The Typical Cardiac Arrest

The Typical Cardiac Arrest

Oct 7, 2014

As I mentioned last week, I had the privilege of teaching a fully sponsored, free pit crew CPR class to about 90 EMTs and paramedics. The class was so well received that I was approached by a couple of departments who were interested in bringing the training as well as the policy and procedure to their department.  There has been an aggressive push to improve cardiac arrest survival in our system, and it is great to see the leadership of many of the BLS services taking a proactive approach to be part of it.

The desire to change a mindset of what people view as a “traditional” cardiac arrest is extremely encouraging. There is a genuine want to learn and do better. In fact, I was recently on a CPR that ran very smooth from beginning to end, complete with an EMT using his iPhone’s stopwatch to call out changes in CPR. It was the true embodiment of “EMTs owning CPR” just like the Seattle Resuscitation Academy talks about.  If our compression fraction was less than 90%, I would be surprised.  It is amazing how far we have come when running a typical cardiac arrest.

I remember the very first cardiac arrest that I worked as a cleared paramedic. Airway was king. Nothing else seemed to happen until that tube was in.  Do compressions but they are not that important. We need to get oxygen into the body before we can think about pushing it round and round, and passing an ET tube, well, there is no better way to do it than that, right? My bag was filled with antiarrhythmics. We carried bretylium, for example, and if you encountered one of those rare refractory v-fib patients who remained in that rhythm amidst the long pauses in CPR to get that patient intubated, then you might actually give it.

Then there was post resuscitation care. There was not much stress on it because we did not get people back very often. If it happened, you threw up dopamine on a hypotensive patient. If you gave an antiarrhythmic like lidocaine, for example, you hung a drip of the same medication. My Lifepak 10 was not capable of doing 12-lead EKGs and based on the six hour 12-lead class that I had as part of my paramedic training, I could not tell you much about it. Heck, most of that class was spent stressing over trying to figure out what the axis was.  Instead, we watched the little screen intently, and made sure that we did not turn the monitor off after the call.  If we did, the code summary would be lost.  If we were able to print, it whoever had the pleasure of reviewing the call if it was reviewed at all would be greeted with meters upon meters of EKG paper with little information associated with it other than rhythms and defibrillation times.

Here I am fifteen years later riding on the back of evidence that says that nothing is more important than good compressions. If the patient can be ventilated easily, put that tube kit aside for a while. You are getting enough oxygen to the patient to make a difference. Whatever you do, do not stop compressions. This is where pit crew CPR comes in.

That arrest that we worked recently never left the house. While we did not get the patient back, what we did do was give them the best chance possible. The result of the code was bitter sweet. It is a simple fact that we are not going to bring back every single cardiac arrest patient that we work, but what could previously be considered as “controlled chaos” over the years was a well choreographed effort by both BLS and ALS. I walked into the room ready to take the lead, and was excited to see how the people who were on the call that were at my class reacted to the entire process, but I did not have to. All that I had to do was push my meds, keep track of my code markers, and do a little simple compression coaching. The rest of the call took care of itself.

I am proud to work in a pretty progressive EMS system. Our ROSC rate is currently close to 35-40%. I got thinking about what that really means the other day. One out of every three people that we work we get pulses back on. One out of three. That is staggering when compared to the one out of twenty that we seemed to get pulses back on when I started my career.  What it comes down to is pit crew CPR works. The evidence supports it. If your system does it, great! Now keep practicing it, and keep working every single cardiac arrest the same way. It’ll give each of your patients the best possible chance of a favorable outcome. If you don’t, find a class. Get some information. Take a look at what Wake County has done, or Seattle.  Or look up some of the PowerPoints that David Hiltz has put up on Slideshare.  Heck, email me! I will send you everything that I can. Ask your leadership and your medical director, “Why aren’t we doing this?” Push for change. Push for progress. And push to have a ROSC rate that is higher than the one my service boasts about. Do that and I’ll shake your hand, and learn from your successes.