Stroke Destination: An Opportunity for Innovation in System Design

Clinical Scenario:

In June, we posted the following scenario for comment:

EMS is called to the scene of a “possible stroke”.  The patient is a 75 yo female who was last known normal at 8 pm the night before when she went to bed with plans to watch TV before going to sleep.  She fell when she tried to get out of bed at 7 am.  Her daughter lives with her and heard her fall. When she came into the room, she noted that her mother had a right facial droop, right arm and right leg weakness. She also was unable to speak coherently.  The ambulance arrives on scene at 7:30 am and the EMT performs a Cincinnati stroke scale and confirms the findings reported by the patient’s daughter.   

The patient lives 20 minutes away from a community hospital which is designated as a primary stroke center.  The comprehensive stroke center with endovascular capability is located an hour away.

Where should the patient be taken?  What pre-notification alarm bells should be rung?  What criteria should EMS systems use to make these transportation decisions in a way that best serves patients without overburdening both the EMS system and comprehensive stroke centers?

We got many thoughtful comments on the above scenario that highlight the complexity of the systems-of-care decisions that face EMS on a local, regional and national level.

Background:  The Changing Landscape of Stroke care

Only incremental changes in stroke treatment occurred after the approval of IV tPA in 1996 which established a 3 hour window for IV thrombolysis.  After publication of the European trial ECASS III in 2008, the window extended to 3-4.5 hours.   But in 2015, a number of clinical trials were published that dramatically increased the management options available for the treatment of stroke patients and challenged the EMS community to change their destination protocols for stroke patients.  These 5 trials, MR. CLEAN, ESCAPE, SWIFT-PRIME, REVASCAT, and EXTEND-IA,  demonstrated that patients with NIHSS > 6 and proven large vessel occlusion by CT-angiogram may benefit from endovascular reperfusion therapy if they present within 6 hrs of stroke onset [1,2,3,4,5].   A subsequent metanalysis (HERMES) concluded that there may be potential benefit out to 7.3 hours after stroke onset [6].

Similarly to trauma centers, stroke centers are not all equivalent:

-        Primary stroke centers (PSCs) provide good stroke care and intravenous tPA

-        Thrombectomy-capable PSC can do everything a PSC does, but also has the capability to perform mechanical thrombectomy

-        Comprehensive Stroke Centers (CSC) have all of the above, plus extensive resources managing the most complicated patients with dedicated Neuro ICU, neurosurgical services, research and educational resources. 

Given the different capabilities of potential destinations, two main issues complicated EMS transport considerations:

(1)   To be eligible for endovascular therapy patients had to have a proven large vessel occlusion on CT angiogram. EMS needed to screen effectively for large vessel occlusions in the field using physical exam.  A number of scales were developed for this purpose, with varying and less than optimal sensitivity and specificity [7-14, Table 1].

(2)   Most of the patients in the above trials received tPA prior to going to endovascular therapy.  In many areas, bypassing a primary stroke center capable of administering tPA in favor of going directly to a comprehensive stroke center would place patients out of the tPA window.

Table 1:  Sensitivity and Specificity for Prehospital Screens for Large Vessel Occlusion

Above and beyond this, getting the right patient to the right place at the right time also included considerations for not overburdening Comprehensive stroke centers and excluding primary stroke centers.   Primarily in response to the above, the Mission: Lifeline Stroke was formed and  developed a Severity-Based Stroke Triage Algorithm for EMS to balance the competing demands of time to tPA, access to endovascular capability and overtriage/undertriage to comprehensive stroke centers.

While EMS was still collaboratively identifying best-practices for patients with possible LVO presenting within 6 hrs of last known normal, two other studies were published last summer which again challenged us reexamine our stroke process of care by extending the time window of patients eligible for endovascular treatment. 

The DAWN trial was a prospective, randomized, open-label clinical trial comparing thrombectomy plus standard care vs. standard care [15]. The trial included patients with the following characteristics:

• Last known well between 6 to 24 hrs
• NIHSS > 10
• Imaging-confirmed large vessel occlusion (ICA or proximal MCA)
• Mismatch between severity of clinical deficit and the infarct volume as determined by perfusion imaging.

The trial found a significant difference in functional independence at 90 days (49% for thrombectomy arm, 13% for standard care, p < 0.001) but no difference in 90 day mortality.

The DEFUSE-3 trial  was a randomized, open-label trial with blinded outcome assessment that compared thrombectomy + medical therapy vs. medical therapy alone [16].  The trial included patients with:

• Last known well between 6 to 16 hrs
• NIHSS ≥ 6
• Imaging-confirmed large vessel occlusion (ICA or proximal MCA)
• Initial infarct size of < 70 ml
• Evidence of salvageable ischemic tissue on perfusion imaging defined as ratio of the volume of ischemic tissue on perfusion imaging to infarct volume of ≥1.8

Similarly to the DAWN trial, DEFUSE- found a significant improvement in functional independence at 90 days (endovascular therapy 45%, medical therapy 17%, p < 0.001).

