For the first twelve years of my career the answer to most questions was “just take them to the hospital.” Don’t know what’s wrong with them? Take them to the hospital. Paramedics and EMTs seemingly start to “over think” calls? Stop thinking and take them to the hospital. A certain facility doesn’t want our medics to do anything for the patients? Just get them in the truck and take them to the hospital.
More times than not “take them to the hospital” is at least a functional answer. Whether they need to be there or not a trip to the ER either delivers the patient to definitive care or makes them someone else’s problem. Oh, and did I mention that taking them to the hospital allows a department to bill for the call as well? It does. Or at least it did in my former service, but that is another discussion all together.
The big question though is what do we do when taking them to the hospital does not benefit our patients? Who am I talking about? Our cardiac arrest patients of course.
By now many of the readers have seen Tom Bouthillet’s picture of the “Resuscitation Fairy” who magically revives our patients when we deliver them to the ER. While Tom and I don’t always see eye to eye on issues in our industry, I feel like we are not only on the same page, but the same paragraph when it comes to running cardiac arrests. I have been lucky enough to spend enough time with Tom that I have learned a great deal from him. Changing how we do things can be scary. It takes a commitment to do it. We all have our comfort zones and stepping outside of that can be difficult, but we need to for our patient’s sake.
Moving patients kills them, or rather prevents us from saving them. Wake County has studied it and proven it. The simplest thought processes confirm it. A heart needs to beat in order to sustain life. In order to get that heart beating again, we must work for it, whether that be manually or with a CPR assistance device to go compressions for it. Either way, they have to be done. And they cannot be effectively done while moving.
As I have stated before, running cardiac arrests in my old service used to be about speed. You get the tube as quick as you can. You get them moving as quick as you can. You get to the hospital how? You guessed it: as quick as you can. When our trucks used to arrive with a cardiac arrest, our crews used to ask, “Total call time please” prompting the dispatcher to total up the time from the call was received until the unit arrived at the hospital. If they said anything under 30 minutes, people high fived each other. If it was 45 minutes or more, you’d better hope that you were on the far reaches of the city otherwise people would start asking, what happened? What went wrong? We worked as fast as we could but at what expense? The result was billable calls, dead patients at the ER, and an inexcusably low ROSC rate.
My point of view on these calls is completely different now. My new system sees cardiac arrests not as an emergency room’s ultimate problem but as a problem that can and must be solved by the EMS personnel on the scene of that call taking care of that patient. Cardiac arrests are worked on scene, normally with at least three paramedics and a slew of BLS providers all ready to do their two minutes of CPR before they get out of the way and let the next person in. If things don’t work out, the patient may be pronounced on scene. Then, it falls on the paramedics to break the news to the family. Interestingly enough, studies have been done, and it does not matter to a family who tells them of their loved one’s passing, it is more important to them that they are addressed properly. It doesn’t have to be a doctor in a white coat. It can simply be a paramedic in a blue shirt.
Since I have started in my new system I’ve been on scene at a cardiac arrest where we initially got pulses back and started to package the patient for transport. During that packaging the patient arrested again. So now here in front of us is a patient that is all wrapped up and ready to go. Carrying them out of the house and to the stretcher will create a 30 second (or more) lapse in vital treatment. It is a decision that the life of your patient might rest on.
There are many decisions to weigh. What is the patient’s rhythm? What did we have to do to get them back last time? Was it just a simple defibrillation to convert them? Or are we three or four rounds of medications into this cardiac arrest? How far are we from the ambulance, and how are we extricating the patient? It is not always an easy call to make, but it is one that has to be made quickly. And frankly, “just take them to the hospital” is something that we rarely say at that point. It’s usually “get back on the chest.”
What happens when your medical director supports the old way? What happens when they don’t support what is best for the patient? What if your EMS system chooses logistics over life? I’m not really sure what the answer to that one is. We all strive to do the best that we can for the patients with the tools and empowerment that we are given. I guess all that I can do is I can hope that more systems adopt a “patients first” attitude, and they choose to rely more on evidence than the “old way” of doing things.
Times are changing, and we need to evolve, not devolve. Sadly, resistance to change is more contagious than a desire to change. Regardless though, the Resuscitation Fairy can’t save these people, but properly trained paramedics and EMTs can.
Please allow me to start a slow clap.
We, As in You, Me, and everybody reading this, need to demand that CMS start paying for resuscitation attempts where the patient is worked on scene but not transported.
You’re asking us to evolve, not devolve, and yet you ignore the future of cardiac arrests, which would make your central argument completely irrelevant. Both the AutoPulse and LUCAS devices show a marked increase in effectiveness over manual CPR, and do not suffer from decreased effectiveness during motion, or tiring out. Once mechanical CPR devices become the norm in EMS, this entire conversation is null and void. It will always be in the best interest of the patient to load and go to the hospital, so that if ROSC occurs, in-hospital interventions are closer and more timely.
“Marked increase in effectiveness over manual CPR”? Where are you getting this information, because I would like to see it.
Secondly, the terminology “LOAD and GO” needs to die a quick death in EMS. In evolving, we can handle so many more emergencies on the scene, in the patient’s home. There are VERY FEW instances in medicine that require a quick transfer to the hospital and cardiac arrest IS NOT ONE OF THEM.
“In-hospital interventions”?!??!?! What a $10,000 epinephrine and a doctor talking to the family? Get real. Aside from hot cath-ing a persistent VF arrest, YOUR point is null and void. What in-hospital interventions in cardiac arrest are paramount to an active cardiac arrest? Oh yeah, quality CPR and timely defibrillations…and EMS can’t do that.
