Qui du M�decin Fran�ais ou Qu�becois est meilleur ... et en fonction de leur salaire !!! ($/Euro)
Et finalement Les Am�ricains (pas les Fran�ais)vont peut-�tre apporter la r�ponse scientifique du nombre et du temps r�ponse appropri� des soins avanc�s pr�hosp. ! ? ! ? Charles Hors d'oeuvres : http://www.usatoday.com/graphics/life/gra/cpraed/flash.htm http://www.usatoday.com/graphics/life/gra/ems/flash.htm "Mais" Principal : Paramedics not always the saviors of cardiac-arrest patients By Robert Davis, USA TODAY JENKS, Okla. - At first, the regulars in the Homestead Diner thought Bill Twilley was joking when he hit the floor after taking his seat. It was,after all, April Fools Day. And it was, after all, Bill. Some EMS systems are finding that more paramedics don't necessarily equate to better survival for cardiac arrest patients. By Jack Gruber, USA TODAY But when Curtis Conway looked under the table, he saw that his friend had scraped his forehead and his glasses had cut his face. "He got all stiff," Conway says, "and he started turning blue." Twilley, 71, was in cardiac arrest. He was lucky. He was one of an estimated 165 Americans who collapse each day in the most saveable form of sudden cardiac arrest - most saveable because it can be reversed by a shock from a defibrillator, and because it happens in public, where bystanders can summon emergency help. Twilley was saved, but not by paramedics. He was saved by Conway's cardiopulmonary resuscitation and by firefighters who arrived before the paramedics and shocked his heart back to normal. There was no paramedic on the fire engine. In fact, there are no paramedics in the Jenks Fire Department at all, and no plans to hire any. At a time when more cities are trying to put a paramedic on every fire engine - often the first vehicle to reach a medical emergency - Tulsa, which provides emergency medical services to Jenks, is limiting the number of its paramedics. Yet Tulsa's emergency medical system is considered one of the nation's best as measured by the EMS "gold standard," the survival rate of its saveable cardiac arrests. Tulsa's survival rate is 26%. The national average is an estimated 6% to 10%. The city's EMS philosophy - and Twilley's story - illustrate the findings of a USA TODAY study of emergency medical data from 12 of the nation's biggest cities that suggest that victims of cardiac arrest are more likely to be revived in cities that spend fewer taxpayer dollars on paramedics. (Related: Six minutes to live or die) Cities with the highest survival rates, the data suggest, train firefighters and citizens to respond first with defibrillators and CPR, sending in a smaller, closely supervised corps of paramedics minutes later to give advanced care. This is the great divide in emergency medicine. Should a paramedic be on every fire truck, even though most of the calls are not matters of life or death? Or should paramedics be a smaller, more skilled corps that arrives to take over a few minutes after firefighters who just have basic emergency medical training? Most cities opt for more paramedics, despite the expense and evidence that the approach does not necessarily save more lives. Of the cities studied by USA TODAY, Seattle saves more cardiac arrest patients - 45% - with 1.48 paramedics per 10,000 residents. Boston has the second-highest survival rate - 40% - and the lowest paramedics ratio at 0.86. Many of the other cities have substantially lower survival rates and markedly higher numbers of paramedics per 10,000 population. Nashville, for example, has an 8% survival rate with a 3.33 paramedics ratio. Omaha has the highest ratio at 4.70 with a 16% survival rate. Fewer paramedics Seattle, Boston and Tulsa represent cities with fewer paramedics. They believe that a paramedic who rides a fire engine to every call doesn't get enough practice providing skilled care because so few calls are real medical emergencies. So firefighters in these cities are trained in rapid response and basic medical care. They save many victims of cardiac arrest with a shock from an automated external defibrillator (AED). Paramedics, rescuers with more training, experience and medical oversight, typically arrive in an ambulance minutes later. They provide advanced life support - administering drugs through IVs and inserting a breathing tube - to stabilize patients before transporting them to the hospital. These cities put a premium on having no more paramedics than their medical director can closely monitor. "We have a small group of people who are highly experienced and trained, who work only in their specialty," says William Hepburn, assistant Seattle fire chief. Seattle also teaches its citizens CPR. "Most people equate EMS with paramedics," Hepburn says. "EMS should be an integrated system of trained citizens, first responders, paramedics and hospitals. Quick and effective CPR first saves lives." Twilley's case in Jenks is a perfect example: While a waitress at the diner dialed 911, Conway dropped to his knees and began CPR. The firefighters arrived, applied their AEDs and shocked Twilley once, five minutes after the 911 call was made. He was waking up when the paramedics arrived four minutes after that. He was asking for his cap before they wheeled him out. In Boston, the focus is on giving paramedics more opportunities to practice both their technical and clinical judgment skills. "We don't believe in sending our paramedics on every call," says Boston EMS chief Rich Serino. "We want to have highly trained paramedics who utilize their skills often so there is minimal skill deterioration." In Tulsa, Emergency Medical Services Authority (EMSA) medical director John Sacra was instrumental in