If you have a BVM (Bag Valve Mask resuscitator), you should not need naloxone. The problem is inadequate respiration, not inadequate naloxonation.

- Rogue Medic

Top Ten Resuscitation Headlines from Rescue Digest – Read ‘Em and Learn

 

This should catch your attention -
 

RescueDigest’s Top Picks of essential resources for critical topics in emergency services.
 

What should we be paying attention to?
 

Headline #1: EMS Saves Everyone / EMS Saves No One[1]

 

If you read the main stream media, you get one version, or the other, or even both in the same week/month/year.

Why?

If we get our science reporting from the news media, we are not getting valid science reporting.

We are probably getting a poor translation of a secondhand account of what the researcher denied was the result of the study.

Trust the media. We would never misrepresent anything!
 


Image credit.
 

This article provides evidence to explain what the truth is.
 

Does EMS save everyone?

We haven’t put the funeral homes out of business, yet – and we never will.

Does EMS save no one?

Systems that focus on excellent uninterrupted compressions and rapid defibrillation save 40% – 60% of the patients who are in a shockable rhythm when EMS arrives.

You were dead.

No pulse.

No brain function.

Dead.

Dead.

Dead.
 

But – after EMS treatment – you are alive.

This is a true improved outcome, not getting a pulse back only to die in the ICU, or to die in a few weeks/months in a nursing home without ever waking up.

Your brain is working again.

You can play with your children/grandchildren, again.

You are alive.

Only 40% to 60% of patients in shockable rhythms when EMS arrives!

Not perfect, but nothing is perfect. Less than perfect is imperfect, but everything is imperfect. Less than perfect, but better than nothing is still better than nothing. 40% to 60% are better than they would be with nothing.

The NNT (Number Needed to Treat) is a little more than two.

That makes this one of the most effective medical treatments available. Prevention of cardiac arrest is still better, but when prevention does not work, this frequently does.

Less than perfect is the best that is available from real medicine. Charlatans will promise to do better, but they will end up making excuses for failure – and they cannot resuscitate.
 

The basic trouble, you see, is that people think that “right” and “wrong” are absolute; that everything that isn’t perfectly and completely right is totally and equally wrong.[2]

 

What about the rest of the headlines?

Don’t end up like this –
 


Image credit.
 

Go read what Rommie Duckworth is writing.

Go through the slides from his presentation. If you get a chance, go to a conference where he is presenting, such as EMS Today in Washington, D.C., a little over a week from today.
 

Education
2:15PM- 3:15PM
Don’t Lose Your Cool: Dealing With Problem Students

Room: 207B
The Know-it-all. The Worrier. The Heckler. The Rambler. The Cheater. Is one rotten apple going to spoil your whole program? This program provides educators of all levels with insight into the sources of student issues as well as the mistakes that instructors commonly make that contribute to classroom unrest. Using read more…

Speaker
Rommie Duckworth
Director
N.E. Ctr. for Rescue & Emerg. Med.
Sherman, CT, United States
[3]

 

-

Footnotes:

-

[1] RescueDigest Resources: Top Ten Resuscitation Headlines
Rescue Digest
Posted on Jan 29, 2014
Rom Duckworth
Article

-

[2] The Relativity of Wrong
The Skeptical Inquirer
Fall 1989, Vol. 14, No. 1, Pp. 35-44
By Isaac Asimov
Article

Read the whole article. It is not long, but it is an excellent introduction to how science works.

-

[3] EMS Today
February 5-8, 2014
Walter E. Washington Convention Center
Washington D.C.
Information

Results of search for Rommie Duckworth in EMS Today’s schedule search.

.

Mechanical CPR as an Excuse to Just Transport


 

Dr. Keith Wesley usually takes an approach that is focused on the patient.

Dr. Wesley is one of the doctors I use as an example of doctors who truly understand about the ways EMS can improve outcomes.

But . . .

Why is he suggesting that transporting during CPR is a good idea – except when it cannot be avoided?

Did the IAFF (International Association of Fire Fighters – EMS is about speed, not patient care) kidnap someone important to Dr. Wesley?
 

The researchers had a driver cover a predesignated course in the city with typical changes in direction, railway crossings and speeds up to 78 mph.[1]

 

Because it is about the speed of transport, not about the patient.

