Recently, Los Angeles County’s Emergency Medical Services (EMS) Agency has been in the news for its decision to stop transporting cardiac arrest patients to hospitals. This termination-of-resuscitation guideline, made in the context of soaring patient volumes and worries about overwhelming medical resources thanks to COVID-19, has led to concern that EMS personnel will abandon patients and provide suboptimal care. We are here to tell you that this is not the case. In fact, their decision will likely end up saving lives and is consistent with best evidence-based practice.
We are two emergency medicine physicians who work in Baltimore. You may be wondering how that qualifies us to speak on what is occurring in L.A. County. Well, although Baltimore and Los Angeles County may not be geographically close to one another, the state of Maryland also has guidelines for EMS termination of resuscitation. In fact, Maryland adopted its policy years ago. The decision made by the Maryland Institute for Emergency Medical Services System was not based on a global pandemic but rather scientific evidence.
The American Heart Association has long maintained that the most effective treatment for anyone who has suffered a cardiac arrest is performing high quality, continuous chest compressions. These compressions help to keep blood flowing in the patient when his or her own heart has stopped.
When EMS personnel find a patient in cardiac arrest, they have two options. They can stay on the scene and perform CPR or they can attempt to transport the patient to a hospital. While transport to a hospital may seem like the right thing to do, remember that any attempt to move the patient will ultimately delay high-quality CPR and lifesaving interventions such as defibrillation. Additionally, the quality of CPR that a patient will receive in the back of an ambulance is, not surprisingly, subpar. There is very good evidence to show that survival rates are better when EMS providers remain on the scene to treat a cardiac arrest patient rather than rapidly transporting him or her.
Safety of the EMS crews should be considered as well. Motor vehicle collisions are the leading cause of death for EMS personnel. It is impractical for EMS personnel to perform CPR while wearing seatbelts, yet unsafe for them not to wear seatbelts while the ambulance speeds through traffic. EMS providers are highly trained professionals and they are prepared for risks, but these must be weighed against the possible benefits to the patient, which in this case are limited at best. We are surprised it took this long for L.A. County to change their protocols.
The sad truth is that if a patient’s heart does not restart with EMS interventions it is unlikely to restart at all. Over 90% of all patients who experience cardiac arrest outside of a hospital will die. Of those 10% who do survive, only a few walk out of the hospital and live a normal life afterward.
Unfortunately, TV medical dramas such as “House MD” and “Grey’s Anatomy” exaggerate the effectiveness of CPR — one analysis found these shows portray successful resuscitation in 70% of their fictional cases. Unfortunately, this gives the public false hope when it comes to the effectiveness of CPR. In reality, if the patient does not respond in the field to high-quality chest compressions and other medical interventions, chances are that nothing we do in the emergency room will change the outcome.
It may seem cruel to stop trying to save patients without even bringing them to the hospital. But please ask yourself: is it crueler to be honest about prognosis with a patient’s family or to give them false hope by rushing their loved one to the hospital?
We understand that the decision made by L.A. County’s EMS leadership may seem callous. But we promise you that, although this decision was made with conserving medical resources in mind, there is good evidence justifying this decision. L.A. County is making the right call. Allowing EMS providers to remain on scene to give high-quality chest compressions gives the patient the best chance of survival. To do otherwise, especially now, merely puts other lives at risk.
Garrett Cavaliere, DO, and Gregory Jasani, MD, are emergency medicine physicians at the University of Maryland Medical Center. Cavaliere is also a firefighter/paramedic with the Prince George’s County Fire EMS Department.
Last Updated January 22, 2021