Both trials included patients with severe deficits.  Mean and Inter-quartile range NIHSS for patients receiving thrombectomy in the DAWN and DEFUSE-3 trials were 17 (13-21) and 16 (10-20), respectively   

These trials present several new challenges for EMS transport decisions:

(1)   Patients who are clearly ineligible for IV tPA are included, leading to less competition between transport time to comprehensive stroke center (CSC) and tPA eligibility for a significant proportion of stroke patients.

(2)   The time criteria are broadened and include the very important population of “wake-up” strokes which made up a significant proportion of the LVO stroke population in the above trials. While broadening the population of patients to be screened for eligibility for endovascular therapy, the criteria are actually very narrow and imaging-based, increasing the possibility of a significant amount of over-triage to comprehensive stroke centers. In one retrospective review of all patients with acute ischemic stroke presenting to a Comprehensive Stroke Center only 1.7% of all patients would have qualified for DAWN enrollment with an additional 0.6 – 1.0% meeting DEFUSE-3 criteria. [17]. Moreover, while CT angiogram may be available at many primary stroke centers, the imaging software (like was utilized for patient selection in both DAWN and DEFUSE III) to evaluate perfusion is unlikely to be.

The comments we received on this post presented a number of responses and potential solutions to these challenges.

 

Comment Review:  The Brainstorming Phase and Regional Solutions

The Right Patient

 Dr. Aurora Lybeck made several great comments on this post.  She made the very important point that the first step in patient identification starts with the EMT or paramedic at the patient’s side.  Stating that “we shall use X… “ to screen for LVO without providing appropriate education and feedback to the provider at the patient’s side will decrease the sensitivity, specificity and utility of validated prehospital LVO screens:

 “I think there are a few questions to answer before considering if we SHOULD as EMS to screen for LVO strokes and bypass PSCs for CSCs. 1) Can EMS reliably screen for LVO strokes and 2) What benefit is bypassing PSCs and going straight to a CSC going to have to the patient (a small margin of benefit or a large clinically significant benefit) and 3) what is the acceptable over-triage rates at the CSCs?

With regards to training, we can gather some of the evidence that demonstrates that EMTs can successfully perform one of the screening tests (LAPSS, CPSS, LAMS, RACE, or even a full NIHSS), but the implementation of that in a real-life EMS system with not just new training and competency expectations, but also embedded in a new protocol and transport guidelines that can sometimes be confusing depending on geography etc. If you are one medical director and/or educator and have hundreds of EMTs/paramedics, how are you going to adequately train them all? Have them practice the exam? Ensure competency? Scenarios or simulation? It may be possible with a smaller service or one with robust education but in reality, it's an important skill that requires not just skill training but critical thinking and a high degree of clinical competency.” – Aurora Lybeck

 If system-design changes are to succeed, they must include plans for involvement and education of the field provider if they are to effectively improve patient outcomes.

 The Right Place at the Right Time

From a system standpoint, the outcome benefit of endovascular therapy for a very select group of patients must be balanced with resource utilization within the system as a whole.  While it is easy to say that every potential LVO should go to a Comprehensive stroke center, this “transport intervention” could come with a significant amount of unnecessary overtriage that may overburden already-overcrowded centers and add significant cost to the system.

Several of the commenters specifically addressed the issue of over-triage to comprehensive stroke centers.  While there was general consensus that embolectomy candidates should be taken to CSC, there was variability in what their path to the stroke center should be.  In some cases, it was felt that prehospital LVO scale was sufficient to warrant PSC bypass.  In others, there was consideration whether the role of the PSC could still play a critical role in the care of these patients by offering a “secondary screen” in which imaging criteria was used to further narrow embolectomy candidates in such a way that significant time was not lost. While in the end this will vary by region structure and resources, these comments highlight the importance of considering different solutions to the same problem, implementing effective system metrics and measuring patient outcomes:

“If the patient has signs and symptoms of a large vessel occlusion than bypass the primary stroke center for the comprehensive stroke center because tpa alone at the primary may not be effective against the large clot and clot retrieval will be needed anyway, I think???” – Kyle

 “RACE LAMS or CPSSS positive for LVO need to go to a comprehensive center. These are the prehospitally validated scales for LVO. If it is to far or time intensive call the helicopter. We are happy to help because time is brain and minutes matter.” – Bill K

“What criteria should EMS systems use to make these transportation decisions in a way that best serves patients without overburdening both the EMS system and comprehensive stroke centers?
- Patient time since last known to be normal
- Willingness of comprehensive stroke center to be OK with a certain amount of over triage.” – Greg Friese

“RACE LAMS or CPSSS positive for LVO need to go to a comprehensive center. These are the prehospitally validated scales for LVO. If it is to far or time intensive call the helicopter. We are happy to help because time is brain and minutes matter.” – Bill K

