPR class seriously. Tim also brought up how seasoned paramedics believe they are above practicing intubation on mannequin, even with compelling evidence that we do not do it well as an industry.
Professional athletes spend 90% of their work week practicing to perform for 10%. “Practice how you play” is drilled into little league baseball players, but we wink and toss out CPR cards. When compressions are clearly the most important part of managing arrests and they make up 1% of the calls we go on, how is a short class every 2 years enough? Can’t we at least take it seriously when we do go? Until we get this straightened out, it’s not even worth discussing what drugs might work.
3. Teamwork and inter-agency cooperation are other barriers that were discussed. Multiple agencies participate in all of the systems that boast high survival rates. In King County, WA, each fire department provides BLS first response. A few fire departments also have paramedics that cover larger areas, and another portion of the county is covered by a third-service paramedics. All operate as one system, and their V-Fib survival rate is above 50%. In Rochester, MN, the police and fire departments provide BLS first response and the paramedics work for a private/hospital affiliated service. As of the writing of Dr. Eisenberg’s book Resuscitate!, their V-fib survival rate was 46%. In Wake County, NC, there is a country run paramedic ambulance service, a few independent contracted paramedic ambulance services, and a few dozen BLS fire department first responders. Their V-fib survival rate is also above 50%.
The one thing all of these systems have in common is an active medical director who is in charge of all elements of the system. Everyone is on the same team, at least while they are with a patient.
4. Tim mentioned that he prefers “Crew Resource Management” (CRM) over the pit crew concept. I also like CRM, but believe the pit crew is a better teaching tool. The pit crew provides a real, simple, concrete, visual example of how to run arrests. Chest compressions are time on the track, and any time off must lead to better track time. My experience is that people are less familiar with how CRM has evolved from the airline industry. It has also become a management buzz word, which automatically loses credibility with some in-the-trench audiences.
All in all, it was a great discussion that I’m sure will continue. So what do you think? Is the pit crew a good concept? Does it make things more or less complicated? I’d love to hear some positive and negative examples of how it is applied.