When the patient is dead, it is a good idea to slow down and transport safely, not try to make the rest of the occupants even more dead than the patient with the mechanical pulse.
 
 

 
Avoiding patient care, because we can drive fast!

How many of the Low Information Voters of EMS will look at this ridicule of IAFF policy and be proud that they value speed more than they value their patients’ lives?[2]

 
 

Keith Wesley’s Comments
Many may be asking why I reviewed a study with such obvious results.
[1]

 

Because the IAFF took your baby away?
 

Performing chest compressions is fatiguing and the back of an ambulance rolling lights and sirens through the night is downright dangerous. So dangerous, in fact, I consider it bordering on employer negligence if condoned or even sanctioned.[1]

 

This was a study comparing negligence with machine compressions to prove that it is less negligent to use a machine during transport.

We already know that we should be resuscitating patients on scene.

Does this study provide any kind of evidence of improved outcomes from this rush to transport as compared with treating real patients on scene?

No.

Does this even attempt to demonstrate benefit?

No.
 

When you combine the poor outcome of these cardiac arrest victims receiving worthless CPR while exposing the responders to career- or life-ending injuries, I simply wonder who is reading the science at all. If this information was well-known and accepted, then every ambulance in America would be equipped with a mechanical CPR device. So why aren’t they?[1]

 

Why are apples not oranges?

Why are we putting apples on every ambulance?

Because of oranges!
 

This is EMS. We need to know if rapid transport with a machine to be resuscitated in the hospital improves survival when compared with resuscitating patients on scene.
 

Perhaps the idea of replacing a human being with a machine to save a life is unsettling.[1]

 

Allow me to rewrite that –

Perhaps the idea of replacing a human being with a machine to save a life transport a dead body is unsettling.
 

But the science doesn’t lie. If we’re going to save more victims of cardiac arrest, we have to overcome all obstacles and embrace the value—and effectiveness—of technology.[1]

 

Then show how this saves lives.

Where is the evidence of improved survival to discharge?

Surrogate endpoints lie.

This is just a surrogate endpoint paper.

This is just a lie with bad science.

What next? Scientists sat, this one trick will cure cancer.
 

Blood-letting is an excellent treatment – based on surrogate endpoints.

Should we go back to bleeding patients to death just because it makes the surrogate endpoints look good?

-

Footnotes:

-

[1] Mechanical CPR Could Save More than the Patient’s Life
Karen Wesley, NREMT-P | Keith Wesley, MD, FACEP
December 2013 Issue | Tuesday, December 10, 2013
JEMS
Article

-

[2] EMS: The low information voters of healthcare – Making decisions purely on emotion and superficial knowledge
September 02, 2013
The Ambulance Driver’s Perspective
by Kelly Grayson
EMS1.com
Article

.

What Can EMS Expect From 2014? #2 Prehospital Therapeutic Hypothermia


 

It was the sexy new EMS treatment.

The use of fluids for prehospital therapeutic hypothermia was rushed into protocols.

Now that we have evidence, was a mistake?

Some of us are now trying to defend the rush to treat before evidence.
 

CONCLUSIONS:
In unconscious survivors of out-of-hospital cardiac arrest of presumed cardiac cause, hypothermia at a targeted temperature of 33°C did not confer a benefit as compared with a targeted temperature of 36°C.
[1]

 

Cooler was not better in this study.

Patients were cooler, but outcomes were slightly worse for the cooler patients.

The difference was not statistically significant.
 

Conclusion and Relevance Although use of prehospital cooling reduced core temperature by hospital arrival and reduced the time to reach a temperature of 34°C, it did not improve survival or neurological status among patients resuscitated from prehospital VF or those without VF.[2]

 

Patients were cooler, but outcomes were slightly worse for the cooled patients.

The difference was not statistically significant, but all measures trended toward worse with prehospital cooling.
 

There was one study that did trend toward improved outcomes for asystole/PEA (Pulseless Electrical Activity) patients, but the results were not statistically significant.
 

