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Blind defibrillation by basic EMTs
ch~ique§ p e r m i t large q u a n t i t i e s of fresh p l a t e l e t s to be ~pplied for infusion. Thus, carefully screened b a n k blood 0uld be t r a n s f u s e d t h r o u g h a f i l t e r a n d p l a t e l e t s pC,~lPi e d v by a s e p a r a t e u n f i l t e r e d infusion.
ft0
~he i s s u e of t r a n s f u s i n g fresh as opposed to s t o r e d l00d, where the l a t t e r m a y be supplied as the s u m of ashed r e d cells, frozen p l a s m a and fresh platelets, reains unresolved. U n t i l it is, it will be well to keep filrs readily at h a n d in the e m e r g e n c y d e p a r t m e n t . Stanley R. Gold, MD, J A C E P Editorial Board l. Collins JA: Problems associated with the massive transfusion Ifstored blood. Surgery 75:274-295, 1974.
~lind Defibrillation by Basic EMTs IWENTY-TWO YEAR OLD G.S. pointed with pride to his edentials - an A d v a n c e d R e d Cross First A i d Card, a .auffeur s hcense, ecent completion o f an E m e r g e n c y edical Technician ( E M T ) curriculum and m a n y Saturty night viewings o f Emergency! He had six months o f xperience with a private ambulance company that stood , at professional football games. Their vehicle was outfit'with a new monitor-defibrillator because the N F L reires this in case a doctor needs it on the field, a consid~tion apparently resulting from the Detroit Lions' Chuck ughes' death in 1971. The vendor o f the apparatus had ~pplied some operating instructions and a manual. '
"
r
While the ambulance was being processed through a arwash in preparation for its appearance in that S u n lays game, G.S. was in some manner investigating the lefibrillator w h e n it d i s c h a r g e d . Upon h e a r i n g two thumps (the m a c h i n e on G.S. a n d then G.S. on the loot), the driver p r o m p t l y turned on the red light and sign, extricated the ambulance from the washatorium a n d Fpedto a nearby hospital where, two minutes later, G.S. ~asnoted to be cyanotic and apneic. Various ventricular dysrhythmias, including ventricu~rfibrillation, required four separate 400 watt-second dilet current shocks, intubation, intracardiac epinephrine nd numerous intravenous med~catmns before G.S. s wtal 'tgns stabilized. A n initial left bundle branch block gave ~ay to normal intraventricular conduction over a period Ifseveral days. Anoxic encephalopathy was present for 24 lurs and thereafter improved rapidly. 1
"
"
''
'
'
"
Although one m o n t h l a t e r G.S. bore no d e t e c t a b l e eurologic or c a r d i o v a s c u l a r sequelae, he felt compelled pursue a new vocation. His application for W o r k m e n ' s ~0mpensation was denied. The referee stated: "This was 0t in his line of work . . . if he'd h a d a gun [instead of a ~fibrillator] he s u r e l y would have killed himself." This t r u e case vividly i l l u s t r a t e s t h a t blind f i b r i l l a t i o n ta be as g r e a t a m i s a d v e n t u r e as can blind d e f i b r i l l a t i o n e an a d v e n t u r e . Thus, w h e n the shocker-shockee relai0nship is reversed, c h a n g e s in perspective can be anticipated (as G.S. d e m o n s t r a t e d by r a p i d l y g e t t i n g out of the business). Unfortunately, the r e a l i t i e s of this point have not been tPpropriately e m p h a s i z e d in t h i s issue's article, B l i n d lefibrillation Outside the Hospital (p 512). Its advocacy of ~h01esale p l a c e m e n t of a p o t e n t lifesaving tool, w i t h an
• PJuly 1976
equal c a p a c i t y for lethality, in t h e h a n d s of m i n i m a l l y t r a i n e d i n d i v i d u a l s (who indeed do not function under " u n n e c e s s a r y l i m i t a t i o n s " as the a u t h o r s h a v e suggested) is in direct opposition to r e c o m m e n d a t i o n s of the American College of Cardiology's B e t h e s d a Conference2 T h a t report's section d e a l i n g with p a r a m e d i c a l a s s i s t a n t s emphasized t h a t a " n o n p h y s i c i a n who u n d e r t a k e s the duties or p r e r o g a t i v e s of a p h y s i c i a n is p r a c t i c i n g m e d i c i n e w i t h o u t a license," t h a t w h e n t h e p h y s i c i a n delegates duties, "supervision a n d direction m u s t be intense