Click above for an understanding of where these came from and how they work.
Please provide your impressions of this ECG strip. Leave comments. You will not be chastised for misinterpretation, and I greatly appreciate participation.
Times Are Tough
The following is the opinion of Adam Thompson and does not represent the beliefs or views of any of the other paramedicine 101 contributers.
- The economy is effecting EMS.
- My belief is that the current federal government is doing nothing to save the economy.
- Socialized healthcare will effect EMS
- Things are going to get much worse before they get better
- Things will get better!
I was sitting at the table with a couple firemen that I work with and I could see the pure horror in their eyes. Recently 35 firefighters were let go from a neighboring department, Lehigh Acres FD. Just this week, 18 firefighters were let go from Ft. Myers Beach FD after filing a vote of no confidence in their chief. A presumed 30 pink slips will be handed out to firefighters from the City of Ft. Myers FD, and every department is currently negotiating their union contracts.
Why is payroll the seemingly first option for budget cuts? Do you think that the chiefs of the departments mentioned took pay-cuts? No! I am fortunate enough to work under an EMS chief who had foreseen horrible economic times and has been working under the budget for the past few years. We just HIRED about ten new employees. How could we not know this was coming? Unemployment is up, foreclosure rate is way up, commercial business development is way down. Doesn't that mean tax dollars will go down?
I am an EMS instructor, and the thought of educating people for jobs that aren't there is a tough one. Not only will these brand new EMTs and paramedics be on the market in search for a job, but so will every firefighter, EMT, and paramedic that has recently lost their job. TIMES ARE TOUGH!! Will we see cardboard signs 'will drive an ambulance for food'?
The economy is effecting EMS
This is obvious. Just pay attention to how thin EMS Magazine has gotten. This is because of less advertisement. That particular publication is free and runs entirely off of contributions and paid advertisement. Why is there less advertisement? Well, the manufacturers who advertise in EMS Magazine aren't making any new money. Why aren't those companies making new money? The products look cool, right? Because the agencies that you and I work for don't have the extra money to spend.... umm... duh. Maybe you and I have noticed this by lack of the usual annual raise. Maybe pay-cuts, or even lay offs. It is obvious that the economy is effecting EMS.
My belief is that the current federal government is doing nothing to save the economy.
I am a conservative, but it doesn't take a right-winger like me to know that the government is loaded with liars and rich men. Our current congress is riddled with people who played a big part in getting us into this mess. Barny Frank was a leader in the forcing of subsidizing of loans, and creating loan opportunities to the financially irresponsible and unstable. Don't get me wrong, Mr. Bush did nothing to impress me when it came to fiscal responsibility. The spending of our government is out of control! Then came along Obama with the promise of a net spending decrease. For every dollar he was gonna spend, he was going to find some to cut from the budget--LIAR. I say that emphatically.
Obama is a race-car driver on the highway of government spending. He has forced a trillion dollar spending bill upon a congress that didn't even read it! He promised to save jobs, and he hasn't. Now he says that the answer to our problems is socialized medicine? Are you kidding me? That is absolutely ridiculous.
Medicare, Medicaid, Social Security, The Post Office, The VA, Welfare. Name one of the before mentioned that actually runs well. The government doesn't have the right, and/or ability to run healthcare. It has never worked well, and it never will. We currently have the best system in the world and we encourage competitive medicine which encourages revolution. We should not disassemble our healthcare system. If Obama really cared about healthcare he would have done something as a state senator. The hospital his wife worked at, in his own state, charged more to patients who were uninsured. Most hospitals give a discount. When he was elected senator his wife made an over 200 thousand dollar raise. Real nice.
Spending has not been cut, and is only going up. You can not have capitalism on the way up and socialism on the way down. Saving any private business is not the job of the government and should be considered a criminal act. Let the chips fall where they may. If Ford doesn't survive, it is because they didn't run an efficient business during a crumbling economy.
Socialized healthcare will effect EMS
Please read the article below for great examples of how we will be effected from socialized/universal healthcare.
[Article 1]
A popular topic often debated in political races and amongst health care providers is the need for nationalized medical coverage (socialized medicine). Various other countries like Canada, England and Australia utilize such services. A popular argument for nationalized health care is availability of insurance for all citizens regardless of their financial situation. On the surface, the idea sounds reasonable, but in a nation run by private enterprise it can cause more problems then it's worth.
Insurance coverage provided by both the state and federal government has proven itself to be inadequate and bad for business. As it already stands government funded health insurance reimburses pennies on the dollar for both emergency and non-emergency medical care. Many hospitals, private doctors offices, and medical facilities are turning away these patients because of a significant lack of compensation.
EMS providers are in a bad position as they don't have the option of turning away non-payers or government-funded payers. This leaves ambulance services and emergency departments relying on private insurance companies to make up for the significant losses cause by government-funded insurance. Switching to a nationalized health care plan would be sure to place most private providers out of business.
The loss of private EMS services would require state and local governments to pick up the slack and provide the service at the cost of the tax payers. This of course would significantly increase income and property taxes to pay for the insurance and the services provided in place of private medical operations.
Sure, having more government jobs could result in retirement plans and good benefits, but the amount of jobs available could rapidly decrease. Budget cuts and increasing cost of doing business would either result in raising taxes or cutting jobs. Once government bureaucracy comes into play, you can be assured that the number of ambulances on the streets will be decline. Local police agencies are a prime example. It is hard to find a police department that claims to have adequate staffing. Socialized medicine would leave EMS agencies in the exact same situation.
Our health care system in the United States is far from perfect. Abuse on the system, lawsuits and uninsured patients are constantly increasing the cost to do provide medical care. Work needs to be done to resolve this issue, but not at the expense of the tax payers.
Other problems to consider: At first more people may seek primary care. This will initially lead to a call volume decrease. This would influence agencies to cut resources. Soon, wait times would become ridiculously long at the doctors' offices (google Baltimore's healthcare system) causing the increased use of emergency medical services. The increase will effect the hospitals even more causing increases in patient offload times, patient neglagence, and a decrease in quality care.