In the patients with a cardiac cause of the arrest, 8 of 47 patients (17%) who received pre-hospital cooling had a favorable outcome at hospital discharge compared with 3 of 43 (7%) in the hospital cooled group (p = .146).[3]

 

Maybe there will be some benefit shown for asystole/PEA patients with a larger study, but this is the most positive evidence and it is not statistically significant –

In other words, there is no evidence of benefit and no reason to use this treatment outside of a controlled trial.
 


 

CONCLUSIONS:
In adults who have been resuscitated from out-of-hospital cardiac arrest with an initial cardiac rhythm of ventricular fibrillation, paramedic cooling with a rapid infusion of large-volume, ice-cold intravenous fluid decreased core temperature at hospital arrival but was not shown to improve outcome at hospital discharge compared with cooling commenced in the hospital.
[4]

 

Patients were cooler, but outcomes were slightly worse for the cooled patients.

The difference was not statistically significant, but all measures trended toward worse with prehospital cooling.

There is a free editorial that is important to read accompanying this paper.

There are possible explanations for the consistent failure to improve outcomes.
 

Swine studies show that ice-cold saline delivered during cardiac arrest reduces coronary perfusion pressure (CPP).4,5 Yannopolous et al4 found that iced saline reduced CPP during CPR from 24 mm Hg to only 4 mm Hg, an alarmingly low value that makes survival unlikely.[5]

 

We rushed to implement protocols to give fluids for prehospital therapeutic hypothermia.

Because of our failure to wait for evidence, we need to get rid of these protocols.

When will we learn to wait for evidence?

When will we put our patients’ health above our need to use the new and untested?

-

Footnotes:

-

[1] Targeted temperature management at 33°C versus 36°C after cardiac arrest.
Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J, Hovdenes J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wise MP, Åneman A, Al-Subaie N, Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge JF, Hingston CD, Juffermans NP, Koopmans M, Køber L, Langørgen J, Lilja G, Møller JE, Rundgren M, Rylander C, Smid O, Werer C, Winkel P, Friberg H; TTM Trial Investigators.
N Engl J Med. 2013 Dec 5;369(23):2197-206. doi: 10.1056/NEJMoa1310519. Epub 2013 Nov 17.
PMID:24237006[PubMed - indexed for MEDLINE]

-

[2] Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults With Cardiac Arrest: A Randomized Clinical Trial.
Kim F, Nichol G, Maynard C, Hallstrom A, Kudenchuk PJ, Rea T, Copass MK, Carlbom D, Deem S, Longstreth WT Jr, Olsufka M, Cobb LA.
JAMA. 2013 Nov 17. doi: 10.1001/jama.2013.282173. [Epub ahead of print]
PMID: 24240712 [PubMed - as supplied by publisher]

-

[3] Induction of prehospital therapeutic hypothermia after resuscitation from nonventricular fibrillation cardiac arrest*.
Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W; Rapid Infusion of Cold Hartmanns Investigators.
Crit Care Med. 2012 Mar;40(3):747-53. doi: 10.1097/CCM.0b013e3182377038.
PMID: 22020244 [PubMed - indexed for MEDLINE]

-

[4] Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial.
Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W; Rapid Infusion of Cold Hartmanns (RICH) Investigators.
Circulation. 2010 Aug 17;122(7):737-42. doi: 10.1161/CIRCULATIONAHA.109.906859. Epub 2010 Aug 2.
PMID: 20679551 [PubMed - indexed for MEDLINE]

Free Full Text from Circulation.

-

[5] Cooling heads and hearts versus cooling our heels.
Becker LB.
Circulation. 2010 Aug 17;122(7):679-81. doi: 10.1161/CIRCULATIONAHA.110.968222. Epub 2010 Aug 2. No abstract available.
PMID: 20679546 [PubMed - indexed for MEDLINE]

Free Full Text from Circulation.

.

EMS EduCast – Dr. Ben Abella on Coursera and Therapeutic Hypothermia

 

On the EMS EduCast, Dr. Ben Abella was on the EMS EduCast discussing the Coursera resuscitation course he taught and the way recent research on therapeutic hypothermia [1]should affect prehospital resuscitation.

Go listen to the podcast.