when he is u s i n g u n s k i l l e d persons," t h a t "if the function is an i m p o r t a n t or life-saving one, it r e q u i r e s m o r e supervision," a n d t h a t w h e n n o n p h y s i c i a n s t a f f is used t h e y m u s t ~have been carefully selected a n d qualified" and "have h a d special education, experience, a n d training." This conference f u r t h e r gave t h e explicit opinion t h a t p r o g r a m s t h a t use n o n p h y s i c i a n s to provide elite cardiac care be "judged a desirable m e a n s of s e r v i n g the public by e x p e r t s who are qualified by experience a n d education to m a k e such a d e t e r m i n a t i o n a n d who have a reasonable basis upon which to base such conclusions." Etsell and S m o c k ' s f a i l u r e to p r o v i d e a n y h a r d d a t a or h o m e g e n e r a t e d s u b s t a n t i a t i o n w h a t e v e r r e p r e s e n t s a signific a n t d e p a r t u r e from this requisite. U n q u e s t i o n a b l y , a p h y s i c i a n or group of p h y s i c i a n s m u s t a s s u m e r e s p o n s i b i l i t y for w h a t e v e r acts are performed by field p e r s o n n e l in o r d e r to g u a r a n t e e t h e i r c o m m u n i t y the professional direction, c o m m i t m e n t and conscience n e c e s s a r y to a s s u r e a service of o p t i m a l quali t y a n d p r o p r i e t y . T h i s c a n n o t be done b y p r o v i d i n g s t a n d i n g orders t h a t a r e d e l i b e r a t e l y designed to avoid t r a i n i n g , nor by e q u i p p i n g rescuers w i t h only a fraction of t h e skills necessary to do the complete job. In t h e delivery of field care both the p h y s i c i a n and the rescuer are t o t a l l y d e p e n d e n t one upon the other. The p h y s i c i a n ext e n d s h i s e y e s , h a n d s , a n d j u d g m e n t s to t h e v i c t i m t h r o u g h the rescuer while t h a t rescuer relies upon the p h y s i c i a n not only to p r o p e r l y p r e p a r e h i m to c a r r y out the charge b u t moreover to accept u l t i m a t e responsibility. This i n t e r a c t i o n is w o r k a b l e only if t h e r e is a m u t u a l confidence founded in t h e u t m o s t of skill a t t a i n m e n t and discipline. Shortcuts simply a r e not t e n a b l e to the EMTs, the p h y s i c i a n s or t h e victims, who respectively have t h e i r prides, licenses a n d lives on the line. Beyond these conceptual considerations, o t h e r reasons m i l i t a t e a g a i n s t b l i n d defibrillation by basic EMTs. A r e p e r t o i r e of advanced skills is n e c e s s a r y not only to effect a n d maintain successful defibrillation but,most imp o r t a n t l y , to prevent v e n t r i c u l a r fibrillation in the first place. Of t h e half-dozen critical d y s r h y t h m i a s encount e r e d in the field, only v e n t r i c u l a r t a c h y c a r d i a and/or fib r i l l a t i o n r e q u i r e countershock. Of those t r e a t e d in the first hour by the t e a m s of A d g e y and P a n t r i d g e , 15 over h a l f h a d b r a d y a r r h y t h m i a s or v e n t r i c u l a r ectopics, w h e r e a s only 3% h a d v e n t r i c u l a r t a c h y c a r d i a and 10% h a d v e n t r i c u l a r fibrillation. W h e n e x t e n d i n g t h e i r total p a t i e n t - d y s r h y t h m i a - i n c i d e n c e s t a t i s t i c s over four hours, t h e y found t h a t v e n t r i c u l a r t a c h y c a r d i a increased tenfold a n d v e n t r i c u l a r fibrillation doubled. These d a t a demons t r a t e t h a t in t h e first hour only 13% of serious dysr h y t h m i a s m i g h t be a p p r o p r i a t e l y t r e a t e d by blind deftbrillation, a l t h o u g h if the r e s c u e r does n o t possess a full r a n g e of skills, his o p p o r t u n i t y to e v e n t u a l l y apply a de-
Volume 5 Number 7 Page 543