“We have to be careful when considering this question and come to an answer in a vacuum. EMS triage and destination is critical. But those decisions need to be made in the context of the system of care in region. A regional system of care where the primary stroke center (PSC) can perform a CTA immediately on arrival and upload it to a cloud based imaging viewer that the comprehensive stroke center (CSC) can also immediately review allows the PSC to perform the critical initial function of identifying those that are candidates for embolectomy. Add that to a system where inter-facility transport can be rapidly secured or even auto-launched, the OR can be mobilized ahead of patient arrival, and the patient can be brought directly to the OR at the CSC, and the initial medical contact by EMS to CSC groin puncture time will likely be the same or even less than if the patient was triaged pre-hospital to bypass the PSC and go to the CSC. If too many patients get triaged prehospital to the CSC, then the CSC's resources (personnel, scanners, ED beds, neuro beds) may be overwhelmed and their ability to provide care to their LVO-strokes will be compromised. If there is no LVO or they have an LVO, but aren't a candidate for embolectomy based on the initial imaging acquired, they can be cared for just as well at the PSC as at the CSC in most cases.” - Chris Zammit

“Great discussion!
In this patient with wake up stroke I would transport to PSC first. Although she does have a LA Motor Score/CSTAT and RACE concerning for LVO she is a wake up and would need both a primary stroke work up (CT to evaluate for hemorrhage and CTA head and neck to identify if she has LVO lesion) It the CTA is positive then perform CTP or DWMRI to evaluate if she fits the criteria set fourth by the DAWN trial or DEFFUSE 3 for reperfusion. I believe most of this can be done at the PSC if there is a prior algorithm with EMS and cooperation for door in door out transfer direct to intervention to the CSC if she has an LVO and fits criteria.” – Rob Dickson

“So, if we decide that based on the evidence, an EMT can indeed be taught the chosen LVO screening exam and can indeed implement it within a new stroke transport destination protocol and can retain the skill and demonstrate competency over time, now how is that implemented in a given service or area? Some protocols will suggest a given time guidelines (ie if there is a CSC within 30 min, or bypassing a PSC would not extend the patient's ED arrival more than 20 minutes for example). But there is little to no evidence to guide us on how to geographically on transport- not to mention the reality of time estimates that many of us recognize from practicing in the field. If you plop yourself at any given residential address within your service area, do you know exactly how far you are from the closest PSC? CSC? The difference between those sites? Are they supposed to pull up a map with estimated arrival times and calculate the difference? There is so much subjectivity there, it's worth considering all the possible scenarios before implementing a change as important as bypassing a PSC. For some areas, it's a moot point. Where I trained in residency and in fellowship, we were in major metropolitan areas, where a CSC is rarely more than 15-20 minutes away. Unless your PSC is in the complete opposite direction and you're on the edge of the city, there is likely more to gain and less to lose by choosing the CSC over the PSC- as long as that CSC is willing to accept a lot more stroke patients, knowing that EMS may just default to the "easy" decision of bringing all stroke patients to the CSC (not saying it's the right decision, but with complex decision making we know the easiest generalization is often chosen regardless of the protocol minutiae). However, I currently practice in a more rural and suburban area, where the CSC may be over an hour away. For many of our services, it wouldn't make any sense to implement screening and new protocols for LVO occlusion when their closest local facility is a PSC and transporting to the CSC would be a delay long enough to exclude some patients from receiving TPA if they are not interventional candidates- those patients are much better served being brought to the local PSC, treated with TPA if eligible, and transported to the CSC for intervention if indeed an LVO and eligible for endovascular intervention- ie the model we are currently using.” – Aurora Lybeck

One other consideration for transport time is patient stability balanced with the clinical skills/training of the field provider:

“Where should the patient be taken?
If I am in the story as an EMT ... I am going to the nearest hospital. An hour feels like a long time to be with a patient who potentially needs ALS interventions.” – Greg Friese

“Agree with Greg as well that there are considerations of long transport and risk of airway compromise so provider level of training and capability has to play a role. Also we must consider geographic location and strain on resources from having a truck out of service for 3 hours on this transport.
Lot's depends on geography and capabilities of your particular system” - Rob Dickson

In his expert review of this post, Dr. Pete Panagos (Co-Chair of Mission:Lifeline Stroke) wrote the following:

“A big issue also to at least mention is door-in-door-out (DIDO) from PSC to CSC.  IF the decision is to always go to nearest/closest stroke center, then the PSC, and EMS, must be committed to rapid identification, evaluation and transfer out, literally within 30-60 minutes of arrival and/or decision to transfer.“

