The Silver Lining of Epi

I was out with some coworkers for some frosty beverages last night in celebration of a friend’s birthday, and of course, predictably, the conversation turned to our profession.  We got talking about how we handle and respond to cardiac arrests, and mainly the medications that we give.  While we are all proud of our 40% ROSC rate, one of my friends made a bold, and not complete unexpected comment, “I think we need to get rid of epinephrine.”

It is an argument that has been made by numerous people, including my friend the Rogue Medic, and it is one that is not completely unfounded.  Patients who receive epinephrine in cardiac arrests have worse outcomes.  To me, that is not completely surprising.  Personally, I feel that patients who we save with epi are people we would have not gotten back without it.  That statement might be slightly confusing, but as far as I am concerned, people with better outcomes without epi have those improved outcomes because their cardiac arrest was intervened with sooner, and the underlying cause was one that made them an easier save.

So now we have these ROSC patients who end up with poor long term outcomes and some who might not even make it out of the hospital.  We are saving people only to put them in a vegetative state, or only prolong their lives for a short time, right?  One might think so. . .

Then I looked a couple of seats down at the bar, and the whole purpose of epi, and the entire argument became clear to me.  We were joined that night by and celebrating the birthday of, a former paramedic who gave up her career to go into organ procurement and transplantation.  When we brought in one of these patients that was expected to have a poor or short outcome, which is when her company got involved.  They match donors to transplant recipients and get the ball rolling with screening and dealing with a family.  Her company and profession have saved countless lives over the years.

If our documented ROSC rate tells us we are “saving” four of out every ten cardiac arrests, let’s say, for argument sake, that three of those four do not make it out of the hospital.  How many of those three are viable organ donors?  I have no idea, but maybe I should.  Maybe we should.  The fact remains that our ultimate goal is to try and insure that our patient walks out of the hospital and lives a long and prosperous life but just because we don’t achieve that ultimate goal, that does not mean that there was not a life (or two, or three or four) saved as a result of our efforts.

As we push forward in the mission of “lifesaving” that so many of us have pledged our careers for, sometimes we need to look beyond the traditional measures to find that silver lining that helps us keep at it.  CARES reports, while not nearly public enough, only tell part of the story.  Maybe we need to dig deeper when it comes to the feedback that we receive.

We often look at those “epi saves” with low CPC scores as a letdown.  We look at the call, shrug, and say “better luck next time.”  Maybe it is time to look at them from a different angle.  We need to look at dealing with a cardiac arrest in stages.  Stage one, of course, is to work as hard as we can to achieve ROSC.  ROSC is an absolute: there is a pulse, or there is not a pulse.  The next step should be to work as hard as we can to make sure they have the best outcome possible.  That means we need to get them to the correct facility with the resources to take care of them.  We need to start hypothermia early.  We need to get a 12-lead done and make sure our assessment of them is as good as it can possibly be.

The next time you bring one of those cardiac arrest patients in who when you follow up on them, you are told that they have “no brain activity” do not look at it as a complete loss.  Ask that follow up question, “Are they going to be able to donate any organs?”  You might be pleasantly surprised at what the answer is.  Although it’s not exactly what we are looking for, a life might have been saved.


  1. I’ve sometimes wondered about this myself, but I think that since most of our (EMS in general) codes are medical in nature and involve patients usually too old for donation, it’s still a lot of effort, expense, and risk (to us) for no gain. The most likely candidates for organ donation post-EMS resuscitation are trauma codes, and there is almost no reason to work those at all. As previously stated, I’m not sure potential organ donation is an acceptable transport criteria.

    I definitely agree with you about the epi though. I’ve been fortunate enough to have had several neurologically intact saves in my relatively short ALS career, and 100% of them had ROSC before any ALS intervention (other than manual defib) could be accomplished. All of them also had, while not true bystander CPR, some CPR within the first 2 minutes of arrest prior to my arrival.

    Zero point zero of my patients receiving epi 1:10,000 have survived longer than 24 hours (1 field ROSC and several ED ROSCs in that group).

    • I would like to reply to your comment about “too old for donation” and “most likely candidates are trauma codes”, while this is the common misconception even thought by most health care providers, you are in fact wrong. There in no upper age limit for organ donation and organ donation has been successful among donors well into their 80s. To address your second comment, the most common cause of death of organ donors, is anoxia, followed by CVA, then head trauma.