fibrillator steadily and predictably increases. In these intervals appropriate care of those other dysrhythmias t h a t might eventuate in ventricular tachycardia or fibrillation would be withheld unless a complete armament a r i u m was possessed by the technician. Pain must be relieved, acidosis corrected, myocardial irritability decreased, vagal influence ablated and perhaps fibrillation coarsened - - all adjunctive measures of a criticality that greatly overshadow the glamorous jolting machine. Grace 27 cited four patients in his hospital who received an application of exogenous electrical current when none was required. That their outcomes were not lethal must be attributable to rapid recognition of the induced dysr h y t h m i a s and to those remedial resources available w i t h i n the controlled i n s t i t u t i o n a l setting. B e c a u s e neither factor is assured the basic EMT in the field, it would be cavalier to think t h a t if the technician faults with the defibrillator, he can readily undo the damage by a repeat zap. If, after those same two minutes, G.S. had met up with another EMT bearing only a defibrillator in his holster, a farm would likely have been bought. Should all cases of potential arrests in the field be shocked blindly, w i t h o u t a n y view w h a t e v e r of the heart's intrinsic electrical state, the propriety and/or h a r m would be difficult to objectively evaluate. Cardiac arrests possibly amenable to defibrillation have constituted about 1% of our metropolitan ambulance field experiences (Gordon and Trimble, unpublished data). However, there was a simulacrum of other prostrate patients not in arrest who had potentially undetectable pulses, eg, those with (1) localized arterial disease, (2) bradycardia following vasovagal syncope, and (3) b r a d y r h y t h m i a or e l e c t r o m e c h a n i c a l d i s s o c i a t i o n a t t e n d a n t to t h e hypoxemic myocardial depression of postseizure apnea or advanced shock states. While we are all loathe to admit t h a t our fingers are fallible, it is often exceedingly difficult to "only be able to" determine pulselessness and t h i s c o n s i d e r a t i o n w e i g h t s h e a v i l y for " q u i c k - l o o k " equipment. Should the proposed dissemination of defibrillators be of the "quick-look" type, some people would undoubtedly be extremely disappointed. If forced to look at the heart's activity, they m i g h t be held responsible for understanding what they saw, w h a t it m e a n t and w h a t then to do or not do. The m a n d a t e to possess such education would surely forestall those who would ramble far and wide spectacularly inflicting spasm and defecation upon the u n w a r y , unconscious public. The "valuable time inevitably squandered" in analyzing a heart's status by direct interpretation or through telemetry and those "precious seconds gained in bypassing" such "time consuming procedures" is pure hyperbole. Again, the contention t h a t "seconds count" m u s t be placed in a proper context relative to those rural reaches cited as potentially benefiting from the blind technique. Indeed, in controlled settings such as coronary care units (where all evidence supporting blind defibrillation has been gathered), seconds m a y count. But seconds become irrelevant to systems in which consumer entry, dispatch and arrival of first responders require m a n y minutes. Given the deficient resources of most rural systems, the time critical subsegment will usually place those with
Page 544 Volume 5 Number 7
truly emergent dysrhythmic disease beyond salvabilit~ Even given the vast expenditure for safe, portable del:l brillators and the a r m y of electronic technicians to se~i~ ice them, little real impact o n m o r t a l i t y rate or c~i would be realizedl Software costs alone for appropri~l education and supervision of basic EMTs must be Pr~l hibitive to most present day ruralities. The authors' a~ sertion t h a t "the costs of emergency coronary care will be greatly reduced" is a lure at which m a n y raigit snap, soon finding themselves dangerously hooked ~vittI an inappropriate and overly expensive impediment to t~I real EMS needs of their community. Another real world consideration is experience, ie, t~e n u m b e r of field incidents per person. A recent survey hy the Departmenl: of Transportation tabulated over 250,00~ ambulance and rescue personnel nationwide, of wh0~ approximately 150,000 are basic EMTs, over 10,000 of these are "advanced." The majority are based in urb~ settings where are located most of those 350,000 people who die annually of coronary disease prior to accessi~ professional care. On t h e average, this would