During the podcast Dr. Abella states –
 

I fear, many of the patients that I deal with are much more injured from iscemia reperfusion than the patients in that study. I wonder if the patients in that study just didn’t need that much cooling. You know, if you’re not that sick, you don’t need that much of a dose of medicine, maybe, and if you’re dealing with sicker patients you need more. Now, what I have just said is an unsubstantiated hypothessis. OK. That’s important for people to know. I am not basing that on fact, rather on my experience and opinion.[2]

 

That is only relevant in some cases.

Sometimes sicker patients require more.

Sometimes sicker patients require less.
 

Shock Values - 2004 Anes
 

Even with adequate fluid resuscitation, propofol remains substantially more potent in patients with hemorrhage. In marked contrast, the potency of etomidate is nearly unchanged in shock.[3]

 

According to this, we should only give 10% to 20% of the normal dose of propofol (Diprivan) to the sickest trauma patients, but we should give more than 100% of the normal dose of etomidate (Amidate) to the same patients.

Do the sickest patients require more medicine?

Sometimes yes. Sometimes no.

Pathophysiologists can provide good arguments either way, but pathophysiologists are the philosophers of medicine trying to explain the limited evidence that is available – until more evidence becomes available.

Dr. Abella may be right about starting therapeutic hypothermia prior to transport, but the best available evidence does not support his hypothesis.

Dr. Abella is clear that this is just his hypothesis and he is encouraging more research, because that is the way we find out whether the hypothesis is correct.

Go listen to the podcast.

-

The EMS EduCast is ending. This is the second to last podcast, from Bill Toon, Greg Friese, and Rob Theriault, but they have nearly 200 podcasts archived to listen to.

-

Footnotes:

-

[1] Targeted temperature management at 33°C versus 36°C after cardiac arrest.
Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J, Hovdenes J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wise MP, Åneman A, Al-Subaie N, Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge JF, Hingston CD, Juffermans NP, Koopmans M, Køber L, Langørgen J, Lilja G, Møller JE, Rundgren M, Rylander C, Smid O, Werer C, Winkel P, Friberg H; TTM Trial Investigators.
N Engl J Med. 2013 Dec 5;369(23):2197-206. doi: 10.1056/NEJMoa1310519. Epub 2013 Nov 17.
PMID:24237006[PubMed - indexed for MEDLINE]

-

[2] Dr. Ben Abella and the Coursera Cardiac Arrest MOOC: Episode 194
EMS EduCast
December 16, 2013
Podcast page.

-

[3] Shock values.
Shafer SL.
Anesthesiology. 2004 Sep;101(3):567-8. No abstract available.
PMID:15329579[PubMed - indexed for MEDLINE]

Free Full Text from Anesthesiology.

.

Is Earlier Better for Therapeutic Hypothermia? Part I

ResearchBlogging.org
 

When is the right time to begin TH (Therapeutic Hypothermia) to produce the best outcomes?

In the ICU (Intensive Care Unit)?

In the ED (Emergency Department)?

In the ambulance?

While the patient is still pulseless?

This question was asked in 2010.
 


Click on image to make it larger.
 

Favorable outcomes – 47.5% EMS TH vs 52.6% ED TH.

Worse outcome, but not statistically significant.

Discharge to home – 20.3% EMS TH vs 29.3% ED TH.

Worse outcome, but not statistically significant.

Discharge to rehabilitation – 27.1% EMS TH vs 23.3% ED TH.

Worse outcome, because these patients are not well enough to go home, but not statistically significant.

Dead – 52.5% EMS TH vs 46.6% ED TH.

Worse outcome, but not statistically significant.
 

The great tragedy of Science — the slaying of a beautiful hypothesis by an ugly fact. -Thomas Henry Huxley.
 

EMS TH was added to many EMS protocols because of a lack of clear evidence of harm. EMS needed to Just do something.

The results did not support EMS administration of chilled IV (IntraVenous) fluid for prehospital therapeutic hypothermia, but the study was stopped early, because –
 

At the interim analysis of the first 200 patients, the Steering Committee noted that there was no difference in the primary outcome measure and that it was extremely unlikely that such a difference would emerge between the groups. Therefore, the study was stopped because of futility after 234 patients had been enrolled.[1]

 

In other words – We will not let the numbers convince us that there is no benefit, because numbers that do not support a positive effect are futile?

