The really successful departments have almost moved to a minimalist protocol (Wake County comes to mind) and send enough people home from the hospital to call Mom about it.
Or to write Mom about it –
Dear Mom,
A patient I resuscitated was discharged from the hospital today. She is going home and going back to work. That is my third successful resuscitation this year.
Love,
Your Always Learning EMT.
vs.
Dear Mom,
I had another save today!
They get pulses back after we dump epi into them, but then they die in the hospital.
We need to fix the hospital. We save them, but the doctors kill them. These stupid doctors don’t know what they are doing.
The Heart Association keeps changing the rules. They need to pick something and just stick to it.
Love,
Kitchen Sink Medic.
–
Both mean well.
One helps patients.
One helps kill patients.
.
I kinda wish I could tell my mom about all my saves as a Paramedic, but really they’ve only come as a Basic. Not enough folks use CPR in the area I serve as a Paramedic and it can be upwards of 8-9 minutes for first responders to arrive. But we’re working to fix that by rolling out a community CPR program. So hopefully I can start telling momma about some Paramedic saves.
I think that all saves are BLS saves.
Without good BLS, it doesn’t matter what the medic does.
I had a kitchen sink save – you know, where you gather together all of the empty boxes and try to figure out how to divide the scene time to get the right documentation times – where nobody expected to find out any good news.
The guy was discharged from the hospital without any serious problems (he did have sore ribs, sore throat, et cetera). Nobody expected this.
Down time to ALS was long. Nobody could find the address – except the fire department.
The fire department was on scene doing excellent CPR for over 10 minutes before any of us drug pushers arrived. I think that is the only reason that this patient had a good outcome.
We gave epi maybe a dozen times.
We gave lidocaine at least twice.
We probably gave bretylium and bicarb and other stuff. It has been a while, so my memory of the specific drugs is not what it once was.
We even had 3 medics on scene.
In spite of all of that, the patient survived.
I can’t prove it, but I do think that the only ALS that mattered was defibrillation – they did not permit BLS AED use there at that time, so defibrillation was ALS.
One of my BLS saves had over 35 minutes of CPR, discharged home, no deficit. I try to impress upon the basics that I ride with at the ALS service that only one of the three things proven to increase survival to discharge require a medic, and therapeutic hypothermia appears to only help if you get a pulse back (although it may not hurt during a code).
CPR? BLS. Drop a King, continuous compressions…
Defibrillation? BLS. AED shocks everything a Paramedic would…
Still looking for where I fit into that picture, oh wait I see it now: I can rotate through as a compressor.
Amen!
I just have to ask. As I have read through your site, something keeps slapping me upside the head with what you write about Cardiac Arrests: Do you feel that giving medications contributes to the death of a patient? From the way I read it, you feel that doing nothing but compressions, basic airway adjucts, and AED’s are the way to go to get adequate saves…
In many ways, I think you’re right. Basics relying on the idea that they can do piss-poor CPR until the Medics arrive with the magic box and that saves them is wrong. Medics focusing too much on what’s in their little tackle box o’ drugs is also a piss-poor way to get a save. You can give someone enough Epi that their heart will start pumping again, I’m sure. I’ve had that similar experience of collecting all the little boxes and vials after it’s all said and done trying to figure out just what we did.
BUT.
On the other side of things, certain causes of Cardiac Arrests need the attention of a Medic. While 75% of Arrest patients don’t fall into the H’s and T’s categories, but the 25% that do…
I feel that the focus of working arrests should be on Compressions, Airway, and Early Defib…the simple things…where the medication fits in…not sure yet, but I know they have the same importance, when used correctly, as basic life saving skills.
Good writing! Very controversial ideas, but I love it!
I am shocked that you are Criticizing A Letter To Mom?
I think the problem is pushing drugs without an indication. Obviously, reversible causes of cardiac arrest (H’s and T’s as they so known) require prompt intervention either pharmacologically or procedurally. However, routine administration of medications in a cardiac arrest without an indication other than “cardiac arrest” has not been shown to increase survival to discharge.
Basically cardiac arrests where you have reversible causes (that isn’t PCI) are the exception which prove the rule! No meds/procedures without indication and cardiac arrest isn’t an indication alone.
As far as continuous compressions, basic airway adjuncts, and AEDs being all you need was a bit of a hyperbole on my part, but it makes a point. If compressions, defibrillation, and hypothermia are all that have shown an increase in survival to discharge, anything which hinders them should be avoided.
I have found on arrests without an AED that cardiac monitors do not keep you “to task”. You don’t get a forced reminder every 2 minutes to defibrillate if necessary. Any delay to appropriate defibrillation is bad! Although I’m loving these newer ALS monitors that have live QA for codes and I wish my service had them….
A further, Amen!