present each basic EMT with about one experience of certain le, thality every six months (if one assumes the impossible - - t h a t all such coronary seizures are witnessed and that prompt system access and response ~are universally as. sured). This ratio becomes even more dismal when takin{ into account Simon and Alonzo's 3~ observation that le$ t h a n one in four sudden deaths could be prevented ifa mobile coronary care unit were available in a reasonable a m o u n t of time. Given such an experiential dearth, er0. sion of skills must become the rule. In the development 01 their program, Adgey and Pantridge's 2~ teams did not re. suscitate a patient in the first three months of field oper. ation - - a total t h a t would probably exceed the number of resuscitations by an EMT during a lifetime of service inI the r u r a l i t y . As cited in the s t u d y by Winchell andL Safar, 22 only 12% of trainees performed adequately three months after lecture demonstrations and only 30% performed adequately after intensive practical supervision. From these experiences and those of all others who have addressed this issue, it is obvious t h a t the denominat0~: of success is inversely proportional to the magnitude of shortcomings in training, retraining and/or the lack of opportunity to continuously apply skills. Etsell and Smock's premise t h a t lives m a y be saved by prompt action is, of course, the cornerstone of emergency medicine. We all believe t h a t innovation in any aspect 0it resuscitation m u s t be aggressively pursued. However, the ultimate efficacy of any method in medicine depends upon its inherent risk: reward relationships. Whether blind defibrillation by basic EMTs will eventually, if ever, prove to be an "appropriate" recommendation re. quires extensive prospective evaluation .under the utm0st scrutiny. We have made too much progress at too great a price to risk accepting a suggestion t h a t tasks heretofore done by e x t r a o r d i n a r y p e r s o n n e l now be relegated to those of r a t h e r ordinary qualifications. The palate of quality simply cannot be satisfied by a preoccupati0n with frosting before the cake has been baked.
Cleve Trimble, MD, FACS, JACEP Editorial Board Reference numbering corresponds to references followi~ Etsell-Smock article.
July 1976 , , ~ P
ft0
~he i s s u e of t r a n s f u s i n g fresh as opposed to s t o r e d l00d, where the l a t t e r m a y be supplied as the s u m of ashed r e d cells, frozen p l a s m a and fresh platelets, reains unresolved. U n t i l it is, it will be well to keep filrs readily at h a n d in the e m e r g e n c y d e p a r t m e n t . Stanley R. Gold, MD, J A C E P Editorial Board l. Collins JA: Problems associated with the massive transfusion Ifstored blood. Surgery 75:274-295, 1974.
~lind Defibrillation by Basic EMTs IWENTY-TWO YEAR OLD G.S. pointed with pride to his edentials - an A d v a n c e d R e d Cross First A i d Card, a .auffeur s hcense, ecent completion o f an E m e r g e n c y edical Technician ( E M T ) curriculum and m a n y Saturty night viewings o f Emergency! He had six months o f xperience with a private ambulance company that stood , at professional football games. Their vehicle was outfit'with a new monitor-defibrillator because the N F L reires this in case a doctor needs it on the field, a consid~tion apparently resulting from the Detroit Lions' Chuck ughes' death in 1971. The vendor o f the apparatus had ~pplied some operating instructions and a manual. '
"
r
While the ambulance was being processed through a arwash in preparation for its appearance in that S u n lays game, G.S. was in some manner investigating the lefibrillator w h e n it d i s c h a r g e d . Upon h e a r i n g two thumps (the m a c h i n e on G.S. a n d then G.S. on the loot), the driver p r o m p t l y turned on the red light and sign, extricated the ambulance from the washatorium a n d Fpedto a nearby hospital where, two minutes later, G.S. ~asnoted to be cyanotic and apneic. Various ventricular dysrhythmias, including ventricu~rfibrillation, required four separate 400 watt-second dilet current shocks, intubation, intracardiac epinephrine nd numerous intravenous med~catmns before G.S. s wtal 'tgns stabilized. A n initial left bundle branch block gave ~ay to normal intraventricular conduction over a period Ifseveral days. Anoxic encephalopathy was present for 24 lurs and thereafter improved rapidly. 1
