Emergency medical service systems in acute cardiac care: State of the art

Over the last two decades, emergency medical services in the United States have been greatly improved. Organization of prehospital providers of health care has improved the outcome of many patients, particularly the trauma patient and the acute cardiac patient. In Seattle as many as 40% of outside-the-hospital cardiac arrest victims with ventricular fibrillation have been saved when there is rapid delivery of basic life support by first responders followed by advanced life support by paramedics. Although these systems are growing and improving health care, many lack adequate medical control or physician involvement. Emergency medical service systems must have physicians involved in their management to meet their full capabilities. It has become apparent that four factors are critical in determining the ability to resuscitate an individual once a cardiac arrest has occurred: (1) time to starting any of the rescue procedures, (2) use of electrical defibrillation when indicated, (3) use of epinephrine, and (4) adequacy of the technique of basic life support, particularly the ventilation component. To provide defibrillation at the earliest possible time, defibrillation by first responders such as emergency medical technicians appears to be of benefit. With the advent of automatic and semiautomatic defibrillators, first responders and family members may also be able to defibrillate victims. The use of defibrillation by people with less training than paramedics, however, must be approached with caution to ensure that there is adequate medical control and that the individuals who use these devices are properly trained.