If the data would have indicated a negative effect, but had not reached statistical significance, should we expect the Steering Committee to support continuing the study, or would they support discontinuing the study early to protect the enrolled patients, but leave the question unanswered?

When studies are discontinued early to protect patients, do they discourage further studies?

When studies are discontinued early to protect patients, do they only endanger future patients?

Or does early termination encourage further studies because there is not clear evidence of harm and we want to believe that our interventions are beneficial?
 

What if it works?

Most proposed treatments do not work, so this is just an excuse to continue using something dangerous. What if it works? is the logical fallacy that is used to justify harming patients with alternative medicine.

We should not harm vulnerable patients because of our unreasonable belief in wishful thinking.
 

If it helps just one patient it is worth it.

This is another logical fallacy, because it completely ignores the harm that the treatment causes.

Some patients will improve after almost any treatment – even cyanide.

That means that alternative medicine advocates could should endorse the use of cyanide, because if it helps just one patient . . . .

We need to have unbiased information about the real benefits (if any) and the real harms (if any), before we encourage using anything on vulnerable patients.
 

Is it good to just do something?

Or

Is it good to help patients?

If our responsibility is to help patients, one of the best ways to help patients is to avoid causing harm.

Just doing something, with no evidence of benefit, is causing harm.

How many EMS agencies have prehospital therapeutic hypothermia protocols because of a desire to just do something?

I have been criticized for not being a supporter of treatments that do not have evidence of benefit.

Am I a killjoy, desiring bad outcomes?

No.

I understand that treatment that does not have evidence of benefit is almost always going to do more harm than good.

Just do something?

No.

Just demand valid evidence of improved outcomes.

-

Footnotes:

-

[1] Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial.
Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W; Rapid Infusion of Cold Hartmanns (RICH) Investigators.
Circulation. 2010 Aug 17;122(7):737-42. doi: 10.1161/CIRCULATIONAHA.109.906859. Epub 2010 Aug 2.
PMID: 20679551 [PubMed - indexed for MEDLINE]

Free Full Text from Circulation.

-

Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W, & Rapid Infusion of Cold Hartmanns (RICH) Investigators (2010). Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial. Circulation, 122 (7), 737-42 PMID: 20679551

.

You had me at ‘Controversial post for the week’ – Part II

 
In Part I, I started to look at the kind of trouble that an Ambulance Chaser would be up to.

Waveform capnography was one of the recommendations that the AHA (American Heart Association) has not effectively stressed.

What else does Ambulance Chaser state has been neglected by the AHA?
 

What about dual defibrillation? Therapeutic hypothermia initiated during the arrest? Mechanical CPR devices?[1]

 

Was there good evidence that these treatments improved survival before the 2010 guidelines were written?

Is there good evidence now?

We have enough problems with wishful thinking-based treatments already. We should not be adding to the problem. These treatments should only be used as part of well controlled studies.
 

The “everyone gets a card” mentality means that the current courses have become another example of the “everyone gets a trophy” mentality that permeates our country right now.[1]

 

We have a problem with people who do not understand science claiming that their politics, feelings, opinions, et cetera are as good as valid science.
 


Image credit.
 

We are plagued with climate change denialists, vaccine denialists, evolution denialists, moon landing denialists, 9/11 truthers, and other conspiracy theorists who want their wishful thinking participation trophies.

We have been lowering the standards in America so that every conspiracy theorist can get a preach the controversy participation trophy.

These are not controversies.

Would we let these conspiracy theorists fly a plane we are traveling on, fix our vehicles, grow our food, or do other things that do not require advanced science education?

No, but we put our heads in the sand and pretend that their ignorance is as good as the valid research of the best scientists we have.

Here’s your participation trophy.
 

In fact, if I was a medical director, the only card courses I’d require would be Advanced Medical Life Support (AMLS) and PreHospital Trauma Life Support (PHTLS). Those are courses designed for EMS providers and based on assessment, not blind parroting of rote, already dated protocols.[1]

 

PHTLS (PreHospital Trauma Life Support) still encourages the use of backboards and discourages research to find out if there is any decreased disability with use of backboards, any increased disability with use of backboards, or if the benefits and harms are roughly even.