"
"
''
'
'
"
Although one m o n t h l a t e r G.S. bore no d e t e c t a b l e eurologic or c a r d i o v a s c u l a r sequelae, he felt compelled pursue a new vocation. His application for W o r k m e n ' s ~0mpensation was denied. The referee stated: "This was 0t in his line of work . . . if he'd h a d a gun [instead of a ~fibrillator] he s u r e l y would have killed himself." This t r u e case vividly i l l u s t r a t e s t h a t blind f i b r i l l a t i o n ta be as g r e a t a m i s a d v e n t u r e as can blind d e f i b r i l l a t i o n e an a d v e n t u r e . Thus, w h e n the shocker-shockee relai0nship is reversed, c h a n g e s in perspective can be anticipated (as G.S. d e m o n s t r a t e d by r a p i d l y g e t t i n g out of the business). Unfortunately, the r e a l i t i e s of this point have not been tPpropriately e m p h a s i z e d in t h i s issue's article, B l i n d lefibrillation Outside the Hospital (p 512). Its advocacy of ~h01esale p l a c e m e n t of a p o t e n t lifesaving tool, w i t h an
• PJuly 1976
equal c a p a c i t y for lethality, in t h e h a n d s of m i n i m a l l y t r a i n e d i n d i v i d u a l s (who indeed do not function under " u n n e c e s s a r y l i m i t a t i o n s " as the a u t h o r s h a v e suggested) is in direct opposition to r e c o m m e n d a t i o n s of the American College of Cardiology's B e t h e s d a Conference2 T h a t report's section d e a l i n g with p a r a m e d i c a l a s s i s t a n t s emphasized t h a t a " n o n p h y s i c i a n who u n d e r t a k e s the duties or p r e r o g a t i v e s of a p h y s i c i a n is p r a c t i c i n g m e d i c i n e w i t h o u t a license," t h a t w h e n t h e p h y s i c i a n delegates duties, "supervision a n d direction m u s t be intense when he is u s i n g u n s k i l l e d persons," t h a t "if the function is an i m p o r t a n t or life-saving one, it r e q u i r e s m o r e supervision," a n d t h a t w h e n n o n p h y s i c i a n s t a f f is used t h e y m u s t ~have been carefully selected a n d qualified" and "have h a d special education, experience, a n d training." This conference f u r t h e r gave t h e explicit opinion t h a t p r o g r a m s t h a t use n o n p h y s i c i a n s to provide elite cardiac care be "judged a desirable m e a n s of s e r v i n g the public by e x p e r t s who are qualified by experience a n d education to m a k e such a d e t e r m i n a t i o n a n d who have a reasonable basis upon which to base such conclusions." Etsell and S m o c k ' s f a i l u r e to p r o v i d e a n y h a r d d a t a or h o m e g e n e r a t e d s u b s t a n t i a t i o n w h a t e v e r r e p r e s e n t s a signific a n t d e p a r t u r e from this requisite. U n q u e s t i o n a b l y , a p h y s i c i a n or group of p h y s i c i a n s m u s t a s s u m e r e s p o n s i b i l i t y for w h a t e v e r acts are performed by field p e r s o n n e l in o r d e r to g u a r a n t e e t h e i r c o m m u n i t y the professional direction, c o m m i t m e n t and conscience n e c e s s a r y to a s s u r e a service of o p t i m a l quali t y a n d p r o p r i e t y . T h i s c a n n o t be done b y p r o v i d i n g s t a n d i n g orders t h a t a r e d e l i b e r a t e l y designed to avoid t r a i n i n g , nor by e q u i p p i n g rescuers w i t h only a fraction of t h e skills necessary to do the complete job. In t h e delivery of field care both the p h y s i c i a n and the rescuer are t o t a l l y d e p e n d e n t one upon the other. The p h y s i c i a n ext e n d s h i s e y e s , h a n d s , a n d j u d g m e n t s to t h e v i c t i m t h r o u g h the rescuer while t h a t rescuer relies upon the p h y s i c i a n not only to p r o p e r l y p r e p a r e h i m to c a r r y out the charge b u t moreover to accept u l t i m a t e responsibility. This i n t e r a c t i o n is w o r k a b l e only if t h e r e is a m u t u a l confidence founded in t h e u t m o s t of skill a t t a i n m e n t and discipline. Shortcuts simply a r e not t e n a b l e to the EMTs, the p h y s i c i a n s or t h e victims, who