Everything I have already written pretty much explains this. Obama will end up getting a public option. The US dollar is losing value and we are borrowing money that we can't pay back anytime soon. Do you know what One trillion divided amongst every american citizen equals out to? About 4,000$. Now that is including children, the rich, and the extreme elderly. If we just paid the working class that money the government is planning on spending... we would have a nice chunk of change to go stimulate the economy. Not only will we never see that money--we have to pay for it; with interest!
If the people that are hated the most, the rich, didn't have to pay the biggest chunk of this debt the government has created; they may just have a chunk of change to go stimulate the economy themselves. Think about it. When did the economy really take a turn? When the stock market nose-dove. Who did that effect the most? THE RICH. If the economic effect on the rich stimulated a worsening economy, a positive economic effect on the rich would positively stimulate the economy. This isn't going to happen anytime soon. This isn't the first time the country has been here, but our government seems to think it is. They haven't decided to look at the past and see what worked and what didn't. I can tell you that, because SPENDING sure as hell didn't do the trick before.
Things will get better
"Because of Nixon we got Carter. It took Carter to get Reagan. Because of Bush we got Obama. Hopefully it will take Obama to get our next Reagan!"
-Adam Thompson
Fortunately, hard times never last. Unless we are in the end times (see the book of revelations), this will turn around. It may even turn around with the current president. I don't want him to fail, he just is. Meaning, he needs to change his approach, get the whisperers out of his ears, and his hands out of the pockets of the highest bidders.
I feel it is important, for those of you who may be in school to do this great job, that I emphasize that things will get better. You may have to wait for that EMS job. You may have to make yourself as attractive as possible to hiring EMS agencies, and put up with a tremendously competitive job market. If you want to do this bad enough, you eventually will. Hospitals are hiring techs all the time. Private agencies still seem to hire from time to time and there are other out of the ordinary healthcare jobs out there. If it were me, I would work in the healthcare field however I could and continue my education if financially possible. If you can't afford it, just read this blog...
Whether or not you share my political beliefs, I hope you well. God bless every man
and woman of this great profession. I hope through these tough times you become tougher.
Airway Research
The following study is just another example, supporting my opinion on the outcome of properly trained prehospital personnel. Rogue Medic has been screaming this stuff from the blogshere rooftop. It takes much more training than you would probably think to remain proficient at this dangerous airway skill.
[Pubmed 1]
Background. Emergency airway management is an important component of resuscitation of critically ill patients. Multiple studies demonstrate variable endotracheal intubation (ETI) success by prehospital providers. Data describing how many ETI training experiences are required to achieve high success rates are sparse. Objectives. To describe the relationship between the number of prehospital ETI experiences and the likelihood of success on subsequent ETI and to specifically look at uncomplicated first-pass ETI in a university-based training program with substantial resources. Methods. We conducted a secondary analysis of a prospectively collected cohort of paramedic student prehospital intubation attempts. Data collected on prehospital ETIs included indication, induction agents, number of direct laryngoscopy attempts, and advanced airway procedures performed. We used multivariable generalized estimating equations (GEE) analysis to determine the effect of cumulative ETI experience on first-pass and overall ETI success rates. Results. Over a period of three years, 56 paramedic students attempted 576 prehospital ETIs. The odds of overall ETI success were associated with cumulative ETI experience (odds ratio [OR] 1.097 per encounter, 95% confidence interval [CI] = 1.026-1.173, p = 0.006). The odds of first-pass ETI success were associated with cumulative ETI experience (OR 1.061 per encounter, 95% CI = 1.014-1.109, p = 0.009). Conclusion. In a training program with substantial clinical opportunities and resources, increased ETI success rates were associated with increasing clinical exposure. However, first-pass placement of the ETT with a high success rate requires high numbers of ETI training experiences that may exceed the number available in many training programs.
[Pubmed 2]
STUDY OBJECTIVE: This study compares adhesive tape, non-adhesive tape and a commercial endotracheal tube holder in terms of the force required to extubate endotracheal tubes from a cadaver. METHODS: A newly deceased, unembalmed cadaver was orotracheally intubated. Senior paramedic students secured the endotracheal tube using adhesive tape applied using the Lillehei method, non-adhesive tape and the Thomas Tube Holder in a random order. The time taken to secure the endotracheal tube and the force required to remove the distal tip of the endotracheal tube from the glottis were recorded. RESULTS: Use of adhesive tape using the Lillehei method resulted in greatest resistance to tube dislodgement, although it took significantly longer to apply than the other two methods. CONCLUSION: Although the Lillehei method provided the greatest resistance to tube dislodgement, it may not be ideal for the prehospital or emergency department context. The Thomas Tube Holder was quick and effective and may provide a good compromise in these environments, although once time is no longer important, clinicians may elect to revert to the Lillehei method which provides greater security.
Check out the ET securing methods below.
Badly Written Questions - I
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Since there seems to be a desire to focus more on the basics, I thought I would address test taking in the various EMS classes.
According to some instructors, there are no badly written questions. There is always one best, right answer to these questions.
There is one right response to that statement and it is not very polite. OK. There are many possible responses. They are not all impolite, but they should all disagree with the statement.
The people who defend badly written questions, even just disputed questions, are the people who are destroying EMS education.
First, we need to admit that there are badly written questions. Not only are they badly written, but they reteach the material, and they do it in a way that is misleading.
Are badly written questions useless?
Not at all. Badly written questions can be very useful. They are a great opportunity to have a discussion, whether with the entire class, a part of the class, or just an individual, about what is wrong with the question and why.
This is an opportunity to improve the understanding of the students, and maybe the instructor. Passing up this opportunity and defending the question is abandoning our students, just as we might abandon a patient.
Disputed questions may be written intentionally to stir up debate, but they are only useful on a quiz, when you can devote a part of class, or an entire class, to the discussion.
