The Evolution of Cardiac Arrest Care

As we start to dive down the rabbit hole of what makes an effectively run cardiac arrest, it is important to understand the roots of what we are actually doing.  Personally, I could go back some 23 years to 1993 when I received my first CPR card.  I learned the importance of opening the airway.  Looking, listening and feeling.  If the patient was not breathing, and I could not give a rescue breath, I had to reposition the airway.  Simply put, until the patient had a patient airway, and was effectively being ventilated or breathing on their own, not a single compression was done.

If I had somebody with me, for every five compressions that were done, a ventilation was given.  If it was just me, it would be 15:2.  Sometimes I am amazed that we saved anyone at all following that.  In the system that I started in, I feel like we were ahead of the curve.  CPR calls were commonly not transported to the hospital.  We would work them at home and leave them at home.

Fast forward now seven years to my time as a paramedic student and my early days as a paramedic.  Not much from that airway focus had changed.  ROSC was rare.  Survival to discharge was even more rare.  Every workable cardiac arrest was transported to the hospital regardless of rhythm or downtime. The success and failure of the care provided rested on two factors: whether the patient was turned over to the emergency room staff intubated, and whether or not the call time was short.  We would walk away from a code high fiving each other for delivering a dead body to the ER in 30 minutes or less, like we were some glorified Dominos delivery drivers.

Throughout my career, my views on EMS and the impact that we have on the general public has swung to both ends of the spectrum.  I’ve felt that we were completely necessary for the well being and survival of every single person that we encountered, and I’ve felt used and abused by the system.  As I enter my 16th year as a paramedic though, I can without a doubt say that the place where prehospital providers make the most difference is in cardiac arrest care.  We should strive to be resuscitation specialists.

For example, in the summer of 2015, I attended the Institute of Medicine’s workshop regarding their recommendations for cardiac arrest care.  One of the topics discussed was the challenges commonly faced while working in-hospital cardiac arrests.  The segment’s presenter identified some of the challenges that hospitals face with their own cardiac arrest response.  Ironically, many of the challenges presented mirrored the hurdles that are commonly faced in the out of hospital setting most notably accuracy in charting and the complete variability of skill level and personnel that one might have on any given arrest.

During the question and answer period, I posed the question as to whether or not the avenue of allowing paramedics to train in hospital providers or just simply adopting an out of hospital cardiac arrest style of response for the in hospital setting had been discussed in the breakout session.  The panel stated that it had not, however based on the response from the room, any in the audience agreed with the notion that hospital staff could learn a lot from out of hospital cardiac arrest response.  One doctor went as far as to say that he “always tells people that if I go into cardiac arrest in the hospital, drag me out to the ambulance bay and call 911.”

The most important time for a patient in cardiac arrest are the moments that immediately follow their event.  Factors such as bystander intervention and involvement and post-resucitation care are some of the things are most commonly overlooked.  In the coming weeks and months, we will take a closer look at them and many other factors that we, as paramedics and EMTs need to look at to be better resuscitators.