respectively have t h e i r prides, licenses a n d lives on the line. Beyond these conceptual considerations, o t h e r reasons m i l i t a t e a g a i n s t b l i n d defibrillation by basic EMTs. A r e p e r t o i r e of advanced skills is n e c e s s a r y not only to effect a n d maintain successful defibrillation but,most imp o r t a n t l y , to prevent v e n t r i c u l a r fibrillation in the first place. Of t h e half-dozen critical d y s r h y t h m i a s encount e r e d in the field, only v e n t r i c u l a r t a c h y c a r d i a and/or fib r i l l a t i o n r e q u i r e countershock. Of those t r e a t e d in the first hour by the t e a m s of A d g e y and P a n t r i d g e , 15 over h a l f h a d b r a d y a r r h y t h m i a s or v e n t r i c u l a r ectopics, w h e r e a s only 3% h a d v e n t r i c u l a r t a c h y c a r d i a and 10% h a d v e n t r i c u l a r fibrillation. W h e n e x t e n d i n g t h e i r total p a t i e n t - d y s r h y t h m i a - i n c i d e n c e s t a t i s t i c s over four hours, t h e y found t h a t v e n t r i c u l a r t a c h y c a r d i a increased tenfold a n d v e n t r i c u l a r fibrillation doubled. These d a t a demons t r a t e t h a t in t h e first hour only 13% of serious dysr h y t h m i a s m i g h t be a p p r o p r i a t e l y t r e a t e d by blind deftbrillation, a l t h o u g h if the r e s c u e r does n o t possess a full r a n g e of skills, his o p p o r t u n i t y to e v e n t u a l l y apply a de-
Volume 5 Number 7 Page 543
fibrillator steadily and predictably increases. In these intervals appropriate care of those other dysrhythmias t h a t might eventuate in ventricular tachycardia or fibrillation would be withheld unless a complete armament a r i u m was possessed by the technician. Pain must be relieved, acidosis corrected, myocardial irritability decreased, vagal influence ablated and perhaps fibrillation coarsened - - all adjunctive measures of a criticality that greatly overshadow the glamorous jolting machine. Grace 27 cited four patients in his hospital who received an application of exogenous electrical current when none was required. That their outcomes were not lethal must be attributable to rapid recognition of the induced dysr h y t h m i a s and to those remedial resources available w i t h i n the controlled i n s t i t u t i o n a l setting. B e c a u s e neither factor is assured the basic EMT in the field, it would be cavalier to think t h a t if the technician faults with the defibrillator, he can readily undo the damage by a repeat zap. If, after those same two minutes, G.S. had met up with another EMT bearing only a defibrillator in his holster, a farm would likely have been bought. Should all cases of potential arrests in the field be shocked blindly, w i t h o u t a n y view w h a t e v e r of the heart's intrinsic electrical state, the propriety and/or h a r m would be difficult to objectively evaluate. Cardiac arrests possibly amenable to defibrillation have constituted about 1% of our metropolitan ambulance field experiences (Gordon and Trimble, unpublished data). However, there was a simulacrum of other prostrate patients not in arrest who had potentially undetectable pulses, eg, those with (1) localized arterial disease, (2) bradycardia following vasovagal syncope, and (3) b r a d y r h y t h m i a or e l e c t r o m e c h a n i c a l d i s s o c i a t i o n a t t e n d a n t to t h e hypoxemic myocardial depression of postseizure apnea or advanced shock states. While we are all loathe to admit t h a t our fingers are fallible, it is often exceedingly difficult to "only be able to" determine pulselessness and t h i s c o n s i d e r a t i o n w e i g h t s h e a v i l y for " q u i c k - l o o k " equipment. Should the proposed dissemination of defibrillators be of the "quick-look" type, some people would undoubtedly be extremely disappointed. If forced to look at the heart's activity, they m i g h t be held responsible for understanding what they saw, w h a t it m e a n t and w h a t then to do or not do. The m a n d a t e to possess such education would surely forestall those who would ramble far and wide spectacularly inflicting spasm and defecation upon the u n w a r y , unconscious public. The "valuable