A coalition of researchers, state health officials and fire/EMS agencies throughout Arizona—already a national leader in improving out-of-hospital cardiac arrest survival—is turning its attention to another all-too-common cause of injury and death: traumatic brain injury (TBI).
The Arizona Emergency Medicine Research Center at the University of Arizona College of Medicine–Phoenix recently received a five-year grant from the National Institutes of Health to launch a project that will bring first responders, the Arizona Department of Health Services and university researchers together to improve prehospital TBI treatment throughout the state.
“The first 10 to 15 minutes after you’ve had a brain injury is crucial to your outcome,” says Ben Bobrow, M.D., a principal investigator and medical director of the Bureau of Emergency Medical Services and Trauma System for the Arizona Department of Health Services. “For years, we’ve been delivering people to trauma centers who are essentially dead, and a lot of things we used to do we now know are exactly the wrong things to do. We’re trying to change that.”
Called the Excellence in Prehospital Injury Care Project, the initiative, which launched in May, has several objectives, including:
- Training paramedics and EMTs in the latest evidence-based prehospital brain injury guidelines and making sure those protocols are implemented
- Collecting and analyzing prehospital and hospital data on brain-injured patients cared for by EMS providers
- Tracking patient outcomes for six months after discharge to study outcomes
About 50,000 Americans die from TBI annually, while 235,000 are hospitalized, according to researchers. Though the latest prehospital TBI guidelines were issued by the Brain Trauma Foundation in 2007, a survey of members of the National Association of State EMS Medical Directors, as well as EMS agencies in Arizona, found that not everyone is following them.
“Very few had formally adopted them, and none had a state protocol adopting the new guidelines or were closely following and evaluating the implementation of those guidelines,” Bobrow says.
Hyperventilating patients to avoid brain swelling is one example of how TBI care has changed. It used to be common practice until animal and observational studies in humans showed that hyperventilation is associated with decreased survival.
“For years we taught [EMS] to hyperventilate, and only recently we taught them that’s the wrong thing to do,” Bobrow says. “It takes years to change mindset, and even longer to change practice. It’s very easy to over-ventilate in an emergency situation. It takes a really structured plan to modify that behavior.”
Limiting fluids to avoid brain swelling was another common practice, yet today, it’s known that administering fluids can help avoid dangerous dips in blood pressure that can significantly impact a patient’s chance of recovery.
“Even a single blood pressure reading below 90 mmHg systolic is associated with a doubling of mortality with severe brain injury,” Bobrow says. “Administering IV fluids early is a way of raising blood pressure.”
Arizona has already gained recognition for a statewide initiative to improve prehospital sudden cardiac arrest care. Between 2004 and 2009, cardiac arrest survival rates in that state rose from 3.7 to nearly 11 percent.
They’ll rely on the same network of fire/EMS agencies that were instrumental in improving SCA care in the brain injury project, Bobrow says. Though the grant is to study only adult brain injury, they’re applying for a second grant to also include pediatric brain injuries.
“There’s very strong evidence that the care provided in the first few minutes has a profound impact on survival,” says Dan Spaite, M.D., director of research for the Arizona Emergency Medicine Research Center. “The idea that the outcome of TBI is solely determined by the care occurring at the hospital has changed radically. There is now overwhelming evidence that rapid response by fire or EMS personnel, combined with state-of-the-art prehospital treatment, could double or even triple survival rates.”
To view the latest guidelines for prehospital TBI care, visit braintrauma.org/pdf/Prehospital_Guidelines_2nd_Edition.pdf.
Los Angeles Hires a Bill Collector
To better collect on unpaid debts to the city, the Los Angeles City Council recently voted to create a new position, inspector general of collections. Last year, a city commission found that the city was owed $541 million, of which $248 million was unpaid debts to the Los Angeles Fire Department—mostly ambulance bills, according to news reports. The council voted May 25.
Death Benefits for Volunteer EMS Makes a Small Gain
The extension of eligibility under the Public Safety Officers’ Benefits (PSOB) program to paramedics and EMTs who are employed by, or volunteer for, private nonprofit EMS agencies and suffer a fatal or permanently disabling injury in the line of duty seems to be moving closer to reality.
Last year, the Dale Long Emergency Medical Service Providers Protection Act, which would extend the benefits, was introduced in the Senate but did not make it out of committee. During this Congress, bill language from the Dale Long Act was inserted into the Federal Aviation Administration Reauthorization Bill, which is currently in conference committee.
That means that a version of the bill has passed both the House and Senate and is now in conference committee to resolve the differences between the two bills, a process called reconciliation. After the bill is reconciled, the House and Senate will vote on it; if approved, it will be sent to the president for his signature.
“I can’t say how likely it is that the Dale Long language will stay in the FAA bill, but the FAA reauthorization is in the home stretch,” says Dave Finger, director of governmental relations for the National Volunteer Fire Council (NVFC).
Current federal law limits PSOB benefits for EMS personnel to those who work for governmental agencies.
“EMS organizations ... have been working on this issue since 2002,” says Advocates for EMS President Kurt Krumperman. “There continues to be slow but steady progress. I am hopeful this year may be the year we get some legislation passed.”
There’s also a version of a death-benefits extension bill pending in the House. In May, Rep. Michael Fitzpatrick (R-Pa.) introduced the Danny McIntosh Emergency Medical Service Providers Protection Act, which has language identical to the Dale Long Act. Daniel McIntosh was a paramedic with Bensalem EMS in Bucks County, Pa., who died in March 2010 at age 39 from a heart attack after chasing down a suicidal man.
Read the NVFC’s letter to Congress here: nvfc.org/files/documents/EMS_Providers_Protection_Act_Letter.pdf.
New Yorkers <3 FDNY
In a survey that asked New York City residents to rate their governmental agencies, the FDNY came out on top. About 87 percent of respondents rated the department as excellent or good. The 911 system was second with 73 percent, while EMS, public libraries, drinking water and the 311 system followed close behind with a score of about 70 percent, according to the Marist/Dyson Foundation poll.
Police got a 62 percent favorable rating, while road and highway maintenance were at the bottom with 27 percent.
