It's Time to Create The "Survival Ladder"

For years, we have heard about the "Chain of Survival" -- the links necessary to save the life of a person in cardiac arrest. The American Heart Association has summarized the most important factors that affect survival of cardiac arrest. The four components of the Chain of Survival include early access, CPR, early defibrillation and early advanced care. An EMS system in which there are strong links in this chain provides a better outcome for a victim of cardiac arrest.

But the Chain of Survival deals only with patients in cardiac arrest. What about patients who have suffered a serious illness or trauma, but are not in cardiac arrest? It is time to create the "Survival Ladder" for those who are not suffering cardiac arrest, but would be if it were not for the progressive and rapid care they receive from aggressive EMS systems and sophisticated hospitals.

Unfortunately, the only tool we use to measure the effectiveness of an EMS system is cardiac arrest survival rates. But usually cardiac arrest patients make up less than 1% of all calls to which an EMS system responds. What about those patients who never went into cardiac arrest because of a quick response by advanced life support (ALS) first responders and ALS transport vehicles and where appropriate intervention took place? With the Survival Ladder, each rung you move up is another step closer to survival. Any "misstep" on a rung or missing a rung breaks the climb and can adversely affect patient outcomes.

One excellent opportunity for using the Survival Ladder is with the introduction of STEMI (ST-segment elevation myocardial infarction) programs around the country. It is estimated that approximately 865,000 heart attacks occur in the United States each year. While many of these heart attacks do not show an ST-elevation on an EKG and are not easy to identify, ST-elevated heart attacks can be quickly recognized and treated to reduce heart damage. The approximately 400,000 STEMI heart attacks that occur each year can be easily recognized by firefighter/paramedics in the field.

The whole idea behind STEMI programs is to open the arteries in the heart of a person suffering a myocardial infarction within 90 minutes from arrival at the hospital. There are two ways of opening the arteries of a STEMI patient: clot-busting drugs (thrombolytics) or angioplasty, where a tiny wire is inserted into the blocked area of an artery and a balloon is inflated to re-open the artery and restore blood flow.

Most STEMI patients now are diagnosed in the emergency room after they arrive, which delays treatment. To improve outcomes for STEMI patients, not only do the first two rungs of the Survival Ladder (easy access to 911 and quick and accurate access to pre-hospital instructions) need to be in place, but the third and fourth rungs (fast access to ALS first responders and swift access to an ALS transport vehicle) also must be available. When these two components are in place, firefighter/paramedics are able to interpret and/or transmit 12-lead EKGs to a hospital with a cath lab for diagnosis of STEMI.

Some more progressive EMS systems have changed their protocols to allow paramedics to activate the cath lab from the scene and totally bypass the emergency room upon arrival at the hospital. This has dramatically decreased the goal of door-to-balloon time of 90 minutes. In one EMS system north of Houston, TX, the door-to-balloon time averaged 47 minutes for 41 patients and 87 minutes from the time 911 was activated.

Of course, the fifth rung of the ladder (immediate access to multifaceted hospital services such as a cath lab or trauma teams) must be in place for STEMI patients. Taking a STEMI patient to a hospital that does not have a cath lab would be counterproductive and useless.

The principle of the Survival Ladder model is applicable to other scenarios. Trauma is a leading cause of death in the United States. The Survival Ladder is also appropriate where a gunshot victim has all five rungs on the ladder available. The patient's outcome will be determined by the strength of each rung.

For years, I have heard the detractors of paramedics say we make no difference. Some have even done studies to prove their points. Most of these critics have never ridden on an engine company or in the back of an ambulance. All along, though, we knew they were wrong because we see the effect of our actions on critical patients. Not only will the Survival Ladder create a model for EMS systems to become stronger, but it will be better for patients and perhaps even silence the cynics.

GARY LUDWIG, MS, EMT-P, a Firehouse® contributing editor, is a deputy fire chief with the Memphis, TN, Fire Department. He has 30 years of fire-rescue service experience. Ludwig is chairman of the EMS Section for the International Association of Fire Chiefs (IAFC), has a master's degree in business and management, and is a licensed paramedic. He is a frequent speaker at EMS and fire conferences nationally and internationally, and can be reached through his website at