Don’t Forget the Basics…

 “Overall, while I think the prospect of identifying LVOs in the field accurately and transporting them to the most definitive care/CSC is exciting and their expedited treatment and recovery is a clinically important outcome to focus on, I don't want to lose sight of excellent basic stroke care for all patients. For high functioning urban systems with robust education and training that can implement such new screening skills and protocols, maintain competency, and demonstrate success in patient outcomes and acceptable over-triage rates to the CSCs, I think it's great. For most other services though, I think that time in education and emphasis is best spent on excellent basic prehospital stroke care- timely, accurate, checking a glucose and performing a basic Cincinnati stroke scale, appropriate monitoring, sending a stroke alert to the nearest appropriate facility, and bringing the patient straight to CT for the ED team to jump into action. Who knows, maybe someday our more rural services will start identifying LVO strokes and utilizing our HEMS services to get them to a CSC in the future. Thank you to everyone out there putting the time and passion into researching, implementing and closely QA'ing these new clinical changes. Looking forward to the research that will come out of all the systems out there implementing LVO screening by EMS, and certainly hope to see a significant clinical benefit to patients!

For reference and example, here are some Wisconsin LVO protocols currently in use:
-Milwaukee's (using BEFAST): http://county.milwaukee.gov/ImageLibrary/Groups/cntyOEM/EMS/Standards-of-care/Cardio/Stroke2018.pdf
-Madison/Dane County's (using FAST-ED, see page 73): https://em-ems.countyofdane.com/documents/pdf/2018%20DRAFT%20EMS%20Protocols%20-%20DRAFT/DCEMS%20Protocols_%203.9.18%20FINAL%20(web).pdf
-LaCrosse/TriState (using FAST-ED, see page 28): http://www.tristateambulance.org/documents/TSA%20Medical%20Guidelines.pdf” – Aurora Lybeck

Last Words

 “Why would it be necessary for EMS to make this decision alone? Call stroke alert and report to online medical control” – Mario

Prehospital stroke care does not exist in isolation. The advent of endovascular therapy for stroke challenges the specialty of EMS to  take innovative approaches to system design that incorporate best evidence to improve patient outcomes while balancing the strain on resources.  The best solutions will consider regional factors, focus on field provider education and value comprehensive quality improvement initiatives that acknowledge the critical role of the EMS provider in the stroke care continuum.

Discussion Summary by EMS MEd Editor, Maia Dorsett MD PhD (@maiadorsett)

Peer Reviewed by Peter Panagos, MD (@panagos_peter)

References:

 1. Berkhemer, O. A., Fransen, P. S., Beumer, D., Van Den Berg, L. A., Lingsma, H. F., Yoo, A. J., ... & van Walderveen, M. A. (2015). A randomized trial of intraarterial treatment for acute ischemic stroke. New England Journal of Medicine, 372(1), 11-20.

2. Goyal, M., Demchuk, A. M., Menon, B. K., Eesa, M., Rempel, J. L., Thornton, J., ... & Dowlatshahi, D. (2015). Randomized assessment of rapid endovascular treatment of ischemic stroke. New England Journal of Medicine, 372(11), 1019-1030.

3. Saver, J. L., Goyal, M., Bonafe, A., Diener, H. C., Levy, E. I., Pereira, V. M., ... & Jansen, O. (2015). Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. New England Journal of Medicine, 372(24), 2285-2295.

4. Jovin, T. G., Chamorro, A., Cobo, E., de Miquel, M. A., Molina, C. A., Rovira, A., ... & Millán, M. (2015). Thrombectomy within 8 hours after symptom onset in ischemic stroke. New England Journal of Medicine, 372(24), 2296-2306.

5. Campbell, B. C., Mitchell, P. J., Kleinig, T. J., Dewey, H. M., Churilov, L., Yassi, N., ... & Wu, T. Y. (2015). Endovascular therapy for ischemic stroke with perfusion-imaging selection. New England Journal of Medicine, 372(11), 1009-1018.

6. Goyal, M., Menon, B. K., Van Zwam, W. H., Dippel, D. W., Mitchell, P. J., Demchuk, A. M., ... & Donnan, G. A. (2016). Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. The Lancet, 387(10029), 1723-1731.

7. Nazliel, B., Starkman, S., Liebeskind, D. S., Ovbiagele, B., Kim, D., Sanossian, N., ... & Duckwiler, G. (2008). A brief prehospital stroke severity scale identifies ischemic stroke patients harboring persisting large arterial occlusions. Stroke, 39(8), 2264-2267.

8.  de la Ossa, N. P., Carrera, D., Gorchs, M., Querol, M., Millán, M., Gomis, M., ... & Escalada, X. (2014). Design and validation of a prehospital stroke scale to predict large arterial occlusion: the rapid arterial occlusion evaluation scale. Stroke, 45(1), 87-91.

9.  Katz, B. S., McMullan, J. T., Sucharew, H., Adeoye, O., & Broderick, J. P. (2015). Design and validation of a prehospital scale to predict stroke severity: Cincinnati Prehospital Stroke Severity Scale. Stroke, STROKEAHA-115.

