Adapting to Change

Most of the time when we see change, our gut reaction is to resist it, and do what we can to poke holes in it.  At least that has been my experience at many EMS services.  I guess I am just not lucky enough to work in an environment where fluid change occurs.

Some change is really for the positive, and there is no more positive change in EMS that I can come up with than the new ACLS guidelines prioritizing chest compressions.  The problem though is breaking old habits.

For my entire EMS career, it was always drilled into our heads that we “must get the tube” and we must do it well or someone would take the ability to intubate away from us.  Since the beginning of time, paramedics have seen their “right” to intubate patients as this sacred lifesaving skill that they must have and that no one should touch.  Through progressive thinking though, it has become more and more evident that intubation is not a lifesaving skill, but it is actually more of a life sustaining one.  In most instances, intubating a patient will help keep their airway patent and keep them alive, especially when sedated.

I have studied up on CPR in Seattle and one thing that they discuss at great length is the importance of chest compressions and the minimization of interruptions.  We all need to keep that in mind and we all need to adopt that.  Nine out of ten times, airway is not important.  Early CPR, early defibrillation, and the minimization of interruptions are what are proving to be lifesaving interventions, not pauses in compressions to get a tube or vigorous bagging of a patient to get oxygen in.  Blood needs to go round and round in order for that air going in and out to be effective and measuring end title CO2 proves that.

Have you ever had your APNEA alarm on your monitor go off?  The cause might not be a bad tube; it might actually be inadequate compressions.  Low CO2 output is a sign that there is little to no gas exchange at the alveolar level because there is not enough blood going round and round.  The compressions being done are not adequate.  Give a few really good pumps on the chest (and then just keep going) and watch that apnea alarm turn off on its own.

It has become apparent to me that more times than not, when it comes to EMS and providing care, seeing is believing.  We do not realize how much of a difference the tedious practice of putting on a HARE Traction splint is until you actually see the difference it makes for a patient.  ACLS changes don’t carry much weight either until we see for ourselves their benefits and these changes to the cardiac arrest algorithm are no exception to that.  Repetition, and past experience would have told us to pull out the atropine because it “can’t hurt” but they did not want us doing that anymore.  It might not hurt, but it does not help much either.  That time is better spent pumping away on the chest.

Some might think that the reduction of meds in their drug bag is a bad thing.  They view it as their ability to care for a patient is being reduced because someone does not feel they are capable of handling all of the responsibilities.  Well, that could not be farther from the truth.  In actuality, they have found a better way to do things, and despite the egos of the paramedics providing the care, they decided to go with it for the benefit of the patient.

About a month ago, I had a great experience with a witnessed cardiac arrest and four paramedics that I work with.  Through teamwork and a focus on compressions, the result of the care that we provided was a ROSC prior to leaving the scene.  Personally, I think that if we had rushed the patient along and not provided the quality of compressions that we did, and worried more about that “A” rather than the “C” in the CAB’s of CPR, I do not think that we would have had the prehospital outcome that we did.

While the in hospital outcome was not as beneficial, (the patient expired a week later) what the five of us were able to see was the importance of chest compressions and what the result should be if that code is run exactly the way they want us to.

If you work in a system that allows field terminations, I envy you.  You’re on the right track.  For those of you, who are loading up your patients and heading off to the hospital, don’t rush.  Remember: that patient’s best chance of survival does not depend on an immediate arrival in an emergency room; it depends on your actions in the first ten minutes of that cardiac arrest.  Adapt to change.  Make those compressions the priority.  Do not be afraid to stay and play for an extra minute or two, and realize that with a little patience and reliance on your training, you can make a difference.

  • Carl Viera

    I could not agree with the last paragraph more. There are way too many providers that try to break land speed records with their total call times. Chances are, unless the call is in the hospital parking lot, there would be no chance of a return of neurological function if a “dead” patient is wheeled into the ER. I personally believe the tube should come last. CPR needs to start immediately, then there needs to be a rhythm check (if you lose a shockable rhythm, chances are it’s all over anyway), followed by meds, and then the tube. A BLS airway is a functional substitute while more “important” things are done. I am not sure why there is such an emphasis on total call time seeing as ACLS is ACLS, no matter where it is done.