By Niall McCormack.
Innovation is the lifeblood of many industries. It is the key driver that enables companies like Tesla, Facebook and Apple to continue their dominance of the tech scene. New innovations are heralded, branded and sold as soon as possible to stay ahead of their competitors. However, some industries, while still reliant on innovation, can be very slow to introduce these changes. A perfect example is healthcare. Any new drug or procedure must be tested, retested and tested again to comply with strict regulatory guidelines. Historically, change has always been quite slow in medicine, even when the change can lead to significant improvements for patients. There is a fear that changes that at first appear beneficial, may prove over time to lead to worse outcomes for patients. There is also another factor to consider. The medical profession has a long and proud history. Unfortunately, the weight of history can often stifle innovation. One area that has cast off the shackles of history, embraced innovation and undergone major changes in Ireland, and around the world, over the past few years is the area of pre-hospital emergency medicine. For this post, I will focus on one area; the response to cardiac patients.
For many years in Ireland, a heart attack was a death sentence for many. Because of our desire to own a house on our own piece of land, it often meant that our nearest neighbour was a few hundred metres away. This is a major problem for the provision of an ambulance service and results in long waiting times and stress for both patients and responders. When the ambulance arrived, the main treatment included oxygen for the patient and diesel of the ambulance. If things worsened, the patient could stop breathing and their heart could stop beating. The only treatment for this is CPR and defibrillation. If either of these treatments are not given quickly, the person will die. Quite simply, this is the sickest patient you can get.
So, a quick bit of history to set the scene. In May 1967, 24 men gathered at Ratra House, Phoenix Park for the first ever ambulance training course in Ireland. Up to this point, "ambulance drivers" were selected from a pool of local authority drivers and had no formal training. They would drive to the local hospital, collect a nurse, then drive to the scene of the emergency to collect the patient. For the following 30 years, progress was slow. While ambulance crews changed to two ambulance personnel, without the need for a nurse, and some additional training was given to staff, the focus remained the same; attend the scene, give first aid, collect the patient and bring them to the local hospital. To the general public, the staff of the ambulance service were still largely regarded as “ambulance drivers”, not skilled pre-hospital practitioners. Indeed, some staff in the health service held the same view. We needed change. Thankfully, major change was on the horizon. This piece would be much longer if I went into detail on all the various changes we have seen over the past few years. Instead, we’ll look at 5 areas of innovation and change. Some are small, some are major government policies that were implemented, but all resulted in huge changes on the ground.
1. Creating a vision and a plan
The word quango has become a dirty word for many in Ireland but the advent of The Pre-hospital Emergency Care Council has revolutionised pre-hospital care in Ireland. For the first time in this country, we had a vision for the future of pre-hospital care in Ireland. The government realised that the status quo was stagnant and leading to poor outcomes for ill patients and needed urgent change. Dr. Geoff King and his team at PHECC set about changing the archaic system that we had into a world class, lifesaving system. If they were going to succeed in making their vision a reality it was going to require courage, determination and innovative thinking. Over the past 17 years, the skill sets, medications and scope of practice of pre-hospital practitioners has vastly increased. We have gone from lagging at the back of pack, right up to competing with the best in the world.
2. Centralising cardiac services
If you want to provide the best possible service, in any industry, it makes sense to centralise your service. If you try to provide a great service to everyone, a range of different offering, in multiple locations, at the same time, with the same team you run the risk of your system collapsing. The same is true of healthcare. It does not make sense to have every hospital in the country trying to provide all possible services regardless of location and population. Many governments and Ministers for Health in Ireland have been ridiculed for attempting to centralise services such as cancer care, coronary care and now trauma care, but for the most part it makes sense. There are 5 PCI centres in Ireland that provide emergency catheter labs on a 24/7 basis. If you suffer a heart attack, paramedics can transmit a trace (ECG) of your heart to a PCI centre where they can discuss your case with a cardiologist. If you need emergency stents inserted, the ambulance service will bring you to one of these centres even if it means bypassing your nearest hospital. If they can’t get you there within the designated time frame, you can be flown by helicopter or they can stabilise you in a closer hospital before continuing the journey.
3. Empowering the community
Volunteers and community groups are often the central pillars of a community. This is even more true in rural areas. The community council, the youth club, the Tidy Towns committee and countless others provide services that the government simply cannot provide. During the mid 2000’s, communities began to form responder groups to respond to cases of heart attacks and cardiac arrests in their communities. The groups were registered with the National Ambulance Service and alerted when a 999 call was received for someone in their area. Because they are responding to calls in their community, they often reach the patient ahead of the ambulance service and can begin treatment, or provide lifesaving CPR. This movement has grown over the years and there are now 135 volunteer groups around the country providing this service.