Link to autopulse info http://www.zoll.com/medical-products/cardiac-support-pump/autopulse/clinical-studies/
And while a non biased study showing increased efficacy of the Lucas hasn’t been published yet, it has been shown to be AS effective as manual CPR, and is not negatively affected my movement.
Lastly, if you’re going to criticize a post, it would be in your best interests to read it first. Your entire last paragraph highlights your poor reading comprehension. My “in-hospital interventions” statement was directly predicated by “if ROSC occurs”. You know that thing where the pulse comes back and they need to be at a hospital soon, where Labs can be drawn to diagnose metabolic causes, effective hypothermia can be induced to increased likelihood of a positive outcome, surgeries can be done, etc. Nobody ever said that we can’t perform an ALS code as well as anyone else, you just failed to read properly.
Okay, first of all, I dont think it was a matter of criticizing posts, so let’s not get off on the wrong foot here. We can, however, have a friendly, informative conversation about CPR and what ROSC means, because, if you are reading and commenting on this post chances are you are already familiar with that.
Take a look at some of the systems with higher ROSC rates.. Seattle, Wake County being two of them, do not use any CPR assist devices. My system which is currently sporting a 40% ROSC rate over the last 16 months with a sizable number of “walkie talkie” saves does not have a single LUCAS device or auto-pulse in service either. We do CPR, our paramedics are empowered to make decisions in the field, and care is effective in the prehospital setting because of it.
I dont think the evidence is there yet to prove that CPR assist devices have a marked increase in effectiveness.
40% eh? Pretty good. Imagination time: We get on scene and we start our care. The clock starts ticking. We get our line, we get our tube, all the while, our Lucas device or AutoPulse is pumping along, providing (as Zoll and Physio claim) equal or better CPR. We get our first couple rounds of drugs in, maybe perform a shock or two. Check your watch, we’ve been on scene 10 mins, still no ROSC. We don’t have to worry about decreasing efficacy of our CPR in transport, so we package and tear off towards the nearest ER.
Say we are 10 minutes into our transport, a couple minutes out from the ER, we get ROSC! If we were still sitting on the living room floor, we would be 10 minutes further away from the ER. 12 minutes further away from in-hospital interventions such as induced hypothermia, surgery, labs that could prevent another arrest, or improve the patient’s outcome! How many hours is that? 40% comes out to possibly hundreds of calls, depending on your service’s size. Every minute after the point at which we became ready to transport, is more time that ROSC patient went without the benefit of in-hospital post arrest care.
Hours. Possibly dozens of hours. If future definitive studies come out that prove that these devices, or better future versions of them, improve or equal the effectiveness of manual CPR, It would be silly to ignore that lost time. You can certainly discount the AutoPulse and Lucas for now, but if more positive studies come out in their favor, I urge you to remember this discussion, and those wasted hours, as reason to modify the way you work your codes. Loading and going in the future (maybe now, the stats just may not be there) may save lives and improve patient outcomes..
As for my response to Grinder, if he is going to be condescending in his ill sighted criticisms of my post, he is going to get it right back. Simple as that. He can post his exclamation points, question marks, and sarcasm, and I’ll show him where to shove them. If you don’t like it and don’t find my discussion provocative or positive, you have my email and a couple of IP addresses to ban.
I don’t believe in banning, as long as the discussion stays civil. We ALL need to take the higher ground at times. . . That said, if we want to have a discussion about who’s ET tube is bigger, that is going to have to occur in a different forum than my blog. I’m sure Grinder understands that, and I ask for nothing more than the same understanding from you as well.
In the RIGHT system, the care that they get in the field provides them the opportunity to receive all of the in-hospital treatments that you speak of. A prehospital 12-lead EKG with paramedic interpretation warms up the cath lab and moves the patient there quickly upon arrival of the patient to the hospital. In the right system, STEMI patients spend very little time in the emergency room at all. Is blood pressure low? Pressers can be started in the field as well. Hypothermia is begun prehospital.
Surgical cases are unique calls, and are things that quite often might not be able to be diagnosed in the prehospital setting unless there is some known history.
Take a look at the links that I shared above. They contain a lot of information from some rather smart people from both sides of the discussion.
The evidence is out there to prove either of us right or wrong, and people need to collect it. How many ROSCs occur after arrival at the hospital or more than 10-15 minutes outside of EMS contact that have a favorable outcome for the patient? What interventions were performed in those cases that could not have been performed in the prehosital setting?
The LINC study left a lot of gaps in the information and both Sean Eddy and the Rogue Medic point that out. More complete and impartial studies need to be done with all CPR assist devices and the situations where they are truly beneficial.
I would disagree that Lucas devices show a marked increase in effectiveness. Physio’ s own LINC study proved that there was little difference in ROSC rates with traditional CPR vs Lucas CPR
Here are a couple of interesting posts worth reading on the topic of the LUCAS…
Rogue Medics’s 4 part post starts here:
http://roguemedic.com/2014/03/in-defense-of-no-improvement-by-medic-madness-part-i/
He misses the mark with the first post if you ask me, but makes some good points in the following 3…
Here are some of Peter Canning’s thoughts on using the LUCAS:
http://www.medicscribe.com/2014/03/16/whup-kit-and-chihuahuas/
Brooks Walsh from Mill Hill Ave Command:
http://millhillavecommand.blogspot.com/2014/03/we-had-lucas-save-no-you-didnt.html
And finally, Sean Eddy’s post on the LUCAS:
http://medicmadness.com/2014/03/in-defense-of-the-lucas/
Thanks for the great post. It was inspiring. How inspiring? I wrote my own. Don’t worry, I dropped you a plug. Check it out, if you have a second. And keep your great stuff coming. Great Blog!
http://www.hippocratesworkshop.com/should-i-stay-or-should-i-go