10.  Kummer, B. R., Gialdini, G., Sevush, J. L., Kamel, H., Patsalides, A., & Navi, B. B. (2016). External validation of the cincinnati prehospital stroke severity scale. Journal of Stroke and Cerebrovascular Diseases, 25(5), 1270-1274.

11.  Lima, F. O., Silva, G. S., Furie, K. L., Frankel, M. R., Lev, M. H., Camargo, É. C., ... & Nogueira, R. G. (2016). Field assessment stroke triage for emergency destination: a simple and accurate prehospital scale to detect large vessel occlusion strokes. Stroke, 47(8), 1997-2002.

12.  Hastrup, S., Damgaard, D., Johnsen, S. P., & Andersen, G. (2016). Prehospital acute stroke severity scale to predict large artery occlusion: design and comparison with other scales. Stroke, STROKEAHA-115.

13.  Demeestere, J., Garcia-Esperon, C., Lin, L., Bivard, A., Ang, T., Smoll, N. R., ... & Parsons, M. (2017). Validation of the National Institutes of Health stroke scale-8 to detect large vessel occlusion in ischemic stroke. Journal of Stroke and Cerebrovascular Diseases, 26(7), 1419-1426.

14.  McMullan, J. T., Katz, B., Broderick, J., Schmit, P., Sucharew, H., & Adeoye, O. (2017). Prospective prehospital evaluation of the Cincinnati stroke triage assessment tool. Prehospital Emergency Care, 21(4), 481-488.

15. Nogueira, R. G., Jadhav, A. P., Haussen, D. C., Bonafe, A., Budzik, R. F., Bhuva, P., ... & Sila, C. A. (2018). Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. New England Journal of Medicine, 378(1), 11-21.

16. Albers, G. W., Marks, M. P., Kemp, S., Christensen, S., Tsai, J. P., Ortega-Gutierrez, S., ... & Sarraj, A. (2018). Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. New England Journal of Medicine, 378(8), 708-718.

17. Jadhav, A. Desai, S., Kenmuir C, Rocha, M, Starr, M, Molyneaux, B, Gross, B, Jankowitz, B, Jovin, T. (2018).  Eligibility for Endovascular Trial Enrollment in the 6- to24- hour time window: Analysis of a Single Comprehensive Stroke Center. Stroke. 49:00-00.

Article Bites #4: Learning from the Military - Association between Prehospital Blood Product transfusion & survival for Combat Casualties

Article:

Association of Prehospital Blood Product Transfusion During Medical Evacuation of Combat Casualties in Afghanistan With Acute and 30-Day Survival

Shackelford SA, Del junco DJ, Powell-Dunford N, et al. Association of Prehospital Blood Product Transfusion During Medical Evacuation of Combat Casualties in Afghanistan With Acute and 30-Day Survival. JAMA. 2017;318(16):1581-1591. [PMID: 2906742]

Background & Objectives:

Given that hemorrhage is the leading cause of death in patients suffering from severe traumatic injuries, the utility of prehospital blood product transfusion has been a highly debated topic. Despite the important role of early transfusion in the management of hemorrhagic shock, the majority of published data at this time has shown inconclusive findings with regards to survival benefit from prehospital blood product transfusion, particularly within civilian trauma systems. Many of these studies suffered from significant flaws, and therefore, the verdict is still out on the role of prehospital transfusion. The purpose of this study was to address these deficiencies in the medical literature by studying the effect of prehospital transfusion within the context of the US military experience on MEDEVAC aircraft in Afghanistan. More specifically, the authors of this manuscript wanted to study the following question: Is prehospital blood product transfusion among military combat casualties associated with improved survival at 24 hours and at 30 days?

Methods:

The investigators conducted a retrospective cohort study of US military combat casualties in Afghanistan between April 1, 2012 and August 7, 2015. Patients were recruited from the Department of Defense trauma registry, the prehospital trauma registry, and the Armed Forces Medical Examiner System Database. Inclusion in the study was predicated on the following criteria being met: 

1.     US military service member who survived until MEDEVAC rescue from point of injury AND

2.     At least 1 of the following criteria for prehospital transfusion for severe trauma 

· 1 or more traumatic limb amputations with at least 1 amputation located above the knee or elbow OR 

· Hemorrhagic shock defined by systolic blood pressure <90 mmHg or heart rate >120 beats per minute 

The interventions that were examined were 1) initiation of prehospital transfusion (red blood cells and/or plasma) and 2) minutes from MEDEVAC rescue to initiation of transfusion regardless of setting (i.e. in the field vs surgical hospital). As stated earlier, the key outcomes that were examined were survival at 24 hours and at 30 days. Interestingly, the investigators compared individuals who received prehospital transfusion to nonrecipients of prehospital transfusion. These individuals were frequency matched based on 5 characteristics including mechanism of injury, prehospital shock, type and severity of traumatic limb amputation hemorrhagic torso injury assessed by Abbreviated Injury Scale (AIS) and finally severity of head injury assessed by AIS score. Using Cox regression analysis, further stratification was performed and adjusted for age, injury year, transport team, tourniquet use and time to MEDEVAC rescue. 

