Barreling down the road, ambulance lights ablaze, Jay Bradshaw would stand over a patient, struggle to keep his balance around corners, over bumps, and press down with all his might.
One, two, three, four. One, two, three, four.
“Once upon a time, when I started as a paramedic, we used to do CPR in the back of an ambulance,” said Bradshaw, director of Maine Emergency Medical Services. “We had law enforcement clear intersections; we’d go lights and sirens to the hospital.”
New science suggests the odds of survival are improved by staying put, which is having a ripple effect on emergency care in Maine.
More people in cardiac arrest are getting worked on at the scene.
And when they can’t be brought back, more bodies are being left where they lie.
The trend comes as Maine emergency medical technicians are newly empowered by state law to stop treatment without first calling an emergency room doctor. They’re facing families, and now what?
“You can’t just walk out the door and say, ‘Goodbye,’” said Sabattus EMS Chief Tom Avery.
Emergency responders say they’re still wrestling with the changes. People still expect to call 911 and have an ambulance swoop in and drive them off to the hospital to be saved.
South Portland firefighters, who run that city’s ambulance service, considered public outreach around the new protocol. They weren’t sure what to say.
“Obviously, the common perception amongst people is, ‘I’m going to call 911, the ambulance is going to come, they’re going to grab Grandma and they’re going to take off,’” said South Portland Deputy Chief Stephen Fox. “I see where that might be an issue. The public doesn’t necessarily have an understanding of our level of training. ‘You guys are just ambulance drivers. I want you to take my family member to the hospital where they’re going to get the care.’”
This winter, when a customer collapsed in a Sears bathroom, South Portland paramedics tried to resuscitate him on the bathroom floor. When that customer died, a funeral home drove to the Maine Mall to pick him up. There was no trip to the ER by ambulance.
According to Maine EMS, when emergency crews arrived on a scene in 2010 and administered CPR, 83 percent of the time those patients were taken to a hospital.
In the first six months of 2012, 50 percent of the time they were not.
Amid the changes, there are exceptions, Bradshaw said. Insist Grandma go to the hospital, and she probably will. Collapse in a public spot, and you might not get treated where you fall.
“I’ve heard people say, ‘Do you want them left in the frozen food section at Hannaford’s?’” Bradshaw said. “Absolutely not. It’s not quite as black and white as that.”
In an analysis for the Sun Journal, Maine EMS counted 548 ambulance runs in 2010 in which an emergency crew responded to a scene, most often a home, and started CPR on a down patient. (The count doesn’t include arriving to find someone dead or with a “Do not resuscitate” order.)
In those 548 cases, 455 times, or in 83 percent of cases, the patient was treated at least preliminarily on scene and taken to a hospital.
In 2011, out of 607 runs, 464, or 76 percent, eventually went to the hospital.
Maine updated its EMS Prehospital Treatment Protocols guide in December 2011, giving EMTs and paramedics the authority to stop resuscitation efforts after 20 fruitless minutes. Before, those first responders would reach out to medical control, often an ER doctor, to make the call on when to stop.
The update seemed to reiterate the value of on-scene care, rather than trying to resuscitate in the back of a rushing ambulance.
Since January, in 311 runs, 155 people were taken to the hospital and 156, or 50 percent, were not.
The move away from load-and-go started at least a decade ago.
“We’re becoming much more aware of what works and doesn’t work, and what’s safe and isn’t safe,” Bradshaw said. In 2000, the American Heart Association “started to hint the traditional way of thinking about CPR isn’t as effective as they originally hoped.”
What works, he said: inch-and-a-half to two-inch chest compressions without interruption. “The Bee Gees song ‘Stayin’ Alive’ is actually a good pace. It’s a little over a hundred beats a minute.”
What doesn’t: Stopping to load someone onto a stretcher, stopping again to get out of the house, again to load the stretcher into an ambulance.
“When they have those types of pauses, whether it’s for doing ventilations or whether it’s for moving a patient, the survivability of that patient takes a significant drop every time that happens,” Bradshaw said. “Once it takes a drop, it’s not made up. If cardiac arrest patients are going to make it, quite candidly, they don’t make it in the hospital. They make it at the scene.”
In cases where treatment stops and a first responder says there’s no hope, a trip to the hospital ties up doctors, adds expense and doesn’t change the outcome, he said.
But more treatment at the scene means more dying there, too. The vast majority of those 311 ambulance runs so far this year were to homes. It has meant more paramedics and EMTs breaking sad news to families, a role some say they’re not trained for:
Your loved one is gone. Now, how can I help you?
“You can teach people how to put on a bandage, but teaching people how to give death notices, boy, that’s tough stuff,” Bradshaw said.
Training, setting the record straight
Lisbon Emergency Chief Jim MacDonnell has been an EMT for 12 years. He had that difficult conversation the first time a few weeks ago. A woman got up for a drink, and her husband heard her fall. They worked on her for 40 minutes and couldn’t bring her back.
“The family was in the other room,” MacDonnell said. “One of the (police) officers came to me, ‘Jim, do you want to go tell the family?’ I said, ‘I have no experience.’ He said, ‘Well, you’re learning. I’ll be right behind you.’”
MacDonnell has held one in-house training session on talking to family and plans a second for the fall, trying to get an undertaker and a grief counselor to participate.
Bradshaw said it’s up to each ambulance service to decide how they want to proceed, whether to have names of funeral homes at the ready.
This winter, Fox, in South Portland, reached out to funeral directors for the first time.
“Prior to this rule, if we had a person in our ambulance, we took them to either Maine Medical or to Mercy,” he said. “There’s never been a third option.”
He has enough staff to designate one person in charge of explaining everything to loved ones during an emergency.
“If you can look in their face and see that this isn’t sinking in, you bring them over, and you get an emergency room doctor on the phone and have the emergency room physician say, ‘Yes, those are medics there. They’re doing everything they can. We don’t want them to bring the person in right now. We want them to work on them for 20 minutes,’” Fox said.
For departments with small or volunteer staff, it’s tricky.
“I’m reaching out to my peers: ‘What are you doing? What is your interpretation of this?’” said Avery in Sabattus. “You came there for one reason, which was to hopefully save that person, but now you are thrust into the situation where there’s nothing you can do. Just as important, right then, you have to be able to help the family.”
He plans a staff training session with a mental health worker.
Nathan Yerza, United Ambulance’s performance improvement coordinator, said he’s noticed that after an unsuccessful resuscitation, staying with the body until police, the Medical Examiner’s Office or a funeral home intervenes ties up ambulances for anywhere from 15 to 90 minutes. They’ve had to staff accordingly.
United provides ambulance service to Lewiston, Auburn, Greene, Sabattus, Minot and Mechanic Falls.
Yerza has heard concern from the public, too, after the guidebook change, that EMTs will only work on someone for 20 minutes, not a minute more. Not true, he said.
“It could be a lengthy effort if people stayed in what we call a shockable rhythm,” Yerza said.
Bradshaw has also heard that rumor, along with concerns that rules now prohibit CPR in the backs of ambulances (Also not the case. “What we’ve said is it’s better for the patient to do CPR at home”) and he’s heard hypotheticals such as leaving someone in the aisle at Hannaford.
In that situation, “they may care for the patient in the grocery store, but if the resuscitation was terminated on scene, they would make arrangements for where and how the body would be moved and/or transported,” Bradshaw said.
There isn’t enough data yet to confirm the new protocol is saving more lives, “but the national and international literature supports that treating at the scene is better for the patient,” he said.