We don’t know and we don’t want to know, because as long as we cannot prove that there is increased disability, we can have our wishful thinking participation trophies. :oops:

This is dangerously irresponsible, but it is what happens when wishful thinking becomes more important than valid evidence.
 

Perhaps it has not been demonstrated safe but it has never been demonstrated unsafe either. Better stay with the known than go to the unknown. If you want to develop a research project, please go ahead and do it. But without proof that they are bad, we cannot just assume that they are bad.

 

We are irresponsibly assuming that backboards are beneficial, as we did with blood-letting (how many did doctors bleed to death?), prophylactic post-heart attack antiarrhythmics (estimated 60,000 dead), dumping fluids into patients with uncontrolled hemorrhage (how many did EMS kill?), . . . .

Assuming that something is beneficial may be OK – as long we are the only ones assuming the risk.

We are not the ones assuming the risk. Our patients are the ones injured by our hubris.

We appear to have abandoned ethics in favor of wishful thinking.
 

It’s time EMS progresses beyond rote memorization and embraces assessment-based interventions and sound science. Kudos to those EMS medical directors and EMS systems who’ve moved their protocols to accept the current science — and who don’t let the possession of a “card” define competency or currency in resuscitation science.[1]

 

The whole purpose of merit badge cards is to relieve the medical director of responsibility for oversight of competence.

How was I to know the medic was incompetent? He had a license to kill merit badge to kill and that is all anybody can require.

I wash my hands of any responsibility for actual oversight.

Plausible deniability is the reason for merit badge requirements.

We are trying to hide from responsibility by adhering to low standards.

-

Footnotes:

-

[1] Controversial post for the week
October 9, 2013
The Ambulance Chaser
Article

.

You had me at ‘Controversial post for the week’ – Part I

 
What kind of trouble would an Ambulance Chaser be up to?

 

Time to stir up some controversy here.

I would no longer require any resuscitation “card courses.” No more ACLS, CPR, or PALS.[1]

 

The saddest part about this is that this is controversial.
 


Image credit.
 

First, I disagree with some of the points about how slow the AHA (American Heart Association) is. The AHA is not as bad as portrayed, but much of this is the failure of the AHA to communicate effectively.
 

Heck, it wasn’t even until this go-round of ACLS revisions that waveform capnography was added.[1]

 

To protect against unrecognized esophageal intubation, confirmation of tube placement by an expired CO2 or esophageal detection device is necessary.[2]

 

That is from the 2000 ACLS (Advanced Cardiac Life Support) guidelines.

Necessary is not an ambiguous word, but the guidelines were not taught this way by many people.

If our attitude is that unrecognized esophageal intubation is only a problem for our patients, then we can get away with lesser means of tube confirmation.
 

The following is from the 2005 ACLS guidelines.
 

In the patient with ROSC, continuous or intermittent monitoring of end-tidal CO2 provides assurance that the endotracheal tube is maintained in the trachea. End-tidal CO2 can guide ventilation, especially when correlated with the PaCO2 from an arterial blood gas measurement.[3]

 

The AHA guidelines did not stress continuous waveform capnography until 2010. Maybe the attitude of the AHA was unrecognized esophageal intubation is only a problem for someone else’s patients.
 

    Key changes from the 2005 ACLS Guidelines include

  • Continuous quantitative waveform capnography is recommended for confirmation and monitoring of endotracheal tube placement.[4]

 

What is the key change?

Continuous

or

quantitative waveform

or

recommended

or

confirmation and monitoring

of endotracheal tube placement.

Why was the AHA not stressing this Class I, LOE (Level Of Evidence) A assessment?

There is no good reason.
 

Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube (Class I, LOE A). Providers should observe a persistent capnographic waveform with ventilation to confirm and monitor endotracheal tube placement in the field, in the transport vehicle, on arrival at the hospital, and after any patient transfer to reduce the risk of unrecognized tube misplacement or displacement.[4]

 

If a medic, emergency nurse, emergency physician, . . . disconnects waveform capnography from an intubated patient is that a sign of incompetence?

EtCO2 in the field, in the transport vehicle, on arrival at the hospital, and after any patient transfer to reduce the risk of unrecognized tube misplacement or displacement.

Probably.

Feel free to disagree, but any such argument should avoid logical fallacies.