Key Results:

During the specified time frame of the study, there were 502 casualties who met inclusion criteria. 55 individuals received prehospital transfusion vs 447 individuals who did not receive transfusion. Of these individuals who did not receive transfusion, 345 were frequency matched to prehospital transfusion recipients based on the characteristics mentioned above. The key findings were as follows:

With respect to the entire study population:

· Within 24 hours of MEDEVAC rescue, 3/55 (5%) of prehospital transfusion recipients died compared to 85/447 (19%) of non-recipients (between group difference -14%; 95% CI -21% to -6%; p=0.01). 

· Within 30 days of MEDEVAC rescue, 6 prehospital transfusion recipients died (11%) compared to 102 non-recipients (23%) (between group difference -12%; 95% CI -21% to -2%; p=0.04)

With respect to matched study cohorts:

· Within 24 hours of MEDEVAC rescue, 3 (5%) prehospital transfusion recipients died compared 69 (20%) matched non-recipients (between group difference -15%; 95% CI -22% to -7%; p=0.007)

· Within 30 days of MEDEVAC rescue, 6 (11%) prehospital transfusion recipients died  compared to 78 (23%) matched non-recipients (Between group difference -12%; 95% CI -21% to -2%; p=0.05)

With respect to survival analysis:

· Among the 386 patients within the matched groups, adjusted hazard ratios were calculated. The investigators reported the adjusted hazard ratio for mortality to be 0.26 (95% CI 0.08 to 0.84; p=0.02) within the first 24 hours. Within the first 30 days, the adjusted hazard ratio for mortality was 0.39 (95% CI 0.16 to 0.92; p=0.03). 

With respect to time to first transfusion:

· The study revealed that time to initial transfusion was associated with reduced mortality within 24 hours only up to the first 15 minutes after MEDEVAC rescue (adjusted hazard ratio 0.17 95% CI 0.04-0.73; p = 0.02)

Takeaways:

· For US military casualties in Afghanistan, prehospital blood transfusion was associated with a statistically significant improvement in survival at 24 hours and 30 days compared with a matched sample that received no prehospital transfusion. 

· Early prehospital transfusion was associated with improved mortality but only within the first 15 minutes of MEDEVAC rescue. 

What this means for EMS:

There is no question that civilian trauma care has been greatly influenced by lessons learned on the battlefield. While this study performed on MEDEVAC helicopters in Afghanistan supports the notion that improved mortality can be achieved with prehospital blood transfusion for hemorrhagic shock, the translation of these findings to EMS systems back home may be more challenging. For starters, the logistical implementation of prehospital blood transfusion would require massive utilization of precious resources. Refrigeration, coordination with blood banks and hospitals, and care as to avoid wasting of life saving blood products are few of the many obstacles to ubiquitous implementation of prehospital blood transfusion in the civilian EMS world. Furthermore, the advanced resuscitative capabilities of MEDEVAC aircraft may not always be readily available in civilian systems, which may have accounted for the improved mortality observed in the study. Overall, while the results from the study were extremely encouraging, more research needs to be done to evaluate the precise role of prehospital transfusion in civilian EMS settings. 

Mentorship Matters.

By Christopher Galton, MD NRP

When we start our EMS careers, the path forward seems easy.  You want to run every great call there is to run and you tell yourself that the path to becoming the best paramedic or EMT is through sticking tubes into people, covering up holes in the chest, and driving fast down the road.  After a few years, most of us realize that longevity in this career comes from being satisfied with the less sexy calls.  I was recently standing around with a group of EMS colleagues and we were talking about how the people that stay in this career don't depend on the drama to keep them going.  This discussion got me thinking about the value of mentorship.

My three.

Three very important people in my career shaped the paramedic and physician that I am today.   These three people helped guide me toward a healthy EMS career and are a large part of why I continue to work in EMS even though the cost to my personal life is frequently high.

My first medical director was one of the early Denver General paramedics.  After a long paramedic career, he went on to be a very successful emergency physician and eventually the EMS medical director of Colorado.  Arthur Kanowitz was the physician that introduced me to the idea that EMS patients don't need to suffer.  He believed that EMTs and paramedics had the ability to make positive impacts on the lives of every patient they interacted with.  In the late 1990s, the mindset in EMS was that pain medications were potentially dangerous and should be used in only the worst cases.  Dr. Kanowitz challenged that idea and pushed back against many powerful and prominent physician EMS leaders.  He did research on the use of prehospital analgesics and demonstrated both safety and efficacy.  He took that information to his colleagues and fought for what he believed in.  His passion for looking past the "emergency" part of what we do and treating ailments without regard to circumstance, continues to change EMS minds across the country.  Art is the reason that I am so passionate about treating pain and the reason that I will not stop preaching his vision until our collective performance is at a high level.  

