EMS/Medic One doctor talks reasons for survival success

For National Emergency Medical Services (EMS) week (May 21 – 27), we’re honoring the local heroes that make up our EMS/Medic One system in King County. Each day, we’ll be sharing a unique perspective on saving lives from the people doing this work every day.

Rea, Thomas EMS week 052617
Dr. Tom Rea, King County Emergency Medical Services Program Director

On this final look at the EMS system for the week, we asked Dr. Tom Rea, Emergency Medical Services Program Director for King County, to wrap it up with a look at how our system works together to save lives and provide excellent care wherever you go in the county.

In addition to his role with King County, Dr. Rea works clinically at Harborview Medical Center where he is a University of Washington Professor of Medicine. He’s dedicated his career to improving care for emergency conditions.

What constitutes a good EMS system?

The key to your question is the word “system.” For example, consider a serious motor vehicle crash where there are multiple injured persons. Many take it for granted but consider what happens: there is a 9-1-1 call to the emergency dispatch which triages the event and sends appropriate resources. These resources often include law enforcement, firefighter-EMTs, and paramedics who will undertake a series of timely and coordinated actions that keep the scene safe, efficiently extricate the patients from the wreckage, quickly assess each patient and make expert interventions to provide life-sustaining therapies, inform the hospital so they can be poised with appropriate resources, and navigate the prehospital environment to arrive at the hospital…with the expectation to return to the station and do it all over again in a consistent and expert manner.

So when we think about what makes a good EMS system, we are really asking a two-fold question: how well does a given organization perform their individual assignment and how well do organizations work together. In King County, we are very fortunate because all of the professional emergency system stakeholders appreciate that the total can be greater than the sum of the parts when we consider a high-performing EMS system. The individual organizations understand that the best EMS systems function as a high-performing team, where each stakeholder makes the other just a bit better.

Are there key design features in the King County that help it succeed as a system?

In King County, we have a true tiered system whereby EMTs respond to all calls and highly-trained paramedics respond to a subset of the more critical patients. This tiered approach enables our system to deliver very efficient and effective EMS care. The response strategy has fostered strong EMT involvement that provides high-quality foundational care for all patients while enabling King County paramedics to become some of the world’s most-experienced prehospital critical care clinicians. And evidence has repeatedly indicated, increasing experience corresponds to clinical excellence – and our EMS providers are some of the most experienced in the world.

If we take a step back, the first tier of professional response is really the 9-1-1 communications center which applies a criteria-based assessment to send resources and when appropriate deliver lifesaving instructions over the phone. The EMTs are the next tier and are truly some of the best EMTs in the world. They arrive first to the scene and are experts at patient assessment and basic life support. These initial steps are critical in identifying and treating illness, and enable the next tier – the paramedics – to efficiently deliver critical-care interventions that can stabilize patients and sustain them to the hospital. In each instance, the preceding tier “sets the table” for the subsequent tier. If any of these stakeholders comes up short, the next steps for the patient will suffer. Because of this true interdependence, each tier is continuously accountable as part of the teamwork required to achieve optimal patient outcomes.

People often talk about “world-famous Medic One.” Can you explain what is meant by Medic One?

I think some of what constitutes Medic One is described by the aforementioned team approach. But if we trace it back to its roots, Medic One began almost 50 years ago when public service joined forces with traditional medicine – Chief Gordon Vickery of the Seattle Fire Department and Dr. Len Cobb of the University of Washington and Harborview – moved forward with their vision to provide the citizens of King County with the very best prehospital emergency care.  Their plan was to bring together the Fire Department model of operational excellence with the medical model of clinical assessment and health outcomes. This strategy leverages operational excellence but takes it one step further to determine how operations and critical decision making affect clinical outcomes and ultimately impact the public’s health. The Medic One model critically examines the who, what, why, how, and when of operations to understand if and how to improve the patient’s outcome. We make no assumptions and challenge one another to think about what’s next – how can we as a system get better?

Can you provide some examples?

Certainly, there is our core metric condition of cardiac arrest resuscitation. We have long been committed to measuring and improving how we care for persons suffering cardiac arrest. Cardiac arrest is a condition that is almost always fatal without a coordinated and expert emergency response. Resuscitation from cardiac arrest is one of the most difficult scenarios that challenges each operational stakeholder (lay citizen, dispatch, law enforcement, EMT, paramedic, and hospital) to be at their best. Each of these resuscitation participants has a formative role that has evolved over time.

We have learned so much by evaluating all the details of care and clinical outcomes.  The advances in understanding have translated over many years of effort to outstanding survival. Each year in King County, over 200 persons are successfully resuscitated from clinical death to return to a full life – most returning home ready to regain full health.  Few systems in the world can rival this success. And yet, the King County system must strive to get better.

There is a range of critical conditions that we measure with the goal to understand how we can improve patient outcome. For example, the EMTs in the fire departments across King County have worked very hard over the last several years to accurately determine serious allergy/anaphylaxis and treat quickly and correctly with epinephrine. Such treatments can be lifesaving. We review each of these cases as part of quality improvement to identify where we can refine even just a bit to make things even better. We are also working hard to incorporate new treatments for acute major stroke that requires early identification and triage for the sickest stroke patients. The EMTs and paramedics have fully embraced the more sophisticated stroke assessment and care strategy; we work every day to match each patient with the best care.

What are the biggest challenges to EMS here in King County? 

We first need to consider context: King County has one of the finest EMS systems in the world, so we should work hard to preserve and strengthen its core commitment to accountability, measurement, and improvement. The participants of the team involve citizens, emergency dispatch, law enforcement, fire department EMT, paramedic, private ambulance, and hospitals. All these groups work together to place the patient first, and we need to stay true to this interdependent team concept that prioritizes clinical outcomes. Thus we need to evaluate change – as often change in one domain will have unexpected or even unintended consequence. We need to be both innovative but also discerning as our EMS evolves to improve.

I think perhaps this is the challenge then – to maintain our regional approach to EMS here in King County. The dispatch, EMTs, and paramedics are trained to common and high standard through a range of resources including King County EMS, University of Washington Paramedic Training, and perhaps most importantly the commitment and effort by the individual EMS organizations. There is friendly rivalry across EMS organizations but also a willingness to share best practices and help neighbors. I see this collaboration currently as multiple stakeholders work together to deliver the best curriculum to train new EMTs. We are better as a collective who works together and relies on one another.

As a consequence of this regional dynamic, we have an equitable EMS system that provides the very best care to each person when an emergency occurs. This approach has enabled prehospital excellence throughout all of King County. My hope is that we can strengthen these regional relationships as we look to advance emergency medical care here in King County.

Featured image via StopCRP1st.

Originally posted on May 26, 2017.