I’ve been thinking a lot about cardiac arrests, CPR, and the barriers that I face in the system that I work in. Chances are, if it is a problem here then it is a problem somewhere else, which makes it worth talking about.
In the system that I work in there are two types of dead people: people who are not workable; that is to say, they have some injury incompatible with life, or conclusive signs of death. The second kind is one that ends up on a stretcher in an emergency room. That’s right, if you get CPR, you get a ride to the hospital.
After doing some research earlier this year for a class I was teaching about running a better code, I found a clip from Wake County, North Carolina where their medical director Dr. Brett Myers talked about the key points to the quality of cardiac arrest that they provide. The one big one that stuck with me was “Don’t move them. Work them where they drop.” I realized very quickly that Wake County had one very important component to high performance CPR that my system lacked.
Over the last two years we have learned a lot about quality of compressions and their importance. Anyone who has taken ACLS or an ACLS refresher has heard that you never stop compressions, or at least you greatly minimize interruptions but what they fail to address is the importance of knowing when to say when and affording us enough options and guidelines telling us when to stop CPR. Actually, let me rephrase that. The content and evidence is there, but a few systems have chosen to ignore it.
So am I saying that knowing when not to do CPR or when to stop doing CPR is an important piece to improving ROSC rates? You better believe i am. Let me describe a common cardiac arrest in my system:
The crew gets on scene to a confirmed code with fire department first response and more times than not, a second ambulance is coming behind them to assist. When that truck arrives, the patient is loaded into the best way to extricate them from where they are found. More times than not, we find that our patients are backboarded inside and carried out of residences. Occasionally though, a crew is able to get a stretcher right to the patient’s side, or on even more rare occasions they are loaded into a stair chair for a short time because a backboard extrication is not possible.
While the patient is moved and carried to the stretcher, CPR is often times not occuring or it is lacking in effectiveness. While they are being actively loaded into the ambulance, again, CPR is not occuring. When we are forced to transport these codes, pauses in CPR become more frequent and lengthier, and quality of compressions dips significantly.
The answer to increased ROSC rates is better ceasation protocols. Sure, there are some logistical issues that need to be sorted out, but those pale in comparison to giving patients the best chance that they could possibly have at survival. The AHA given us the tools that we need to run a better code, and now it is up to us to use them.
Sometimes staying and playing is the right answer and modern effective cardiac arrest care is one of those situations. If paramedics are told that they do not have to worry about loading and transporting these patient and they can instead concentrate on what is really important: getting that heart going again.
Already doing it here in Maine… what we needed that hasnt happened is public education on why we either are or aren’t loading and moving. I worked a code here in a somewhat public venue (golf course) and it wasnt a save. Bystander CPR had been going 20+ minutes. Eyes were fixed and dialated, and he was asystole much of the time we worked the code. We worked him 25 minutes and I chose to call it. The expectation was that we would leave and go to the hospital and when we didnt, we got some cross-eye’d looks. It took me just as long to educate bystanders on our protocols as it did to work. We did get a pat on the back from another bystander, who is medically oriented, and told the course owner how professional my crew was.
We definitely seem to be quite behind in this area in terms of appropriate cardiac arrest protocols. I’m sure it is true in plenty of other systems but it seems it will be quite difficult to change to focus from trying to have the shortest total call time to a more scientifically proven method. This is especially true in a number of our multiple story building with either no elevators or those too small to support a stretcher. The CPR interruption just from that move is entirely too long, not to mention the list of other possible interruptions. ACLS is ACLS no matter where it is performed. Even with a 20 minute total call time, if there is no ROSC on scene, chances are the long term outcome is going to be poor. We need to change the culture from racing the clock and “getting the tube” to one of CPR and the current ACLS protocols.
I have been able to talk with family (when they are there) and ask them how they want the patient treated.
Preparing them, by explaining that the chest compressions are because the patient’s heart is not beating, the ventilations (because our system still requires this witchcraft) are because the patient is not breathing, the lack of response is an indication that the brain and/or heart have been dead too long for us to be able to do anything, and the drugs are because we are so desperate that we will try anything. Medical marijuana is just as effective as any of the drugs we use.
Of course, I do not include the sarcasm, but I try to give them time to recognize the futility of the situation before we get to a transport decision.
We are supposed to be considering the family in this, so the medical command doctor appreciates having input from the family on the decision, rather than an irate family member with a large – and completely unnecessary – bill.