The first "ALS chief" I ever worked for was another early Denver General paramedic named Jeff Forster.  Jeff was a legend in Denver as one of the best paramedics they ever turned out.  He was the type of guy that people turned to when things were going bad, and he was the paramedic that every other paramedic wanted to be, including a baby paramedic named Galton.  He was a legend for a variety of reasons, and he taught me an immense amount about not only EMS, but how to treat employees, how to lead by example, and the meaning of being a leader instead of a manager.  One day, when the world was blowing up, he hopped on an ambulance and we went on a call together.  After the call, he cleaned the back of my ambulance better than it has ever been cleaned before.  I told him that I was happy to clean up after myself and asked him why he not only cleans the floors of my ambulance so diligently, but still rides at all hours of the day taking any call that came his way.  He looked me square in the eyes and said one of the most impactful things I have every heard.  He said "never ask someone else to do something that you are not willing to do yourself."  He led by example, and of all the great people I have met over the course of my professional life, he stands out as someone that worked hard everyday to earn, and then maintain, the respect from those around him.  It did not matter whether they were the chief medical director, entry level paramedic, or housekeeping staff cleaning up at the end of the day.  He was always happy to help anyone do anything just to demonstrate that he valued them as much as we valued him.  To this day, if he called me for help, I would claw my way through a brick wall to help him without even a thought.  

Finally, I want to end with the person that had the most significant impact on the way I operate as a paramedic today.  Thom Hillson (aka Thom Dick) is a columnist for multiple different EMS magazines and journals.  He has written books about caring for patients and fellow EMS colleagues.  To this day, I have never met another human being that cared more for every other living sole in this world.  I started off my EMS career working the night shift for eight years, and I loved it.  One of the drawbacks of the night shift is this creeping cynicism that becomes suffocating because of the typical clientele that make up your regular call volume working in an urban/suburban EMS system.  I had the pleasure of working with Thom for 4-5 years early in my career when I was an impressionable paramedic.  I remember thinking he was a wise old sage that had been everywhere and seen everything.  The two of us developed a wonderful relationship and he ended up writing me the best letter of recommendation for medical school that I have ever seen.  

One day Thom pulled me aside and asked me to go grab lunch with him and he was the type of guy that you wanted to be around all the time, so I was thrilled.  While we were out eating, he asked me if everything was all right.  Initially I thought this was just banter, but he continued to say that he was worried about me.  He had noticed a deterioration in my typically positive, upbeat attitude.  I told him about being a little depressed lately because of some bad outcomes and how I was likely going through a period of burn out, but I really just tried to blow it off.  He did not let up and we proceeded to have lunch weekly for the next few months.  During those lunch meetings, Thom and I talked about a wide variety of things, many times not mentioning EMS at all.  It was at one of these meetings that he used a phrase that has stuck with me to this day and is ever present when I am working in EMS.  We were talking about customer service in EMS and why I was worried that I stopped caring about my patients.  He specifically challenged me by saying "why not."  What he meant by that was much more complicated than I initially appreciated.  He was really asking why I was not willing to go the extra mile anymore to take care of people and why was I staying in this job if that was the case.  This was the point that I realized that a career in emergency services is not about you, it's about the people that need you.  This is when I finally understood that being an EMS professional was not about the person that could put an endotracheal tube in upside down with a patient stuck in a car that was hanging off a cliff in a snowstorm.  It was about knowing that someone is calling 911 because they need your help.  That might be taking them to the hospital because they are having chest pain, but it also might mean helping them clean up after falling on the way to the toilet.  You don't get into this career because you want to help an elderly person change out of urine soaked clothes and then start a load of laundry.  You do stay in this career because you realize that those are the patients that need your help the most and you are the person that they turned to in their moment of need.  I would encourage you to take Thom's advice and ask yourself "why not"if you ever have a question about customer service and the needs of the citizens that we are charged to care for in their time of crisis.

 

Finding the Right Mentor

My mentors are a large part of why I have been able to achieve professional success and reach goals that I would have thought were out of reach.  Most high level leaders at Forutne 500 companies insist that their employees have mentors and embrace those relationships while accepting the lost time required to build them.   They know that they will get more out of their employees in the long run when mentees have goals, purpose, and guidance. 

I’m sure you have all heard the phrase “it’s not what you know, it’s who you know.”  Your mentor is the “who” in that expression that is capable of opening doors and making connections on your behalf.  My mentors have frequently made phone calls, sent emails, and made personal introductions to connect me with the right people.  That is how business is done and you should not be embarrassed to take advantage of those connections. 