Most of these badly written questions seem to be multiple choice questions. Many are on course completion exams. There will be no further classes, unless the student retakes the class.
Determining whether someone passes a course, based upon a multiple choice exam, is one of the more idiotic things we do in EMS.
The ability to recognize the correct answer - correct according to the person who wrote the test - is not even close to being the same as understanding the material.
The ability to recognize that same correct answer, has nothing top do with competence.
.
Induced Hypothermia Part V
More support for induced hypothermia:
[Pubmed 1]
Mild therapeutic hypothermia (32 degrees C-34 degrees C) is the only therapy that improved neurological outcome after cardiac arrest in a randomized, controlled trial. Induced hypothermia after successful resuscitation leads to one additional patient with intact neurological outcome for every 6 patients treated. It protects the brain after ischemia by reduction of brain metabolism, attenuation of reactive oxygen species formation, inhibition of excitatory amino acid release, attenuation of the immune response during reperfusion, and inhibition of apoptosis. Potential side effects such as infections have to be kept in mind and treated accordingly. Mild hypothermia is a safe and effective therapy after cardiac arrest, even in hemodynamically compromised patients and in patients undergoing percutaneous coronary intervention. Its use is recommended by the American Heart Association and the International Liaison Committee on Resuscitation for unconscious adult patients with spontaneous circulation after out-of-hospital ventricular fibrillation cardiac arrest. Further research is needed to maximize its potential benefits.
[Pubmed 2]
This article is a support paper for the National Association of EMS Physicians' position paper on induced therapeutic hypothermia in resuscitated cardiac arrest patients. Induced hypothermia is one of the newest treatments aimed at increasing the dismal neurologically intact survival rate for out-of-hospital cardiac arrest patients. Two landmark studies published in 2002 by the New England Journal of Medicine led to the American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care IIa recommendation of cooling unconscious adult patients with return of spontaneous circulation after out-of-hospital cardiac arrest due to ventricular fibrillation to 32 degrees C to 34 degrees C for 12 to 24 hours. Despite many limitations of those studies, the AHA also suggests that this therapy may be beneficial for patients with non-ventricular fibrillation arrests. However, the literature is lacking in answers with regard to the best methods to utilize in cooling patients. While avoiding delay in the initiation of cooling seems logical, the literature is also lacking evidence indicating the ideal time at which to implement cooling. Furthermore, it remains unclear as to which patients may benefit from induced hypothermia. Finally, the literature provides no evidence to support mandating induced hypothermia in the prehospital setting. Given limited prehospital resources, sometimes consisting of only two providers, attention first needs to be given to providing the basic care with the utmost skill. Once the basics are being delivered expertly, consideration can be given to the use of prehospital cooling for the resuscitated cardiac arrest patient in the setting of continued cooling in the hospital.
Support for the use of induced hypothermia on stroke patients:
[Pubmed 3 ]
BACKGROUND: Local hypothermia induced by intravascular infusion of cold saline solution effectively reduces brain damage in stroke. We further determined the optimal temperature of local hypothermia in our study. METHODS: Seventy-eight adult male Sprague Dawley rats (260 - 300 g) were randomly divided into 3 groups: group A, ischemia/reperfusion without cold saline infusion (n = 26) (control group); group B, infusion with 20 degrees C saline before reperfusion (n = 26); group C: infusion with 10 degrees C saline before reperfusion (n = 26). In each group, we chose 15 rats for monitoring physical indexes and the temperature of the brain (cortex and striatum) and body (anus), measurement of brain infarction volume, assessment of neurological deficits and the survival rate of reperfusion at 48 hours. Another 8 rats from each group was chosen for examining brain edema, another 3 from each group for histological observation by electron microscopy (EM) and light microscopy (LM) at 48 hours after reperfusion. RESULTS: There was no significant difference among the 3 groups for physical indexes during the examination (F((2, 45)) = 0.577, P = 0.568; F((2, 45)) = 0.42, P = 0.78 for blood pressure and blood gas analysis, respectively). The brain temperature was significantly reduced in the group C compared to the other groups (F((2, 45)) = 37.074, P = 0.000; F((2, 45)) = 32.983, P = 0.000, for cortex and striatum temperature respectively), while the difference in rectal temperature between group A and B or C after reperfusion was not significant (F((2, 45)) = 0.17115, P = 0.637). And the brain infarct volume was significantly reduced in group C (from 40% +/- 10% in group A, 26% +/- 8% in group B, to 12% +/- 6% in group C, F((2, 45)) = 43.465, P = 0.000) with the neurological deficits improving in group C (chi(2) = 27.626, P = 0.000). The survival rate at 48 hours after 10 degrees C and 20 degrees C saline reperfusion was increased by 132.5% and 150%, respectively, as compared to the control group (chi(2) = 10.489, P = 0.005). The extent of the brain edema showed no significant difference (F((2, 21)) = 0.547, P = 0.587) after cold saline infusion compared to the control group. No obvious vascular injury was found by electron or light microscopy in either infusion group. CONCLUSIONS: Regional hypothermia with 10 degrees C cold saline infusion can significantly decrease the infarction volume, improve the neurological deficits, and 10 degrees C seems to be the optimal temperature in inducing a cerebral protection effect during stroke. This procedure could be adopted as a further treatment for acute stroke patients.
[Pubmed 4]
Hypothermia is considered nature's "gold standard" for neuroprotection, and its efficacy for improving outcome in patients with hypoxic-ischemic brain injury as a result of cardiac arrest is well-established. Hypothermia reduces brain edema and intracranial pressure in patients with traumatic brain injury. By contrast, only a few small pilot studies have evaluated hypothermia as a treatment for acute ischemic stroke, and no controlled trials of hypothermia for hemorrhagic stroke have been performed. Logistic challenges present an important barrier to the widespread application of hypothermia for stroke, most importantly the need for high-quality critical care to start immediately in the emergency department. Rapid induction of hypothermia within 3 to 6 hrs of onset has been hampered by slow cooling rates, but is feasible. Delayed cooling for the treatment of cytotoxic brain edema does not provide definitive or lasting treatment for intracranial mass effect, and should not be used as an alternative to hemicraniectomy. Sustained fever control is feasible in patients with intracerebral and subarachnoid hemorrhage, but has yet to be tested in a phase III study. Important observations from studies investigating the use of hypothermia for stroke to date include the necessity for proactive antishivering therapy for successful cooling, the importance of slow controlled rewarming to avoid rebound brain edema, and the high risk for infectious and cardiovascular complications in this patient population. More research is clearly needed to bring us closer to the successful application of hypothermia in the treatment for stroke.
