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Patient Care

The Top 5 Papers of 2016: #2

Every year, three EMS experts take to the stage at the National Association of EMS Physicians annual conference to sum up the top five research articles of the previous year. Their goal? Identify research that is relevant, counter-intuitive and practice changing—research that is important to the patients who call 9-1-1 with the expectation that they will be served with the best available care possible. This year, paramedic and emergency room resident Blair Bigham describes the articles he and co-experts Drs. Jon Rittenberger and Michael Millin selected.

The Case of the Doctor On Scene

The Case: A 50-year-old man collapses three hours into a transatlantic flight on an Airbus A330 aircraft. An overhead announcement is made by a flight attendant requesting medical assistance from qualified passengers. Two European physicians step forward; both have extensive experience working in the field. Two North American paramedics also step forward; both have worked in urban centers for a combined 30 years. Despite their strong Canadian, American, Scandinavian and German accents, the team work together using standard resuscitation guidelines to successfully defibrillate the man. The captain of the aircraft diverts to Reykjavik, Iceland, and the man undergoes coronary angioplasty. He is released from hospital four days later.

The Evidence: Böttcher BW, et al. Influence of EMS-physician presence on survival after out-of-hospital cardiopulmonary resuscitation: systematic review and meta-analysis. Critical Care, 2016, 20:4.

In this systematic review, 14 low-quality studies compared physician- vs paramedic-led cardiac arrest treatment in the field. It is common in Europe for physicians to lead prehospital teams, while in North America paramedics and EMTs run most field arrests. Over 126,000 patients were included, though most came from one Japanese study.

The Results:

Survival to hospital discharge:

EMS Physician 15.1% (95% CI 14.6 – 15.7)

Paramedic 8.4% (95% CI 8.2 – 8.5)

OR 2.03 (95% CI 1.48 – 2.79; p < 0.001)

The results indicate that the odds of surviving double when a physician is on scene.

The Bottom Line: The experts note many problems with the comparison made in this review, and caution against cursory impressions of this “apples and oranges” comparison.

First, in North American EMS services, survival rates are highly variable and in some paramedic-based services is higher than 15.1%. Second, in some of the studies where physicians work in the field, paramedics perform only BLS functions. Third, physicians may be more selective in whom they initiate resuscitation, leading to a smaller denominator as cases perceived to be futile are not intervened on; most paramedic-based systems resuscitate everyone not obviously dead, leading to higher denominators and relatively less survivors. Lastly, EMS systems are highly variable, and the studies in this review are highly biased due to the design features of the studies.

The experts did not feel that physician-based services were significantly better than paramedic-based services, but did feel physician presence on scene may offer motivation and coaching components that are difficult to measure but may lead to improved team performance and clinical outcomes.

After a decade working as a helicopter paramedic, Blair Bigham, MD, MSC, ACPF, completed medical school in Ontario, Canada, where he is now a resident physician in the emergency department. He has authored over 30 scientific articles, led major national projects to advance prehospital research and participated in multiple collaboratives, including the Resuscitation Outcomes Consortium. He has taught and mentored clinical and academic paramedics and loves his new role teaching medical students. He serves as a volunteer on the board of directors for the MedicAlert Foundation of Canada and is a task force member for the International Liaison Committee on Resuscitation. 

Michael Millin is a board certified EM and EMS physician from Baltimore, MD. He is a member of the faculty of the Johns Hopkins University School of Medicine and medical director of the Johns Hopkins Lifeline critical care transport program. He is also medical director for the BWI Airport Fire and Rescue Department, Maryland Search and Rescue, and associate medical dDirector for the Prince George’s County Fire/EMS Department.

Jon Rittenberger, MD, is an associate professor of emergency medicine and medical command physician for UPMC Prehospital Care. In addition to his emergency medicine practice, he is a founding member of the Post Cardiac Arrest Service at UPMC Presbyterian hospital. His research interest is in brain resuscitation during critical illness states. He brings over 20 years of EMS experience as a provider and researcher.

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