persuading Tulsa officials to keep a smaller, more skilled and more supervised corps of paramedics. "The more paramedics you put into the system, the more medics that are doing fewer procedures," Sacra says. "It's a problem." Tulsa stands on the opposite side of this great theoretical divide from Oklahoma City, which is increasing its paramedics corps. The two cities, 100 miles apart, save about the same percentage of cardiac arrest victims - 26% in Tulsa and 27% in Oklahoma City. But their fire departments have different views on how many paramedics they need. In Tulsa, each resident spends $3.29 per year in taxes for 128 paramedics. In Oklahoma City, residents each pay $11.40 for 226 paramedics. In Tulsa, five of 30 fire engines have paramedics. In Oklahoma City, almost half of its fire engines have paramedics - 17 of 35. More paramedics Omaha and Nashville represent cities with more paramedics. Their philosophy: Fire engines are almost always first on the scene of an emergency, and a paramedic on the engine means the most trained rescuer arrives first. So they continue to hire, train and employ more paramedics to ride on fire engines. Nashville fire officials put paramedics on seven of the department's 39 fire engines, and reduced the time it takes for a paramedic to reach a victim by 21% to 25%. There have been no scientific studies showing that this approach saves more lives. But it consistently appears to be what the public and most politicians want. "In my experience, response times, response times, response times are of greatest concerns to those we serve," says Stephen Halford, Nashville's fire chief. Robert Dahlquist, Omaha's fire chief, says paramedics are the best way to provide emergency medical services to his community. "I'd like to have more paramedics," he says. James Love, Omaha's assistant fire chief, says 42% of the EMS calls require advanced life support. "This is the reason that we staff the paramedic coverage that we do. We continue to strive for 100% paramedic engine coverage," Love says. Los Angeles is an anomaly because it has both a low survival rate - 6% - and a low paramedic ratio per 10,000 population at 1.55. But in raw numbers it has the most paramedics of any city studied, boosting its paramedic force from 594 to 730 in the past year. "We have so many calls and so many sick patients," says Marc Eckstein, the city fire department's medical director. "I live in the city. I want a paramedic at my neighborhood fire station." But Eckstein acknowledges he can't keep track of all his paramedics and their skill levels. "If you have 500 paramedics spread out over 500 square miles going to 60-some-odd receiving hospitals, it is clearly impossible to get a handle on how well the medics are performing," he says. Corey Slovis, Nashville's EMS medical director, who oversees 196 paramedics, agrees. "If you have 50 or 60 paramedics, you are able to tell which ones are great, which ones are mediocre and which ones need to come in and get checked out," he says. "Between 80 and 100, you can't keep track of them all." What's next? After considering the USA TODAY findings, a number of fire and EMS officials say that a national, scientific study should be undertaken to determine how paramedics should be deployed in big cities. "Fire departments have been (adding more paramedics) because they think it's going to make a positive difference," says John Sinclair, a fire chief and former paramedic who heads the EMS section at the International Association of Fire Chiefs. "Maybe we do have a problem. It's not really counterintuitive if you look at it. The more medics, the fewer that are taking care of really sick people." U.S. Surgeon General Richard Carmona, a former paramedic and EMS medical director, says cities must look at their paramedic deployment and ask, "What did a paramedic add to this call to reduce pain or morbidity?" "It's not a matter of right or wrong, but how can we do this better?" he says. "Fire chiefs and police chiefs and EMS directors should always say, 'Show me the science. Show me how this will benefit my citizens.' The idea is to do better with meager resources." For 25 years, Slovis says, he has believed that having a paramedic on every fire engine was the best way to save more lives. "Now I realize that the best systems may be the ones with the limited number of paramedics who are elite - highly trained," he says. "I have completely changed." Find this article at: http://www.usatoday.com/news/health/2005-03-01-ems-cover_x.htm ..................................... Posted 3/1/2005 11:07 PM Updated 3/1/2005 11:14 PM Survival by the numbers USA TODAY studied 12 cities that measure their cardiac-arrest survival rates by the international gold standard called the Utstein template. This tool is the best indicator of EMS life-and-death performance because the victim's outcome is determined in the field, not in the hospital. The template considers only the most savable of cardiac-arrest victims: those who collapse in front of a witness and need a shock from a defibrillator. It counts as survivors only those who leave the hospital with good brain function. The study is not definitive; it covers a comparatively small number of cities, but interviews with emergency medical experts across the nation support the findings. These figures, supplied by the cities, are the most recent available. (Survival rates are from 2001; paramedic ratios are per 10,000 population from 2003.) �Seattle. Survival rate 45%; paramedic ratio 1.48 �Boston. Survival rate 40%; paramedic ratio 0.86 �Oklahoma City. Survival rate 27%; paramedic ratio 3.44 �Tulsa. Survival rate 26%; paramedic ratio 2.95 �San Francisco. Survival rate 22%; paramedic ratio 3.83 �Houston. Survival rate 21%; paramedic ratio 1.40 �Kansas City, Mo. Survival rate 20%; paramedic ratio 3.12 �Omaha. Survival rate 16%; paramedic ratio 4.70 �Tucson. Survival rate 12%; paramedic ratio 3.15 �San Antonio. Survival rate 9%; paramedic ratio 2.82 �Nashville. Survival rate 8%; paramedic ratio 3.33 �Los Angeles. Survival rate 6%; paramedic ratio 1.55 http://www.usatoday.com/news/health/2005-03-01-ems-numbers_x.htm ........................................ Simpler method for CPR coming By Robert Davis, USA TODAY In what may prove to be the biggest shift in emergency care of cardiac arrest in 40 years, cities across the country are leading a move away from the familiar practice of using mouth-to-mouth resuscitation. (Related story: Many 911 dispatchers eliminating mouth-to-mouth) In its place, the cities are recommending simple chest compressions � pushing down repeatedly on the victim's chest � to mimic a steady heartbeat. The emergency medical directors who are behind the shift say research in Seattle and Richmond, Va., suggests it will save many lives. (Related story: People die in just a few seconds lost) The movement became a full-fledged national trend last week at a meeting of emergency medical services (EMS) medical directors from 21 of the nation's largest cities. Doctors from a dozen cities, including New York, Los Angeles and Chicago, decided to make the switch. They join at least seven other cities that already are advising 911 callers to do chest compressions without mouth-to-mouth "rescue breathing." Seattle saved more lives by advising compressions alone, and Richmond rescuers arrived to find 10 times more victims (60% vs. 6%) getting lifesaving compressions when not distracted by advice on breathing techniques. For now, the shift applies primarily to untrained bystanders, the group most likely to reach victims in the first critical minutes. In such emergencies, lives generally are saved or lost within six minutes. The emergency directors agreed that trying to talk 911 callers through mouth-to-mouth procedures was doing more harm than good because it wasted time. The American Heart Association is considering similar changes to its guidelines, but a decision is not expected until 2005. In the meantime, the switch is well on its way to becoming standard practice. "We are convinced this is the appropriate thing to do," says Corey Slovis, EMS medical director in Nashville, where new instructions will begin within two weeks. "People are very excited about this." James Loflin, medical director in El Paso, says his city changed Monday. Larger cities say it will take weeks, perhaps months, to make the change. "We want the fire department and the legal folks to look at it," says Neal Richmond, deputy medical director in New York. The medical directors are taking action before the heart association does, partly in response to findings from a USA TODAY series published in July. The 18-month investigation by the newspaper found that at least 1,800 people die needlessly each year in the nation's 50 largest cities because EMS care is fragmented, inconsistent and slow. While the heart association would prefer that all adults be trained in CPR so that they can practice their skills before they are faced with a crisis, officials with the association agree that immediately beginning compressions alone is better than waiting even a minute or two to begin CPR. "We strongly support this," says Mike Bell, vice president for emergency cardiovascular care programs. "This gets something done." These cities are following the lead of at least seven other cities that have simplified 911 rescue instructions to increase cardiac-arrest survival: � Atlanta � Austin � Chicago � Cleveland � El Paso � Fort Worth � Los Angeles � Nashville � New Orleans � New York � San Antonio � San Francisco http://www.usatoday.com/news/health/2004-02-23-cpr-usat_x.htm ................................ The method: Measure how many victims leave the hospital alive By Robert Davis,USA TODAY How did USA TODAY calculate the numbers used to compare cities' emergency medical system performance and estimate how many lives are needlessly lost each year? Throughout this series, the newspaper uses sudden cardiac arrest survival rates as the measure to compare the performance of emergency medical systems in the 50 largest U.S. cities. It isn't the only measure of emergency medical performance. How medics treat trauma, asthma and other medical emergencies also matters. But sudden cardiac arrest is the purest measure because victims can be saved only by fast, heroic action. If victims live, it is primarily because of the efforts of rescuers who rush to their side. "If you can handle cardiac arrest OK, you can probably handle most things OK," says Leonard Cobb, founder of Seattle's emergency medical system, which has the best save rate in the country among big cities. No one knows exactly how many sudden cardiac arrest victims could be saved if the emergency medical systems in every city performed flawlessly. The American Heart Association estimates that 250,000 people nationwide die from cardiac arrest outside of hospitals each year, and that only 5% of such victims survive. Not all of those who collapse can be saved, but the association estimates that if the survival rate improved only to 20%, about 40,000 more lives would be saved. The heart association's estimate is based on "what ifs." What if every victim were discovered the moment he fell? What if the person who saw the victim fall were trained in CPR? What if the person performing CPR had access to a defibrillator? What if advanced emergency medical help came quickly? In reality, many victims collapse without being noticed. Only about half of those who are seen going down get immediate CPR, which can buy a little more time for the heart. And rarely is a defibrillator on hand to deliver a lifesaving shock. After six minutes, the victim no longer has a much of a chance. 