[Pubmed 5]
OBJECTIVE: Hypothermia has long been known to be a potent neuroprotectant. In this mini-review, we highlighted clinical experience that hypothermia protects the brain from cerebral injury. We discussed the clinical practice of hypothermia in ischemic stroke. RESULTS: Multiple factors play a significant role in the mechanisms. Clinical application drew first from two clinical trials with comatose patients after cardiac arrest is attractive. The Australian and European study have led to renewed interest in these patients. More and more evidences bring the insight into its effects on cerebral ischemia. The type of cooling technique to be used, the duration of cooling and speed of rewarming appear to be key factors in determining whether hypothermia is effective in preventing or mitigating neurological injury. Although until now, there are no clear therapeutic standards of the parameters in therapeutic hypothermia, it is well accepted that cooling should be initiated as soon as possible. By combining hypothermia with other neuroprotectants, it may be possible to enhance protective effects, reduce side effects and lengthen the maximum time. CONCLUSION: In addition to its neuroprotective properties, hypothermia may extend the therapeutic window for other neuroprotective treatment. Thus, combination therapies with neuroprotective, anti-inflammatory and thrombolytic agents are likely to be investigated in the clinical setting in the future.
The Electrocardiogram - Part II
ECG Basics
ECG Paper:
ECGs print out on a type of graph paper with specific measurements.
Horizontally the paper gives a specific time measurement based on real time and the speed in which the paper prints. Each small box is 1mm/1mm and the paper prints at 25mm/sec
Horizontally the paper gives a specific time measurement based on real time and the speed in which the paper prints. Each small box is 1mm/1mm and the paper prints at 25mm/sec- One small box is 0.04 seconds or 40 milliseconds
- One large box is 0.20 seconds or 200 milliseconds
- 5 large boxes equals one second.
Vertically the paper measures amplitude.
- Each small box is equal to 1mm or 1/10 mv
- 10 small boxes or 2 large boxes is equal to 1 mv
A lead is not the same thing as an electrode. A lead is a view of the hearts electrical activity taken from the placed electrodes. Different leads are used for different angles of view.
Bipolar leads - A bipolar lead uses two electrodes, each with different poles (positive/negative).
Your limb leads are the bipolar leads. The limb leads are leads I, II, and III. If you read the axis determination tutorial from the prehospital 12-lead blog, you are a step ahead and should understand this well. If not, just follow along.
The picture above shows you how we get our limb leads. Called limb leads due to the electrode placement.
- In lead I, the negative electrode is on the right arm and the positive on the left arm
- In lead II, the negative is also on the right arm and the negative is on the left leg
- In lead III, the left arm electrode is converted to negative polarity and the left leg is the positive.
Although it looks as if the view from each lead would completely bypass the heart, it doesn't Don't imagine the electrodes being on the wrists and ankles as in the picture. Although this is the appropriate placement, it is much easier to picture the view of the lead if you imagine torso placement. Check out the image below:
The cameras are displaying which angle we are viewing from. Since the positive electrode for lead I is on the left arm, the camera is on the left. This is a hexaxial diagram. This diagram is made up from the first six leads of a 12-lead, and can be formed using only the electrodes placed on the limbs. Leads I, II, III, aVR, aVL, & aVF.
Unipolar leads - Every other lead is a unipolar lead. They have only one true pole, and it is positive. The negative pole is comprised of many other electrodes. aVR, aVL, aVF, V1, V2, V3, V4, V5, and V6 are all unipolar leads.
Augmented limb leads - The a in aVR, aVL, and aVF stands for augmented vector. They are called augmented vectors because they are different angles of view. They use all the same electrodes as the limb leads. The difference is that the augmented limb leads uses a different negative pole. The negative electrode from leads I, II, and III is zeroed out and an exploring lead is created. This is possible due to Einthoven's law I + (-II) + III = 0, or I + III = II.
Check out the diagram below to see where the positive lead is located.
Precordial leads - These are also known as chest leads. V1, V2, V3, V4, V5, and V6 are the last 6 leads, and only viewable with a 12 lead. It is possible to use your limb leads for what is known as MCL or modified chest leads, but this has gone out of favor since 12-lead ECGs have become so common.
The limb leads and augmented limb leads make up the hexaxial reference system. This system shows all the views from the frontal plane. This is also the system that is used to reference the heart's electrical axis.
The electrical axis refers to the general direction of cardiac depolarization. More on this later, or continue reading through the axis determination tutorial.
Too Many Medics? comment from Anonymous
Sorry for the long post, but . . .
In the comments to Too Many Medics?, Anonymous wrote:
Grrr. Really trying to make an inflammatory post, aren't we RM ?
Are you kidding? I tone it down to keep it nice and polite.
Couldn't find a copy of the ACTUAL study, and I'm never a fan of quoting USA Today as a source of anything, other than maybe a horoscope.
I don't read horoscopes, but here is the abstract.
Academic Emergency Medicine; Volume 13 Issue s5; May 2006; pages S55 - S56; abstract number 121:
Cardiac Arrest Survival Rates Depend on Paramedic Experience
Michael R Sayre, Al Hallstrom, Thomas D Rea, Lois Van Ottingham, Lynn J White, James Christenson, Vince N Mosesso, Andy R Anton, Michele Olsufka, Sarah Pennington, Stephen Yahn, James Husar, Leonard A Cobb.