Hopefully I sold you on the value of having a mentor in your professional life.  The first hurdle is finding the right mentor for you.  I think you need to start by identifying the personality traits that you want to emulate.  In EMS, those traits might include unconditional empathy, a calming demeanor, a driving desire to learn, or an altruistic belief in serving the community.  Your mentor should be someone who has established a benchmark for you to work towards.  

The second step is identifying people that you already have a connection to, that are 2-3 steps above you in the pile.  For instance, I am one of the Deputy Medical Directors of Monroe County.  If my professional goal was to become a Chief Medical Director of a county or region, then I would start by identifying people in those positions who would serve as good benchmarks for me.  They are doing the job that I want to have, and are consistently demonstrating  their success in that position.

Step three is approaching the potential mentor.  You anxiety level should be pretty low.  This is not asking someone out of your league on a date or walking into your boss’s office to ask for a raise.  I’ll let you in on a little secret, any good mentor will be flattered that you have asked them to help you grow in your career.  By asking them, you are saying that you think they are doing something right and that they have the ability to guide you to success.  That is a pretty impressive compliment and if they don’t see that, then they are probably not a good mentor for you anyway. 

The final step is developing that relationship.  A potential mentor needs to know that you will value their input and put their advice to good use.  You are asking them to give up their valuable time to guide your forward in your career with little direct benefit for them.  Kathy Caprino, a columnist for Forbes, recently tackled the issue of finding a mentor and she takes it to the next level by saying that a potential mentor has “to like, trust and believe in you already.” She goes on to ask the question, “are you somebody you yourself would like to mentor?”  If you cannot answer yes to that question, then you need to work to become that person before you consider engaging a mentor.  

Mentorship should not be forced.  The relationship needs to develop organically without it being coerced.  This usually occurs during the initial few meetings where your mentor will start to help you set some goals and work on the things that need to occur for you to meet your goals.  A great mentor is someone who can inspire you when you need to be inspired and can put you in your place when you need to get leveled out.  If the relationship is not that strong, then that is not mentorship.  Your mother can be your cheerleader.  Your mentor fills the role of coach, cheerleader, friend, leader, and follower based on what you need, when you need it.  It is a special relationship that should be cherished.

A Productive Mentor-Mentee Relationship

So, now that you have a mentor, how do you turn that into a productive relationship?

When I work with my mentors or I have mentees, I always start with a face to face meeting.  This can be as simple as meeting for coffee, lunch, or some other informal setting.  Before you commit to this, you need to analyze the type of relationship you have or will have with your mentor/mentee.  I think the relationship between a medical student and the dean of the medical school would be different than the relationship between an EMT working through paramedic school and their paramedic preceptor.  Some meetings should happen during normal business hours in a traditional office setting, while some will happen in the corner pub after a long shift.  Where to meet up has a lot to do with the type of relationship that will develop.

The next step is preparing for your meeting.  In my case, that means developing a list of things I want to talk about in the weeks prior to the meeting, and then writing it down on a scrap sheet of paper that lives folded into my wallet until meeting time.  Your list does not need to kill a tree if you are smart enough to use your smart phone.  Maybe it is an email sent ahead of time or memorized if you did not get hit on the head with an oxygen bottle too often.  Even if your mentor makes fun of your list (mine does every time), having a list demonstrates that you value their time and you want to be productive during your meeting.

During your meeting, what type of things should you discuss.  In my mind, this meeting is broken up in three parts.  The first part is usually spent catching up with my mentor on a personal level.  Frequently I speak with my mentor or mentee about how things have been going because this is a relationship so it’s OK to invest into it and be human.  Any good mentor wants to know that their mentee is maintaining adequate priorities and perspective with everything going on, especially when things are getting really busy.  The second part is a review of the previous meeting and progress on the subjects that you discussed at the last meeting.  The premise of this relationship is based on the mentor providing guidance to the mentee, so they certainly want to hear about how you advanced the ideas that you both spoke of previously.  The final part is the new material and this is typically where the list comes into play.

In this busy world, everyone’s time is valuable.  By the time my meeting hits, I have usually thought through what I want to say about the previous subjects as well as the newer things I want to talk about.  It is OK and expected that your ideas are not refined, that is why you have meetings with your mentor.  Part of their role is to help you refine those ideas into viable actions.  A meeting should not be one sided and the mentor expects to have ideas bounced off them.  You should expect them to critique and suggest things that you had not considered.  Along those lines, it is OK to take notes during your interaction.  Any mentor should be flattered that you are writing their ideas down.  It shows that you value their opinions enough that you do not want to risk forgetting.

I have benefited greatly from having positive mentors in my life.  I continue to have multiple mentors today who both directly and indirectly inspire me to be the greatest paramedic, physician, medical director, anesthesiologist, intensivist, coach, and friend that I can possibly be.  If only they could help me find some time to sleep …

The text above first appeared as a three part series in the University of Rochester Division of Prehospital Medicine Newletter.