4. Taking flight
Aircraft were first used to provide medical evacuations during World War 1. Injured soldiers were flown to hospitals on fixed wing planes that reduced journey times from days to hours. Modern HEMS services rely mostly on helicopters. Again, the history is rooted in combat medicine where the United States used them extensively in the Korean and Vietnam wars. Ireland was a bit late to the party in this case and our first official, dedicated HEMS service started just a few years ago in a joint venture between the HSE and the Dept. of Defence. Today in Ireland, there are 5 helicopters available as resources to the ambulance service; 1 provided by the Irish Air Corps and 4 provided by the Irish Coast Guard. Plans are advancing for a charity funded service based in Cork and a similar service was recently launched in Northern Ireland.
5. Bringing the resus room to the patient
The resus room, or resuscitation room, is an area in a hospital Emergency Department where critically ill patients are stabilised. As we have seen, the amount of procedures that can now be carried out in an ambulance or on the side of the road has drastically increased in the recent past. There are some skills and procedures however, that remain beyond the scope of practice of even the most educated and experienced pre-hospital practitioners. They require the skill set of an emergency doctor and once again, the community delivered. There are currently 5 schemes operating in Ireland where highly skilled doctors respond to life threatening emergencies with the ambulance service on a voluntary basis. Doctors in Mayo, Dublin, Wicklow and Cork volunteer under the Irish Community Rapid Response charity and drive response vehicles capable of bringing the skills and equipment of the resus room to your home, your work or the side of the road.
The future…
I believe the most exciting and innovative changes in this area are yet to come. We have enormous untapped potential in our communities in the form of responder groups. These will be the key to increasing survival rates from cardiac arrest and heart attacks. Other resources in communities such as fire fighters, members of the Gardaí, voluntary ambulance crews and GPs remain relatively untapped but with a bit of thought and effort, we could add thousands of additional responders to the mix. The scope of practice for pre-hospital practitioners in continually expanding with new skills, equipment and medications being added every 2-3 years. One very exciting area is Point of Care Ultrasound (POCUS). Like many medical devices, the size and cost of ultrasound scanners have reduced dramatically in recent years while their power and functions have increased. With this, ambulance crews could diagnose a range of illnesses and injuries and begin treatment before getting to the hospital. In terms of education, paramedic programmes are trending towards university degrees rather than vocational training. This will bring challenges, but also huge opportunities for specialisations in the area such as Community paramedics and Critical Care Paramedics.
Recap:
So, in a relatively short time, we have gone from a very basic service comprising of picking up a patient and driving them to hospital, to a complex, integrated pre-hospital system made up of volunteers, highly skilled pre-hospital practitioners and emergency doctors. It is often said that it takes a system to save a life and I am sure that I haven’t done the system justice in this piece but I think it is clear to see the vast leaps that we have taken in this country in the recent past. Let’s look at a realistic scenario to see how all of this has affected patient care:
Jim, 67, wakes up at 5am, alone, in his house outside a small village in rural Ireland. He has a crushing pain in his chest and he feels weak and nauseous. He calls for an ambulance but he knows he lives 40 minutes away from his nearest hospital.
If this had happened Jim 20 years ago, the prognosis would not be good. However, let’s see how this could theoretically play out with today’s system:
The dispatcher knows that Jim is very ill and dispatches an ambulance straight away. The ambulance is 20 minutes away from Jim’s village. Looking at their control screen, they see that there is a responder group available in Jim’s village and a rapid response doctor in a town 15 minutes away. Both of these resources are also activated. Within minutes, there is a knock on Jim’s front door. The local responders arrive and assess him. They relay his condition to the dispatcher and begin treating him. 10 minutes pass and Jim is deteriorating. He suddenly stops breathing and his heart stops beating. The responders get to work quickly, performing CPR and using a defibrillator. The rapid response doctor arrives and performs their assessment. They give emergency medications work alongside the responders. The ambulance crew arrive and work alongside the doctor and responders to get Jim’s heart beating again. They give additional drugs and intubate him. After a second shock, Jim’s heart begins to beat again. The team work to stabilise him and assess his heart. They see that Jim has had a heart attack and that he needs urgent transport to a PCI centre. They transmit his ECG to the cath lab. After a brief conversation with the cardiologist on duty, they both agree that Jim needs stents. The closest centre is almost an hour and a half by road so they request a helicopter. They make sure he is stable and transport him to the local GAA club where a helicopter from the Irish Coast Guard lands. Jim is flown to the PCI centre in just 20 minutes. At 6pm that day, Jim is sitting up in his bed, eating toast and drinking tea. He is the proud new owner of a heart stent.
Innovation does not always look the same in different industries. Sometimes it is quite a small change, an out of the box thought, that can have the biggest impact. The group of volunteers, living in a rural community, that decided they wanted to help their neighbours in the event of a medical emergency. The doctor who wants to use their skills and give something back to their community in their spare time. The cardiologist that wonders if they could remotely do an ECG on a patient in an ambulance. Sometimes, it’s a major cultural and political change. The Minister who authorises the centralisation of cardiac care services. In all cases though, you need that initial person to start the innovating. Someone to ask the question, “what if…?”. That question, if followed through with by an enthusiastic and energetic group of people, has the power to save lives.