The Ohio State University Medical Center, Columbus, OH,
University of Washington, Seattle, WA,
British Columbia Ambulance Service, Victoria, British Columbia, Canada,
University of Pittsburgh, Pittsburgh, PA,
Calgary Emergency Ambulance Service, Calgary, Alberta, Canada,
University of Washington, Seattle, WA,
St. Paul’s Hospital, Vancouver, British Columbia, Canada,
Calgary Emergency Medical Services, Calgary, Alberta, Canada
Objective
Out-of-hospital cardiac arrest (OOH-CA) survival varies widely among communities. We compared OOH-CA survival rates among 5 North American cities to identify factors that influenced survival.
Methods
The AutoPulse Assisted Prehospital International Resuscitation (ASPIRE) Trial was amulticenter randomized comparison of the effectiveness of manual chest compression versus AutoPulse during resuscitation of OOH-CA. Adults with OOH-CA were enrolled in five cities. Survival data collected in each city for patients in the manual arm of the trial were compared. Regression using generalized linear models was used to adjust for covariates.
Results
Younger women with witnessed ventricular fibrillation (VF) arrests in public locations who had short first response times had the best chance of survival. Victims receiving bystander cardiopulmonary resuscitation (CPR) had a trend to better survival. Time to advanced life support (ALS) vehicle arrival was not significant. The mean regression residual by site correlated with cases per paramedic per year (Pearson R = 0.97, p = 0.006).
Conclusions
Significant variation exists among the cities even after known predictors of survival are controlled. A positive correlation exists between more cases treated per paramedic and survival to discharge. Whether that relationship is causal or a marker for some other factor(s) cannot be determined.
Did, however find this nugget in 'Emergency Medicine News' from the MD that authored that study. Note his last comment in the excerpt.
Excerpt:The study was presented at the annual meeting for the Society for Academic Emergency Medicine. Almost instantly, it was the darling of the media, hitting the pages of USA Today under the banner, “Cities that Deploy Fewer Paramedics Save More Lives.”
“It touches a nerve,” said Dr. Sayre in explaining why the findings of an academic presentation made such a splash.
For one thing, it’s a sound bite that sounds too odd to be true: The fewer the paramedics in the system, the more likely patients are to survive.
More Skilled?
He cautioned, however, that what remains unexplained is whether the data reflect a direct result, achieved because a relatively low number of paramedics who administer advanced life support are likely to become more skilled at it or whether the correlation is a sign that something else may be occurring, such as more intensive training among systems that have fewer teams or personnel. “It could be a marker; it could be a causal. We don’t know,” said Dr. Sayre, an associate professor of emergency medicine at Ohio State University Medical Center in Columbus.
Nothing odd about it.
There is no evidence that any of the ALS treatments improve outcomes. So, why would it be important to have paramedics arrive at a cardiac arrest quickly?
The focus should be on excellent BLS care. ALS personnel should understand that and help with the BLS. Many probably do not. In stead, they interfere with the quality of the BLS.
BLS, unlike ALS, has been shown to improve outcomes from cardiac arrest. The longer they focus on the BLS, the better for the patient.
Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation
Henry E. Wang, MD, MS
Scott J. Simeone, BS, NREMT-P
Matthew D. Weaver, BS, NREMT-P
Clifton W. Callaway, MD, PhD
Presented at the Society for Academic Emergency Medicine annual meeting, May 2008, Washington, DC.
Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
Study objective
Emergency cardiac care guidelines emphasize treatment of cardiopulmonary arrest with continuous uninterrupted cardiopulmonary resuscitation (CPR) chest compressions. Paramedics in the United States perform endotracheal intubation on nearly all victims of out-of-hospital cardiopulmonary arrest. We quantified the frequency and duration of CPR chest compression interruptions associated with paramedic endotracheal intubation efforts during out-of-hospital cardiopulmonary arrest.
Methods
We studied adult out-of-hospital cardiopulmonary arrest treated by an urban and a rural emergency medical services agency from the Resuscitation Outcomes Consortium during November 2006 to June 2007. Cardiac monitors with compression sensors continuously recorded rescuer CPR chest compressions. A digital audio channel recorded all resuscitation events. We identified CPR interruptions related to endotracheal intubation efforts, including airway suctioning, laryngoscopy, endotracheal tube placement, confirmation and adjustment, securing the tube in place, bag-valve-mask ventilation between intubation attempts, and alternate airway insertion. We identified the number and duration of CPR interruptions associated with endotracheal intubation efforts.
Results
We included 100 of 182 out-of-hospital cardiopulmonary arrests in the analysis. The median number of endotracheal intubation–associated CPR interruption was 2 (interquartile range [IQR] 1 to 3; range 1 to 9). The median duration of the first endotracheal intubation–associated CPR interruption was 46.5 seconds (IQR 23.5 to 73 seconds; range 7 to 221 seconds); almost one third exceeded 1 minute. The median total duration of all endotracheal intubation–associated CPR interruptions was 109.5 seconds (IQR 54 to 198 seconds; range 13 to 446 seconds); one fourth exceeded 3 minutes. Endotracheal intubation–associated CPR pauses composed approximately 22.8% (IQR 12.6-36.5%; range 1.0% to 93.4%) of all CPR interruptions.
Conclusion
In this series, paramedic out-of-hospital endotracheal intubation efforts were associated with multiple and prolonged CPR interruptions.
[Ann Emerg Med. 2009;xx:xxx.]
Benefit to the patient of these interruptions in BLS treatment?
No known benefit.
Cost to the patients of these interruptions in BLS treatment?
Whatever small chance at resuscitation they had is lowered dramatically.
Why?
We have to have more medics, so that they can interfere with BLS care.
Once everybody is a medic, we will probably continue to argue over who has to put up with doing the demeaning BLS stuff, even though that is all that works in cardiac arrest.
