Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Criticizing A Letter To Mom?

Medic Trommashere writes a response to A Letter To Mom.

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?

When the focus on ALS (Advanced Life Support) distracts from performing good CPR –

ALS Kills Patients.

When the focus on ALS distracts from delivering prompt defibrillation (AED or manual) –

ALS Kills Patients.

When altering the chest compressions to make it easier to get the tube

ALS Kills Patients.

When choosing to transport to the hospital, while performing compressions, just to transport to ALS –

ALS Kills Patients.

When dumping fluids down the tube make sure that the patient gets the benefit of the drugs –

ALS Kills Patients.

When BLS (Basic Life Support) personnel delay treatment so that the medic can do something –

ALS Kills Patients.

If there is ever any evidence that ALS (other than in specific cases and therapeutic hypothermia) does anything to improve real outcomes, then I will revise anything that needs to be revised. Until then, the A in ALS is just for Alternative medicine. Alternative medicine Life Support is BS.

Unprofessional, unethical, uncontrolled, unauthorized, unreasonable experimentation on people who are just too dead to run away. And without any attempt at informed consent.

As with other forms of alternative medicine, the result is unsuccessful.

We need to leave the alternative medicine to the frauds. We need to do what is best for the patient.

Give a drug, just to get a pulse back, so the patient can die in the hospital.

Celebrate an EMS Save.

This is not in the interest of the 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…

I would not include the basic airway adjuncts.

Except in the case of respiratory-induced cardiac arrests, we should probably be ignoring airway completely for the first 10 minutes – maybe for longer.

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.

We agree on that.

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 do not have any objection to looking for potentially reversible causes of cardiac arrest.

Good medicine is about looking for potentially reversible causes of everything we treat.

Why 25%?

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.

Why airway?

The research on cardiac arrest seems to be showing that the less we focus on airway, the better the resuscitation rates.

I don’t know what is the right amount of attention to pay to the airway.

We have not yet been able to come up with any amount of airway attention that improves outcomes, for general cardiac arrest patients.

Yes, we have been taught A, B, CAirway, Breathing, Circulation.

Unless the Airway is obstructed, we should probably ignore A.

Unless a Breathing problem led to the arrest, we should probably ignore B.

We do have research to support focusing on C – and only on C.

OK, we need some DDefibrillation.

Why fight the research?

Respiratory-induced cardiac arrest is a different story, but that falls into the category of potentially reversible causes of cardiac arrest.

Why drugs?

What part of the extensive research of reflexively giving drugs to dead people suggests that we should Just say Yes to drugs?

Maybe we will find some specific instances where epinephrine is beneficial, but I do not see any justification for giving this cardiotoxin routinely to people with probable cardiac illness.

I think that magnesium is a great drug for torsades, calcium is a great drug for hyperkalemia, epinephrine is a great drug for anaphylaxis and for asthma, sodium bicarbonate works for hyponatremia and for sodium channel blocker toxicity and may have a small effect on hyperkalemia (after calcium) and on acidosis – but only give bicarb after the patients is being adequately hyperventilated.

We need to forget about trying for an EMS Save.

We need to work on a real save for a real patient leaving the hospital alive with real brain function.

Everything else is just a distraction from patient care.

Medic A – I got an EMS Save.

RM – Sorry to hear it. Do you want to go get a beer and talk about it?

It would be wrong to refer him for CISM/CISD (Critical Incident Stress Management/Debriefing).

Good writing! Very controversial ideas, but I love it!

Thank you.

.

Comments

  1. I started to reply here, but it began to get lenghty, so if it is alright with you, I will post my reply on my site as to not take up too much room in the comment section.

    ~MT~

  2. OHHH SNAP!

  3. “I can give enough epinephrine to this table to give it a pulse, but it will never again be a tree.” – Larry Cobb RN when asked how much epi is enough in a recus scenario.

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