Paramedics Save More Lives When They Don't Follow the Rules

http://www.heart.arizona.edu/news-info/documents/SHC46WEB.pdf

We had a good thread on the new resuscitation guidelines and compression-only CPR (the "wrong" way) last December here . These people at Arizona are among a handful of communities that are pushing the envelope of traditional resuscitation techniques.

By the way, it seems that the American Heart Association has a new campaign to really ramp up the number of CPR-trained lay people. They have a Family & Friends CPR Anytime training kit that includes a DVD and booklet, plus a small training "dummy" that gives you feedback on whether you're doing compressions forcefully enough by making a clicking sound when you do it correctly. And all this for just $30! You can read more info here. I've been meaning to order one for a while just for the dummy. For those of us who have already been trained, I think just the dummy alone ("Mini Anne") is valuable to help you maintain a bit of "muscle memory" on how hard and deep to push. It's one thing to mentally know how deep to push, it's another to actually practice occasionally for a few minutes and get accustomed to the motion and so that you have more confidence when the time comes to actually do it in real life.

Oh, another recent article in the popular press. AED's are not the end-all and be-all of resuscitation. People still often need CPR even after an AED has worked. Check out the article here .

When I took my EMT course, the first thing the instructor said was, "I'm going to teach you how to pass the state exam, and I going to teach you how to save lives on the street".

Protocols and procedures are there for a reason and this is to protect me (health care provider) and institution (receiving facility). Usually they are created by people who never had to implement them on the scene or in the environment that can't be controlled. EMS personnel knows what works best and knows which corners can be cut and which order of things can be changed in order to benefit the pt or without hurting them. But there is other side to this... lets say you saved someone’s life during cardiac arrest and instead of doing what you should by the numbers you mixed things up a bit (since it worked in the past). Person you save is ok except he/she has a minor speech deficit secondary to oxygen depravation during down time. Now both you (rescuer) and md knows that there was a great chance of anything going wrong and it is a miracle that this person is even alive. Now family finds out that you didn’t cross all the Ts and dotted all the Is and went AWOL on the prescribed procedure. How long do you think before fancy lawyer steps in? How long before your organization settles out of court because not following a medical protocol is a big no-no...

Having said that I think that because there is a possibility of getting sued a lot of EMS providers keep their mouth closed about what works that is slightly out of protocol.

Here in NYC our seizure protocol states to start an IV and give pt sugar just in case seizure activity was induced by hypoglycemia and than if that doesn’t help go with sedatives. Now I don’t know if you ever saw a bad seizure but trying to start an iv on a pt who’s movements are unpredictable is dangerous not only to the patient but also to a medic. Can it be done? Hell yeah but why risk it. Have I done it? Yes many times but more for skills than for anything else. What we do in the field is we give valium thru muscle and when they come down start IV and follow with more sedatives and sugar. Is valium faster thru IV? Yes it is but again there is a risk of accidental needle stick. This protocol was develop in cooperation with top NYC seizure experts based on the condition in the ER. Docs who spoke their mind and chose combination of drugs for us to use already had an IV put in by the nurse. So all they did was show up and do their stuff. None of them docs had to put an IV into patient that is flopping on the floor like a tuna on the deck of the boat. And it sucks because new medics are getting hurt and confused trying to figure out why stuff is done certain way.

It is great to work in the community which is highly tolerant of new stuff and open minded to improvement. Unfortunately many large systems are run by ER docs who cant start ivs ,intubate or read an EKGs since all of it is done by nurses and medics in the field.

Our service is all ALS and has switched completely to the new AHA guidelines. Even on a full megacode, we don't even try to intubate until after 2 minutes of compressions; then we have exactly 10 seconds to land the tube before compressions resume. Didn't hit the tube? Fine, keep bagging w/ the mask.

Lask week I re-certed on BLS for healthcare providers. It is all based on the new AHA guidelines. Some people complain about the changes and talk about some dark conspiracy by the AHA to sell more materials & make more money. But if the research shows the changes to be beneficial (and it does), I don't mind relearning things.

Hey Matt, I hear you loud and clear about those docs who think the outside world runs just like their little kingdoms in the ER.

I will second what Matt has stated, really nothing more to add.

Pete

That is an unfortunately named article. The Cardio Cerebral Rescutation (CCR) is becoming the standard of care in Arizona. While many agencies have adopted the 2005 AHA guidelines, we have added CCR/[url=http://www.azshare.gov/index.htm[SHARE[/url] to our protocols. AHA has made some improvements over the past few years, but they are too driven by where their donations come from. The change to 2 minutes of adequate CPR prior to defibrillation, etc and the change a 30:2 compressions to ventilations ratio are a direct response to the research done by the Saver Heart Hospital and data for Seattle and Wisconsin. This change for out of hospital cardiac arrest (OHCA) patients is a huge improvement in management. Communities around me have been seeing 300-400% improvements in survival rates! We have only used it on a few patients, our demographics lend to cardiac arrest by other causes then sudden cardiac death. For areas that aren?t utilizing this protocol, you can take some key points away from it to help your patients.

1. This is addressed in 2005 AHA, but you need to fluff up the heart a little before defibrillation. 2 minutes of CPR with 100 gorilla compressions/min. Push fast, push hard, push deep! Most victims of cardiac arrest have adequate PaO2 (blood oxygen levels) for a little that their heart will benefit from this gorilla CPR and be more likely to respond to defibrillation. Don?t stop compressions from any reason that absolutely isn?t necessary.

2. Get venous access in early, while your partner is doing compressions and get Epi on board now. Get a few minutes of compressions, drugs and shocks onboard before attempting to Intubate. If your agency allows use quick access devices like IOs and Combi-tubes or LMAs (ILMA if available). These devices save time, your patient?s time. The old standard FAST-1 Sternal IOs work great, and the new EZ-IO and BIG devices are even better! A combi-tube and a LMA are better than an OPA and the patient can be intubated later once they have a return of spontaneous pulses. If you have ventilated you patient for an extended period utilizing a non-definitive airway, remember an OG or NG tube can be a great way to relieve gastric distension and improve ventilation compliance.

3. When you do have a return of spontaneous circulation, BE AGREESIVE. Know you post-arrest protocol, check blood glucose, give fluid, break out the pressors, maintain adequate ventilation, etc. ROSC hearts are more likely to return to arrest again. Good uninterrupted, compressions are the corner stone of CCR and you will be likely to see more ROSC than in the past? be prepared!

All too often protocols are written by those who have never set foot in an ambulance, have never been woken up at 3am for a call, never had to work on a patient in a rundown apartment whose light is from the TV who they are stealing power from their neighbor for. Sometimes EMS protocols make sense, sometimes they don?t. We just rewrote all of ours, and they are a huge improvement over or previous version. Some of the medics are less than enthused about the change; mostly because they don?t allow for have measure paramedicine anymore. But, one of the biggest changes we made were to add some of the field tricks into our protocols. Another is giving medics some options where appropriate, like adding IM Valium or Versed for sedation or seizures if an IV cannot be established quickly or safely.

Polak, we don?t give Dextrose before Valium in an actively seizing patient unless we already have a blood glucose reading. That was a change with our previous protocols, in 13 years I have yet to see an actively seizing patient when had a significantly low bG, postictal or ?seizing? according to the bystanders yes, but not the ?someone help me hold her arm so I can give her some valium? seizing patients. Now if I can only get our medical director to sign off on Auto Injectors for Valium <img src="/images/graemlins/laugh.gif" alt="" />

I still have yet to see any data that proves Amioderone is actually better than Lidocaine... Of course the new AHA building that Amioderone's manufacturer paid for is nice.