From the full text of this journal article:
Assuming the need to reduce endotracheal intubation–associated CPR interruptions, potential strategies include improving paramedic endotracheal intubation skill or altering out-of-hospital airway management techniques. Improving endotracheal intubation skill may prove difficult, given limits in the quantity of paramedic student training and clinical endotracheal intubation experience in the United States.26-28 Although select paramedics attempt endotracheal intubation without stopping CPR chest compressions, the broader feasibility of this technique remains unclear. To minimize CPR interruptions, many EMS agencies have substituted endotracheal intubation with Combitube or King LT airway insertion.13 Select studies suggest the viability of CPR without ventilation, potentially obviating the need for airway management interventions.29,30 The relative effectiveness of these techniques remains unknown.
Why interrupt compressions to intubate?
Why intubate, in cardiac arrest, if an alternative airway is faster?
Why intubate, in cardiac arrest, if an alternative airway is just as good at airway management?
Why rush a medic to a cardiac arrest if the medic makes things worse?
Also, the more medics you need, the less selective you can be in choosing the ones you end up with. If you are going to scrape the bottom of the barrel, because the supply cannot meet the demand, and you will not pay well, you will get bottom of the barrel quality.
Maintaining quality is also important. This study might suggest that PFD (Philadelphia Fire Department) would have an excellent resuscitation rate. From what I was last told, PFD is 250 medics short of being fully staffed. PFD has political obstacles to consistently providing quality care. PFD has some excellent medics, but not because of oversight. The excellent medics are excellent because they work at it on their own. They are balanced by others, who easily dredge up bottom of the barrel analogies.
So, it is not just about numbers. However, the more medics you have, the harder it becomes to maintain quality. The harder it becomes to obtain experience. The combination of quality and experience are important.
More medics means a need for more medical oversight.
Do these everyone a medic systems increase the number of medical directors to keep up with the increase in medics?
Do they aggressively work at simulations to make up for their lack of touch with reality?
This topic will eventually be studied and written about more fully. This particular study is not likely to be published in anything other than abstract form.
Here is a study from Boston, where the number of medics is low and the quality is high:
Volume 52, No. 4: October 2008; Annals of Emergency Medicine; page S153; abstract number 364:
Success Rates in Out-of-Hospital Intubation
Temin E, Harrington L, Mitchell P, Rebholz C, Dyer K, Doyle J, Hughes P, Moyer P/Massachusetts General Hospital, Boston, MA; Boston Medical Center, Boston, MA; Boston Emergency Medical Services, Boston, MA
Background
Previous literature has questioned whether out-of-hospital endotracheal intubation (ETI) success rates can be comparable to those performed in the emergency department (ED). Prior studies report ED success rates ranging from 80%–98% with success rates increasing with the experience of the provider. Large studies on ground out-of-hospital intubation report success rates ranging from 33%-100% and a 77% success rate for rapid sequence intubation (RSI), all after multiple attempts. Although Bulger et al 2002 has reported similar out-of-hospital ETI success rates to the ED, some question whether this success can be reproduced in other services. Boston Emergency Medical Services (BEMS) is a 2-tiered system with all advanced life support (ALS) trucks staffed by 2 paramedics. BEMS has a ratio of 0.5 paramedics to 10,000 population making it one of the lowest ratios in the country.
Study Objective
To assess the proportion of successful paramedic out-of-hospital ETI on adult and pediatric patients in a 2-tiered urban EMS system.
Methods
A retrospective chart review from 7/1/06 to 6/30/07 of ETI data from the Boston Airway Registry was conducted. The primary outcome was the success rate of ETI by number of attempts (blade passing through the lips) overall and for the following subgroups: Cardiac arrest prior to ETI, medically assisted intubation (MAI) (any medication), rapid sequence intubation (RSI) (paralytic and sedative), documented head trauma, and pediatric (age ≤ 12 years old) patients. We used descriptive statistics with 95% confidence intervals for analysis.
Results
ETI was attempted on 569 individuals by 61 paramedics. Two were excluded due to incomplete data. 361/567 (64%) of patients were male, mean age was 56 years. 455/567 (80%) had a cardiac arrest prior to ETI. 97/567 (17%) had ETI attempted with MAI. 77/567 (14%) had ETI attempted with RSI. 107/566 (19%) had documented traumatic injury, of those 73/104 (70%) had documented head trauma. Of the 10 pediatric ETI 4/10 were male, mean age was 2.6 years.
Conclusion
In this EMS system, paramedics achieved high success rates in all ETI, comparable to those reported in ED settings. Further research should determine provider and system factors that contribute to this success.
It is only a matter of time until the research is done. Until then we have to wade through a morass of intubation results from the everybody a medic systems.
A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.
Denver Metro Airway Study Group.
Colwell CB, Cusick JM, Hawkes AP, Luyten DR, McVaney KE, Pineda GV, Riccio JC, Severyn FA, Vellman WP, Heller J, Ship J, Gunter J, Battan K, Kozlowski M, Kanowitz A.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):304-10.
PMID: 19499465 [PubMed - in process]
Objectives
To determine 1) the success rate of prehospital endotracheal intubation; 2) the unrecognized tube malposition rate; and 3) predictors of tube malposition upon arrival to the emergency department (ED) in the setting of a large metropolitan area that includes 18 hospitals and 34 transporting emergency medical services (EMS) agencies.
Methods
Prospective data were collected on patients for whom prehospital intubation was attempted between September 1, 2004, and January 31, 2005. Endotracheal tube (ETT) position upon arrival to the ED was verified by emergency medicine attending physicians. Missing cases were identified by matching prospective data with lists of attempted intubations submitted by EMS agencies, and data were obtained for these cases by retrospective chart review. Successful intubation was defined as an "endotracheal tube balloon below the cords" on arrival to the ED. Patients were the unit of analysis; proportions with 95% confidence intervals were calculated.
