The only reason we get away with giving such large doses of epinephrine to these patients is that they are already dead.

- Rogue Medic

Optimizing Outcomes in Cardiac Arrest

 

One more of the great presentations at EMS Expo was on improving outcomes from cardiac arrest.[1]

Lake Sumter EMS does not follow the AHA (American Heart Association) ACLS (Advanced Cardiac Life Support) guidelines.
 

 

One member of the audience kept asking about the threat of law suits – the mediocrity response.

But you’ll get sued!

Tell me what to do to avoid getting in trouble.
 

There is a great scene in The Eiger Sanction. Clint Eastwood (Dr. Jonathan Hemlock) is an art professor and a pretty student wants to flirt her way to a passing grade. Eastwood responds to the suggestion with –
 

Dr. Jonathan Hemlock: Are you busy this evening?
Art Student: No.
Dr. Jonathan Hemlock: You live alone?
Art Student: My roommate’s gone for the week.
Dr. Jonathan Hemlock: Good. Then… go on home, break out the books and study your little ass off. That’s the best way to maintain a “B” average. Don’t study it all off.[2]

 

We have too many people in EMS who think a magic pill will keep them out of trouble. The right connections or some magic phrase. Scene safe! BSI!

They don’t want to have to be competent at patient care. They just want to stay out of trouble. Perhaps the best way to avoid trouble is to provide competent patient care.

If they don’t know what competence is, they should stay out of EMS to stay out of trouble.
 

Dr. Banerjee responded politely to mediocrity fan boy. His results are better than what the ACLS guidelines would produce. You need to show evidence of harm to win a law suit. Evidence of non-conformity is irrelevant.
 

 

Fewer than 10 systems produce better than 20% VF (Ventricular Fibrillation) survival to discharge.

We need to stop listening to the defenders of mediocrity and stop killing so many patients.

If we are more worried about the lawyers, than we are about our patients, then we should not be making patient care decisions.
 

 

Do these numbers suggest that Dr. Banerjee has any reason to worry about law suits for not following the ACLS guidelines?

No. His only concern would be if he were to start following ACLS guidelines.
 

No ventilations until resuscitated. Eventually, removing ventilations will the ACLS recommendation, but they part with voodoo tradition slowly. Ventilations are not based on research.

Dr. Banerjee is a fan of pressors (epinephrine and vasopressin), but he is also not going to go against the research if research ends up showing that epinephrine is harmful.

The PEA (Pulseless Electrical Activity) protocol is interesting – treat for many of the potentially reversible causes automatically. I do not remember if it is already part of their protocol, but if it is not, they might want to add bilateral needle decompressions to rule out tension pneumothorax.
 

Why do the defenders of mediocrity fight so hard against progress?

Maybe they just don’t want progress.

Footnotes:

[1] Optimizing Outcomes in Cardiac Arrest
Nov 2 2012 1:15PM
Pushpal (Paul) Rocky Banerjee, MD, Medical Director, Lake EMS, FL; Assistant Medical Director, Aviation One – Medical Transport Services
Friday schedule

Cardiac arrest is a medical emergency that is potentially reversible if treated early. With fast, appropriate medical care, survival is possible. Administering continuous chest compressions, along with early defibrillation, can improve the chances of survival until emergency personnel arrive. Lake EMS has developed an innovative approach to cardiac arrest care. Dr. Banerjee will demonstrate why the cardiac arrest resuscitation rates at Lake EMS are among the highest in the world.

[2] The Eiger Sanction
IMDb.com
Movie quote at IMDb

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Comments

  1. Good on them!

    My favorite part is definitely the 720J for refractory VF. I just wish they were even more in-your-face about it and added in hands-on defib with AP pad placement to really jump-start those hearts.

    I’m a bit less enthused about some of their medication choices and emphasis on intra-arrest cooling, but with numbers like those I can’t really disagree. Like you said, the data could go either way over the next few years and I’m sure they’re open to change once there’s any decent research to guide us.

    Thanks for sharing this – I never make it out to these things and haven’t really heard much on the prehospital resus front over the past few months.

    • I work at places which do intra-arrest and post-arrest and as far as I can tell we’ve not seen any difference…which probably means for the relatively small numbers of our area the observed effect of the method of cooling is trumped by higher weighted variables like early CPR or defibrillation.

      I too thought some of the med choices were suspect, but good on them for moving forward!

      If they replaced Narcan with Calcium and D50 with nothing (or ultrasound!) this would be the king of all protocols.

  2. Fewer than 10 systems produce better than 20% VF (Ventricular Fibrillation) survival to discharge.

    Make that 11. The Borg’s numbers are around 24%, but I don’t believe they participate in the CARES registry. We use the same criteria, though.

    We’re doing some of what Lake Sumter is doing, but I wish we did more.

    • Ambulance Driver,

      Fewer than 10 systems produce better than 20% VF (Ventricular Fibrillation) survival to discharge.

      Make that 11. The Borg’s numbers are around 24%, but I don’t believe they participate in the CARES registry. We use the same criteria, though.

      We’re doing some of what Lake Sumter is doing, but I wish we did more.

      Good point. These are not all of the systems doing good work. I think Tom Bouthillet’s system is also producing high numbers. These are just the numbers in the biggest registry of resuscitation data.

      This raises the question – why aren’t more systems contributing to the data?

      I can understand why the systems producing bad numbers might not want to participate, but the systems producing good (or even great) numbers would have an excellent opportunity to compare the way they are doing things to see what they might add, or subtract.

      .

    • Interestingly, from the brief screen shot, I didn’t see our system up there either. Hennepin EMS (Minneapolis & surrounding area) had survival to discharge of V-fib arrests at 50% in 2011…55.6% survival to discharge for those receiving bystander CPR prior to EMS arrival. I haven’t run the 2012 report yet…

      Our protocols roughly follow ACLS…but not strictly. Cooling is done immediately post-arrest. We do participate in the CARES registry.

      Some of their protocols do seem interesting and worth exploring.

  3. Can someone supply a link to (or post a copy of) the actual protocols? For some reason I can’t find them online, and there are some parts of the slide that confuse me. For example, it says continuous compressions without interruptions, yet also talks about King airways and BVM with RSI. Also curious about the 720 J defibrillations; presumably that would be dual monophasic defibrillators and I thought nearly everyone had moved to biphasic.

    • mpatk,

      Can someone supply a link to (or post a copy of) the actual protocols?

      I do not have a link.

      For some reason I can’t find them online, and there are some parts of the slide that confuse me. For example, it says continuous compressions without interruptions, yet also talks about King airways and BVM with RSI. Also curious about the 720 J defibrillations; presumably that would be dual monophasic defibrillators and I thought nearly everyone had moved to biphasic.

      The King and RSI would only be after ROSC.

      During the code, they do not ventilate.

      There initially was a suspected benefit to biphasic defibrillators, but further research has failed to confirm that benefit. They use two defibrillators at 360 joules each.

      .

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