'Most saveable' lives So realistically, how many more lives might be saved now? To get a clearer picture, USA TODAY used a combination of the latest published medical studies, federal population data and expert advice to estimate the number of "most saveable" lives. The most saveable victims are those whose cardiac arrest is brought on by ventricular fibrillation, known to emergency workers as "V-fib." That means an electrical short circuit in the heart has interrupted the normal beating and thrown it into chaos; the heart could be shocked back to normal rhythm if help arrived soon enough. Recent medical studies have put the rate of V-fib cases between 12 per 100,000 (in a study of Rochester, Minn.) and 26 per 100,000 (in a Seattle study) of the general population per year. EMS crews do not reach most victims while they are still in V-fib. Usually, by the time emergency medical crews arrive, the electrical chaos has worn out the heart and the person is dead, so any V-fib count by emergency medical services may be too low to capture the full scope of the phenomenon. But the survival rate still is useful because it gives the best measure available of an emergency medical system's lifesaving performance. And it gives a picture of the "low-hanging fruit" � the victims who might be saved immediately with better EMS performance. To estimate the number of lives that could easily be saved each year in these cities, USA TODAY used 20 V-fibs per 100,000 population a year, closer to the high end of the range, assuming that the rate in other major cities would look more like Seattle than Rochester. Applied to the nation's population, that means 58,000 of the people who fall annually to sudden cardiac arrest are V-fib victims and might reasonably be saved. The most recent nationwide research, reported in the Annals of Emergency Medicine in 1999, found that, on average, emergency medical systems save just over six of every 100 victims of cardiac arrest. Data supplied by the 50 largest cities appear to support a 6% to 10% average survival rate for V-fib victims. While many cities report survival rates that are higher than 10%, nearly half of the 50 largest cities could not say how many victims of cardiac arrest they save. Experts say those cities most likely are below the national average. About 9,000 V-fib victims a year fall within the city limits of the nation's 50 largest cities, USA TODAY estimates. Based on the average 6% to 10% survival rate, these cities' emergency medical systems save 540 to 900 of those people a year. But if all these cities were to follow the steps that a few � including Kansas City, San Francisco, Houston, Tulsa, Oklahoma City, Boston and Seattle � have taken to reach or surpass a 20% survival rate, at least 1,800 lives could be saved. Seattle and other leaders in emergency medicine use sudden cardiac arrest survival rates to monitor their efforts. Using a formula known as the Utstein template � the international gold standard for measuring these rates � they count only the victims who had a chance to be saved, and they count as survivors only those who live to leave the hospital without serious brain damage. Patients who are simply delivered to the emergency room with a pulse do not count as Utstein survivors because many of them die later. This formula filters out patients who are in cardiac arrest because of medical problems other than heart disease. Trauma patients, like those who have been in an accident or shot, for example, aren't counted. But people like Julia Rusinek are (see accompanying story). She falls into a category known as "witnessed cardiac arrest." Somebody saw her collapse, and help was called the moment she hit the ground. Her heart was in V-fib, making her one of the types of patients most likely to be saved by quick use of a defibrillator. Most don't use gold standard Most of the nation's 50 largest cities don't know how many victims they are saving by the Utstein gold standard. Often the measure of "survival" among the nation's rescuers focuses on how many victims were revived by medics in the field and delivered to a hospital with a heartbeat. That is easy to count: Medics check a box on their patient report. But many of these victims do not survive to be discharged, so it gives an inflated view of survival. In USA TODAY's survey, a public health initiative funded in part by the Henry J. Kaiser Family Foundation (not affiliated with Kaiser Permanente or Kaiser Industries), the medical directors in 38 of the nation's 50 largest cities could not or would not answer the survival rate question based on the Utstein standard. That inability to account for lives lost makes it more difficult for cities to improve care. Paul Pepe, who has been the medical director in Dallas since 2000 but who earned a national reputation by improving the survival rate in Houston in the late 1980s and early 1990s, says it will be hard to improve his or any city's results without the true measure. "We really need to know how many people are going back to their families," he says. http://www.usatoday.com/news/nation/ems-day1-method.htm --- URG-L s avez plusieurs adresses email, vous pouvez les envoyer a Frederic Giroux a l'adresse [EMAIL PROTECTED] Un (ou des) alias pourront ainsi etre crees pour que vous puissiez envoyer des messages a travers la liste a partir de n'importe quel de vos alias. 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