Results
Nine hundred twenty-six patients had an attempted intubation. Methods of airway management were determined for 97.5% (825/846) of those transported to a hospital and 33.8% (27/80) of those who died in the field. For transported patients, 74.8% were successfully intubated, 20% had a failed intubation, 5.2% had a malpositioned tube on arrival to the ED, and 0.6% had another method of airway management used. Malpositioned tubes were significantly more common in pediatric patients (13.0%, compared with 4.0% for nonpediatric patients).
Conclusions
Overall intubation success was low, and consistent with previously published series. The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies. Our data support the need for ongoing monitoring of EMS providers' practices of endotracheal intubation.
This is not a system with every person on every apparatus a medic, but their success rates are not good. Less than 80% success? 5% unrecognized esophageal tubes? We need to start improving quality or restricting skills to those who can actually demonstrate skill. Adding more medics only makes this quality problem worse. A system that is just doing more of the same is not one you want taking care of those you love.
Here is one from one of the happy everybody a medic Pollyanna places:
Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Department of Anesthesiology, Miller School of Medicine, University of Miami, Miami, Florida 33136, USA. mcobas@med.miami.ed
Background
Ryder Trauma Center is a Level 1 trauma center with approximately 3800 emergency admissions per year. In this study, we sought to determine the incidence of failed prehospital intubations (PHI), its correlation with hospital mortality, and possible risk factors associated with PHI.
Methods
A prospective observational study was conducted evaluating trauma patients who had emergency prehospital airway management and were admitted during the period between August 2003 and June 2006. The PHI was considered a failure if the initial assessment determined improper placement of the endotracheal tube or if alternative airway management devices were used as a rescue measure after intubation was attempted.
Results
One-thousand-three-hundred-twenty patients had emergency airway interventions performed by an anesthesiologist upon arrival at the trauma center. Of those, 203 had been initially intubated in the field by emergency medical services personnel, with 74 of 203 (36%) surviving to discharge. When evaluating the success of the intubation, 63 of 203 (31%) met the criteria for failed PHI, all of them requiring intubation, with only 18 of 63 (29%) surviving to discharge. These patients had rescue airway management provided either via Combitube (n = 28), Laryngeal Mask Airway (n = 6), or a cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had unrecognized esophageal intubations discovered upon the initial airway assessment performed on arrival. We found no difference in mortality between those patients who were properly intubated and those who were not. Several other variables, including age, gender, weight, mechanism of injury, presence of facial injuries, and emergency medical services were not correlated with an increased incidence of failed intubations.
Conclusions
This prospective study showed a 31% incidence of failed PHI in a large metropolitan trauma center. We found no difference in mortality between patients who were properly intubated and those who were not, supporting the use of bag-valve-mask as an adequate method of airway management for critically ill trauma patients in whom intubation cannot be achieved promptly in the prehospital setting.
From the full text of this journal article (PHI = Pre-Hospital Intubation):
The significant difference we found in the success of PHI performed in connection with air (67%) and ground transport (33%; P < 0.001) may reflect the deployment to aerial units of paramedics with more experience and skills, including intubation, because it is usually a promotion from the ground units. Although this study did not correlate intubation skills of individual paramedics, data from Germany, where air rescue crews perform ETI three times as frequently as ground crews,1 support this. Therefore, clinical experience of those performing the intubation is invaluable and perhaps the most important piece of the PHI puzzle.
The 67% and 33% are a bit misleading. They are the percentages of the overall successful intubations, not the percentage of intubation attempts.
Of the 203 patients, 115 (57%) were transported by air, and within that group, 94 (82%) were properly intubated in the field, and 21(18%) were not. Of the 88 patients who were transported by ground, 46 (52%) were successfully intubated in the prehospital setting and 42 (48%) had a failed PHI (P < 0.001 compared with patients transported by air).
52% is still a number that should not be tolerated in intubation. There are 2 considerations not made clear.
How many of the failed intubations actually had intubation attempts?
How many intubation attempts did they have?
Maybe we need to include another data point? Total intubation attempts.
If almost all of the patients actually had intubation attempts and there were 2 attempts before moving to an alternative/rescue airway and some of the successful intubations were on the second attempt, then the success rate per attempt is possibly much lower than 1 in 3.
How many holes are we dealing with in the airway?
Hush. Let's not be inflammatory. If we throw more medics at it maybe one of them will find the trachea.
In these everybody a medic systems a piñata might live for ever. The patients on the receiving end of the intubation attempts might be jealous of the piñata.
Even the flight crews only intubated 82% successfully. That is about the same as the ground medics in the Denver study above it. It is true that this is trauma, while the others are not limited to trauma.
At least to me, the most important conclusion from that study seems to be (PHI = Pre-Hospital Intubation):
Therefore, clinical experience of those performing the intubation is invaluable and perhaps the most important piece of the PHI puzzle.
What about intubation in the system that had the highest resuscitation rate in the original study - Cardiac Arrest Survival Rates Depend on Paramedic Experience?
Here is an abstract from their 20 year study of intubations. These medics do use succinylcholine. So do the flight crews in Miami. They did break down their results into trauma intubations and medical intubations. How did this system do? They focus on keeping the number of medics low and the quality high. Let's see:
Prehospital use of succinylcholine: a 20-year review.
Wayne MA, Friedland E.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed - indexed for MEDLINE]
Emergency Medical Services, Bellingham/Whatcom County Washington, WA 98225, USA. mwayne@cob.org
Objective
To determine the safety and efficacy of succinylcholine, as an adjunct to endotracheal intubation, administered by paramedics trained in its use.
Methods
Retrospective review of 1,657 consecutive patients, aged 16 years or older, receiving prehospital succinylcholine administered by paramedics. In this community of 175,000 people, trained paramedics intubated both medical and trauma patients with the assistance of succinylcholine. Main outcomes measured were success of intubations, complications of the procedure and/or the drug, and use of alternative methods of airway management.
Results
Paramedics successfully intubated 95.5% (1,582) of all patients receiving succinylcholine, 94% (1,045) of trauma patients, and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative methods. Unrecognized esophageal intubation occurred in six (0.3%) patients. The addition of capnography and a tube aspiration device, in 1990, decreased the incidence of esophageal intubations.
