Category 9

In many EMS systems, Category 9 or some code involving the number 9 is the code for cardiac arrest.  This number comes from the Medical Priority Dispatch System “determinant” codes.   And as we all know, the easiest, simplest, most low-hanging fruit of EMS metrics is some version of cardiac arrest survival.  Dead/Not Dead.  It doesn’t get easier than that.

But there’s a couple of rubs there.   Define “cardiac arrest.”  I think we all agree that there’s a wide spectrum of arrests.   An obvious dead-on-scene in a lot of systems gets classified as a “cardiac arrest” in others.

And then there’s the voodoo.  So many research physicians have convinced that they’ll be the next one to raise Lazarus from the dead if only they adopt XYZ protocol.   Some are dubious, some have potential, and some have raised more questions than they’ve answered.  Witness the debate over some supraglottic airways impeding carotid circulation or the current debate as to whether therapeutic hypothermia works.  What we do know works is good CPR and electricity.  But neither of those are “sexy” per se.

Here’s what bothers me, especially about certain services who constantly brag about a high percentage of “saves.”  Even in the best systems, a successful resuscitation is a 50-50 proposition.  And we know that cardiac arrests represent a very small percentage of EMS calls.   So, in short, you’re designing an EMS system based on a super small percentage of patients.

Let’s work towards a new metric based on what our patients seem to really want — symptom relief.  Did we make your breathing easier?  Did we take your nausea away?  And most importantly – did we take your pain away?

A system based on those metrics is the type of place where I’d be proud to practice medicine.   Because after all, paramedicine is practicing medicine, albeit under relatively defined limits.  And medicine is supposed to be about making people feel better.


  1. Mike Smertka says:

    My friend, anyone who claims there are going to raise people from the dead with a protocol will not have a protocol past the steps 1.Early CPR 2. Early defibrillation. Once you get past that, it is all art.

  2. I agree with your general idea but there’s a huge flaw with your reasoning: symptomatic outcomes can be a hell of a lot different from actual disease oriented outcomes (DOI’s). See this study on albuterol, placebo, sham acupuncture, and no treatment from the NEJM in 2011 (

    The take-home point, contrary to the editorial spin it received from some, is that you can do a lot of things to make a patient feel better (albuterol, placebo, or sham acupuncture) but only one of those treatments will actually make the patient better: albuterol.

    If we design an EMS system oriented to symptomatic relief and not the actual outcomes we want to improve, we may as well just start using sham acupunture and placebos. Did that placebo inhaler make your breathing easier in spite of your worsening FEV1? Did the metoclopramide improve your nausea and dizziness in spite of me missing your cerebellar stroke? Did that morphine improve your chest pain even though I’m missing your subtle-but-real STEMI? Improving the patient’s experience is important, but it’s not the most important aspect of their care and not something we can easily measure.

    The reason why high-performing EMS systems follow cardiac arrest is because it is hard data tied to both system performance and important patient outcomes. Compiling large amounts of clinically-relevant data with clear outcomes is difficult in the prehospital environment and, as you note, cardiac arrest is low-hanging fruit. True, it’s not perfect and every system has a slightly different way of categorizing each arrest and examining the data, but the important thing is that folks are looking at their outcomes.

    First, it shows that a system gives a damn. Second, by making cardiac arrest a big deal, a system can generate a culture that cares about their outcomes and actively strives to get better at treating OOHCA. This might be small beans compared to the abdo pain and N/V calls we see every day if not for one last important point: improvement in cardiac arrest outcomes does not occur in a vacuum or at the expense of other care we deliver.

    An EMS system that is actively trying to improve their cardiac arrest outcomes is a progressive system, and it’s really hard to be progressive in one facet and still act like it’s 1995 in every other. Once a system examines itself, realizes it’s behind the times, and looks at what others are doing; it can’t help but notices that there are places implementing things like more liberal pain control protocols and selective spinal immobilization. Making the explicit decision to improve cardiac arrest outcomes helps create a culture of excellence, and it’s through that changing culture that the this effort in a small subset of our calls can pay dividends. True, there will still be shitty medics who don’t believe folks with abdominal pain deserve narcotics, but a progressive culture makes it hard for them to exist without improving.

    So, while I agree with your notion that we should be doing more to improve our patients’ symptoms and prehospital experience, I don’t think cardiac arrest outcomes are isolated from that and don’t agree that symptom-oriented metrics are the solution. It’s too easy to game the system or create unrealistic standards with the latter, and while cardiac arrest certainly isn’t a perfect measure of what we care about for most calls, it’s a clean measure that plays an important role as a marker of overall system health and culture.

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