time inevitably squandered" in analyzing a heart's status by direct interpretation or through telemetry and those "precious seconds gained in bypassing" such "time consuming procedures" is pure hyperbole. Again, the contention t h a t "seconds count" m u s t be placed in a proper context relative to those rural reaches cited as potentially benefiting from the blind technique. Indeed, in controlled settings such as coronary care units (where all evidence supporting blind defibrillation has been gathered), seconds m a y count. But seconds become irrelevant to systems in which consumer entry, dispatch and arrival of first responders require m a n y minutes. Given the deficient resources of most rural systems, the time critical subsegment will usually place those with
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truly emergent dysrhythmic disease beyond salvabilit~ Even given the vast expenditure for safe, portable del:l brillators and the a r m y of electronic technicians to se~i~ ice them, little real impact o n m o r t a l i t y rate or c~i would be realizedl Software costs alone for appropri~l education and supervision of basic EMTs must be Pr~l hibitive to most present day ruralities. The authors' a~ sertion t h a t "the costs of emergency coronary care will be greatly reduced" is a lure at which m a n y raigit snap, soon finding themselves dangerously hooked ~vittI an inappropriate and overly expensive impediment to t~I real EMS needs of their community. Another real world consideration is experience, ie, t~e n u m b e r of field incidents per person. A recent survey hy the Departmenl: of Transportation tabulated over 250,00~ ambulance and rescue personnel nationwide, of wh0~ approximately 150,000 are basic EMTs, over 10,000 of these are "advanced." The majority are based in urb~ settings where are located most of those 350,000 people who die annually of coronary disease prior to accessi~ professional care. On t h e average, this would present each basic EMT with about one experience of certain le, thality every six months (if one assumes the impossible - - t h a t all such coronary seizures are witnessed and that prompt system access and response ~are universally as. sured). This ratio becomes even more dismal when takin{ into account Simon and Alonzo's 3~ observation that le$ t h a n one in four sudden deaths could be prevented ifa mobile coronary care unit were available in a reasonable a m o u n t of time. Given such an experiential dearth, er0. sion of skills must become the rule. In the development 01 their program, Adgey and Pantridge's 2~ teams did not re. suscitate a patient in the first three months of field oper. ation - - a total t h a t would probably exceed the number of resuscitations by an EMT during a lifetime of service inI the r u r a l i t y . As cited in the s t u d y by Winchell andL Safar, 22 only 12% of trainees performed adequately three months after lecture demonstrations and only 30% performed adequately after intensive practical supervision. From these experiences and those of all others who have addressed this issue, it is obvious t h a t the denominat0~: of success is inversely proportional to the magnitude of shortcomings in training, retraining and/or the lack of opportunity to continuously apply skills. Etsell and Smock's premise t h a t lives m a y be saved by prompt action is, of course, the cornerstone of emergency medicine. We all believe t h a t innovation in any aspect 0it resuscitation m u s t be aggressively pursued. However, the ultimate efficacy of any method in medicine depends upon its inherent risk: reward relationships. Whether blind defibrillation by basic EMTs will eventually, if ever, prove to be an "appropriate" recommendation re. quires extensive prospective evaluation .under the utm0st scrutiny. We have made too much progress at too great a price to risk accepting a suggestion t h a t tasks heretofore done by e x t r a o r d i n a r y p e r s o n n e l now be relegated to those of r a t h e r ordinary qualifications. The palate of quality simply cannot be satisfied by a preoccupati0n with frosting before the cake has been baked.
Cleve Trimble, MD, FACS, JACEP Editorial Board Reference numbering corresponds to references followi~ Etsell-Smock article.
July 1976 , , ~ P