Conclusion
Paramedics trained to use succinylcholine, to assist the process of endotracheal intubation, can safely intubate a high percentage of patients.
They intubated 94% of trauma patients successfully over a 20 year period.
From the full text of this journal article is the most likely explanation for the high success rate.
Following didactic training, each student must successfully complete a minimum of 20 intubations, in the operating room, under the supervision of a board-certified anesthesiologist. Additionally, paramedics are required to successfully intubate at least one patient monthly for three years, post certification, and one per quarter thereafter. At least one intubation, annually, must be performed under an anesthesiologist’s supervision.
I will repeat that Paramedic ≠ Intubation. It may be that intubation is the easiest way to measure paramedic quality. On the other hand, it may be that a lack of intubation skills is a good indicator of a lack of overall paramedic quality, rather than the other way around. It seems that many systems have a significant problem with quality. In some of these low quality systems, the attitude does not appear to be to fix the quality problems, but to make everyone a medic. How is more of the same an improvement?
EMS in Boston and Bellingham/Whatcom County take airway management seriously, while the everybody a medic people in Miami average 1 - 3 intubation per medic per year. After however many attempts at intubation, they still only get it half right.
What do the everyone a medic systems do about quality?
Miss.
A lot.
.
Too Many Medics?
In some of the posts on the recent intubation study,[1] this question keeps coming up: What is the right number of paramedics to provide the best care to patients?
There was an article that covered this.[2] Here is the chart from the article.
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This does not mean that medics should not be sent at all. Rather, it strongly suggests, that in our desire for a quick ALS response for cardiac arrest, we may be making things, not just a little bit worse, but a lot worse.
These numbers agree with what I have been stating about ALS getting in the way of BLS during cardiac arrest treatments (CPR). The numbers do not prove what I have been stating, but they seem to be giving a very strong hint.
The places with fast ALS responses are able to respond quickly because they have a lot more medics. In other words, they have dramatically reduced the amount of experience per medic.
Why?
To make everybody feel good, even though it appears to be killing people.
Almost 7 times as many patients resuscitated with good outcomes in the cities with fewer medics.
Feel good?
More medics means that more people are medics, and can feel good about being medics.
More medics means that more people are having medics respond to treat them, and can feel good about receiving care from medics.
This is just to make people feel good. Then, why not make everyone a medic? The response time would be immediate, unless maybe you fall in the woods, and there is nobody else there to hear you fall. In which case the philosophical question is, If a patient falls in the woods and there is nobody there to call 911, is there a response time? Not, Does the patient make a sound? And, since the patient is a medic, there is already a medic on scene, so there is no worry about response time.
Do the response time rules state that the responding medic has to be alive?
Probably not.
We could have all of the patients in nursing homes become paramedics. Talk about cross-training leading to improved response times!
Too many medics = too many failed resuscitations.
Too much of a good thing can be a bad thing.
Footnotes:
^ 1 Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed - indexed for MEDLINE]
PubMed states that the full text article is free at the journal site, but it is not
^ 2 Fewer paramedics means more lives saved
Updated 5/21/2006 8:58 PM ET
USA Today
By Robert Davis
Article
The chart is from this article.
.
Prehospital Intubations and Mortality - comment from RevMedic
RevMedic is not a name that signifies driving very fast - revving the engine - but that is what pops into my head every time I see his name. I know. I am by-passing St. Peter. I am not collecting 72 virgins. I am going straight to the great big tanning bed. This is not news.
RevMedic does all sorts of photography in the Newberg, Oregon area. If you need a photographer with some common sense, he seems like the guy to call.
Anyway RevMedic knows his stuff. Here is his comment on the post Prehospital Intubations and Mortality - comment from Herbie.
"I would much rather see medics using a BVM during their OR time, than intubating. Good BVM use is far more important than intubation skill."
Absolutely. I can't tell you how many times I've seen ineffectual ventilations with a BVM. There sits the EMT (at any level), blissfully unaware of the air blasting out from underneath the mask and not paying attention to the lack of a seal.
How is it that we graduate EMTs and medics, who are not skilled at airway management?
How is it that we graduate EMTs and medics, who do not understand airway management?
It isn't as if the courses suggest that there is a skill that comes before airway.
Excellent BVM use is all about assessment.
BVM excellence is the cornerstone of airway management.
Without excellence in the use of the BVM, the rest of airway management does not matter.
I prefer to do some of the bagging with patients who need ventilation. It is a skill that needs to be used, to be maintained. This also sets a good example for everyone else. This demonstrates to everyone else that, at least as far as I am concerned, skill with a BVM is a priority.
We also will find that some of the patients do not need to be intubated. Intubation should not be for the benefit of the medics. Intubation should be for the benefit of the patients.
There was another event where I was bagging the patient in preparation for intubation. I was having trouble getting an adequate seal, and asked for another set of hands. We had 4 PARAMEDICS in the rig, and the other three were solely concerned with getting the intubation equipment set up, preparing the drugs, etc. I had to repeat myself several times and finally loudly call one by name and DEMAND his/her assistance, before we achieved adequate ventilations.
One of the best uses for a separate pulse oximeter is to throw the machine at someone, when you need there attention. It can be very effective. It also demonstrates how little importance should be attached to the machine. It is just a tool, a slow tool, that should not be warning you that something happened, but should confirm what you already know from your continuous assessments.
One of the problems with these studies of systems that have horrible intubation success rates, is that their BVM use is probably just as bad. How much of the bad outcome is due to BVM incompetence, rather than the inability to put a tube in the right hole?
If we make the patient hypoxic enough in our focus on the intubation, does it matter if we are successful with the intubation?
No, it does not.
If we allow the patient to vomit and aspirate in our focus on the intubation, does it matter if we are successful with the intubation?
No, it does not.
RevMedic finishes up with:
BVM is the lost art of airway control.
There is only one appropriate response to that:
Amen.
.
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