What else?

What else will be covered in Part II.

-

Footnotes:

-

[1] Controversial post for the week
October 9, 2013
The Ambulance Chaser
Article

-

[2] Tracheal Intubation
2000 American Heart Association Guidelines
Part 6: Advanced Cardiovascular Life Support
Section 3: Adjuncts for Oxygenation, Ventilation, and Airway Control
Free Full Text from Circulation.

-

[3] End-Tidal CO2 Monitoring
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.4: Monitoring and Medications
Monitoring Immediately Before, During, and After Arrest
Free Full Text from Circulation.

-

[4] Part 8: Adult Advanced Cardiovascular Life Support
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Free Full Text from Circulation.

.

Comment on Why Did We Remove Atropine From ACLS? Part I

 

In the comments to Why Did We Remove Atropine From ACLS? Part I is this from BLS in Wichita
 

Another important question…why are we even attempting resuscitation on many of the patients we encounter in sudden cardiac arrest. Many of these lives are not savable, yet it’s all hands on deck for a wasted heroic effort. We dump tons of resources in to a futile effort.

 

We do.

The AHA (American Heart Association) continues to try to come up with better answers for these problems, but they are often not easy to solve.
 

Shouldn’t we be applying our resources where they are needed most, rather than on an octogenarian with multiple medical problems and stage 4 cancer?

 

That raises some important questions.

If ACLS is for hearts too good to die, then why apply it to people who are dying from other causes?
 

It now seems possible that with an adequate program of prevention, continuous monitoring and with a prompt aggressive approach to the prevention and ablation of serious cardiac arrhythmias, fewer acute coronary patients will be dead with “hearts too good to die.”[1]

 


 

This is from 1967, so there is mythology that has been discarded, such as the need to give atropine with morphine to avoid arrhythmia.

However, they do describe their rate of successful defibrillation to some sort of improved outcome.

What is the improved outcome?

ROSC (Return Of Spontaneous Circulation)?

Survival to non-arrhythmic death?

Survival to discharge?

We do not know.
 


 

13% survival to discharge would be good for 1967, especially since the expected alternative would be death, but is it 13% survival to discharge?
 

One reason we try to resuscitate far more people than just the hearts too good to die is that arrhythmia is not the only reversible cause of cardiac arrest.

Another reason is that we refuse to differentiate between quantity of life and quality of life.

We also are not good at recognizing our limitations.

What about a DNR (Do Not Resuscitate) order?

Some patients do not have the kind of DNR that EMS is permitted to follow, so we are required to call medical command for orders to follow a legal document that says don’t do all of the things that we do.

We can be a very destructive force once we are set in motion, because we are required to do things that we would be prohibited from doing to other people outside of EMS – and we are not good at recognizing this.

Some EMS providers will decide that it is more important that they attempt resuscitation, than respect the legally valid decision of the patient – and EMS rules do not discourage this.

The patient knows why he does not want to be resuscitated, but some of us only respect a patient when the patient makes the decision we want him to make.
 

A couple of EMTs from the local ambulance company responded to a call I was dispatched on for difficulty breathing. The patient was about 50 years old and had a DNR. The DNR did not affect care on that call, but both EMTs (older than the patient) stated that they would refuse to honor the DNR, because He is too young to have a DNR.

We have people who think they are helping, but are making things worse.

These are people who should not be in EMS.

EMS is not about taking care of the patient not taking care of our egos.

If the patient’s wishes do not match our desires, we need to grow up and provide patient care.

Resuscitating an octogenarian is something that is not bad. An 80 year old male is expected to live for 8 more years, while an 80 year old female is expected to live for 10 more years.

Quality of life is important. Having stage 4 cancer and being resuscitated to be able to have another painful death is not good patient care, unless that is what the patient wants.

We need to pay attention to quality of life and patients’ wishes and stop trying to force patients to live according to our prejudices.

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Footnotes:

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[1] Hearts too good to die–problems in acute myocardial infarction.
Johnson JB, Cross EB.
J Natl Med Assoc. 1967 Jan;59(1):1-6. No abstract available.
PMID: 6038580 [PubMed - indexed for MEDLINE]

Free Full Text from PubMed Central.

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