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I thought we were working on Why Can't Medics Intubate?
We still are. This is just a change in perspective. A study,[1] not yet published, but available on line, shows part of the problem with resuscitation.
What is that?
As I have stated many times before, we put the ALS (Advanced Life Support) before the BLS (Basic Life Support). We waste time on ALS, that does nothing good for the patient, at the expense of the BLS. The BLS treatments - continuous compressions and rapid defibrillation - have been shown to work. The ALS, well maybe we should start calling ALS Alternative Medicine Life Support.
Alternative Medicine?
We keep making excuses for why ALS does not improve outcomes. Maybe a little homeopathy (pardon the pun), some acupuncture (not on the sternum with the needles), some psychics to talk to the not quite dead, yet . . . .
Ok, OK, what does the study say?
It starts with, SEE EDITORIAL, P. XX., but there is no editorial listed. I think they just realized that this paper would ruffle a feather or two and there will be some ALS apologist will come up with something in a few days.
Editor’s Capsule Summary
What is already known on this topic
Decreased interruption of chest compressions in out-of-hospital cardiac arrest is strongly associated with increased survival in animal models and clinical trials. Little is known, however, about the specific issues that lead to interruptions.
What question this study addressed
What are the frequency and duration of cardiopulmonary resuscitation chest compression interruptions associated with paramedic endotracheal intubation during out-of-hospital cardiac arrest?
What this study adds to our knowledge
In 100 out-of-hospital cardiac arrests, patients' chest compressions were interrupted twice, on average, because of efforts to intubate, with a mean total interruption time of nearly 2 minutes.
How this might change clinical practice
This adds support for the current movement to de-emphasize intubation and delay it until later in resuscitation attempts for out-of-hospital cardiac arrest.
We have been encouraging paramedics to draw people toward the light - the laryngoscope light.
Is there evidence of a benefit of intubation in cardiac arrest treatment?
No.
Intubation in cardiac arrest is as much wishful thinking as epinephrine, lidocaine, bretylium, amiodarone, IV/IO/IC access, et cetera.
Like zombies they follow our voodoo into the ICU as brain dead consumers of massive amounts of resources, but they do not get better.
We know what works - BLS treatments - continuous compressions and rapid defibrillation. We are not satisfied with that, so we come up with things to interfere with the BLS treatments. The above list of ALS treatments have only been demonstrated to be effective at delaying/interrupting/discouraging/interfering with effective treatments.
What has happened to resuscitation rates as ALS has been de-emphasized and more emphasis has been placed on continuous compressions?
They seem to have tripled in most of the places that have cut back on the ALS and emphasized the BLS.
Tripled.
If they were 5%, they are now 15%.
If they were 15%, they are now 45%.
So, why are we still wasting time with ALS?
Maybe we should consider ALS to be a Reversible Cause of continuing Cardiac Arrest.
Footnotes:
^ 1 Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation.
Wang HE, Simeone SJ, Weaver MD, Callaway CW.
Ann Emerg Med. 2009 Jul 1. [Epub ahead of print]
PMID: 19573949 [PubMed - as supplied by publisher]
.
Ahh, how many times must we say this stuff for people to listen??
ReplyDeleteWant to save lives?
Here is how:
-implement a hands-only CPR training program for your citizens
-Adopt the King tube as your primary airway in all cardiac arrests
-purchase a few ResQPods and train on them
-practice 2 minute interval changes on mannequins with adequate chest compressions. Give all your employees an iPod with "staying alive" or "another one bites the dust" on it and tell them to hold that rhythm. It really works!!!! I love the irony.
-Practice the AHA guidelines and use a stopwatch.
-Look into induced hypothermia
This stuff has actual evidence to support it. RM has hit the nail on the head once again, and I can't believe how many medics become defensive when it comes to this topic. How many medics make sure we switch out compressors at 2 min. intervals and provide continuous compressions in between? Maybe our EMTs should run the codes...
I hope we get some good conversation here, post your thoughts, don't hold back.
Over at Rogue Medic, in the comments to this post, there is a bit of disagreement about the usefulness of ALS in resuscitation.
ReplyDeleteI agree with what Adam writes, except for the switching of compressors at 2 minute intervals. I am just getting warmed up and I'm not even in good shape. As long as the continuous compressions can be maintained at the rate of at least 100/minute, I do not see a reason to interrupt compressions to switch.
The whole point is to avoid interruptions, so maybe we should get in better shape and use our body weight more effectively when performing compressions.
When else can you determine a rhythm without the use of see-through devices?
ReplyDeleteHere is the thing... No firefighter I know will ever tell you he is tired when doing compressions. The fact is that at a rate of 100/min. you will eventually become less effective, maybe not at 2 minutes, but I am just going by the AHA recommendations. If practiced you can switch compressors in just enough time to determine your patients rhythm and continue.
I am all for limiting interruptions, and when I see that the compressor is given great compressions after 2 min, I don't force him to change out.. especially not if the person they would switch with may not be the best compressor. I guess I probably do the same thing as you... it just depends on the situation.
I was skeptical too, of the 2-minute time limit.
ReplyDeleteBut when demonstrated using a room full of BLS Instructors and Regional Faculty, many of whom were in good shape, you could definitely tell the difference on a Skillmeter Resusci-Anne.
What falls off first isn't the depth of your compression so much as it is your rhythm. Your pace slows, even though you don't realize it. You tend to lean on the chest more, not allowing full recoil. There is a greater variability in the depth of your compressions, even though all of them may still be sufficiently deep at two minutes.
At the 3-minute mark, though, you'll see that a distressingly high number of your compressions aren't deep enough, you're leaning on the chest a lot, and you've slowed down noticeably.
At four minutes, you generally just suck, period.
I'm cool with swapping out every two minutes. In my mind, the smoothness of the code is all in the choreography anyway.
Checking the rhythm can be done in the time window where you're giving two breaths.
Defibrillation can be done in the ten-second window you have for a pulse check and compressor switch, just be sure everyone understands what "CLEAR" means.
Pulse checks (if indicated by the rhythm check), defibrillation and intubation at the 2-minute mark during the compressor switch, meds at the one minute mark, and everything's hunky dory: a defib 60 seconds after giving the med, every med (if you alternate vasopressors and selective cardiotoxins, er antiarrhythmics), and the shock delivered within a few seconds of ceasing compressions.
And since I'm a stand-back, big-picture, non-interventional, direct-the-work-of-others medic, I tend to have someone else do the compressions anyway. *grin*
"And since I'm a stand-back, big-picture, non-interventional, direct-the-work-of-others medic, I tend to have someone else do the compressions anyway. *grin*"
ReplyDeleteWell isn't that what our title is for... to keep us from having to drive or do compressions at 3am?
I have heard of similar demonstrations to determine how effective compressions are. It's too bad we all can't afford those awesome Autopulse devices. I would like to see some studies on them. I have heard stories about ROSC patients waking up and talking... until the Autopulse was removed; can you imagine?
Ambulance Driver,
ReplyDeleteAt the 3-minute mark, though, you'll see that a distressingly high number of your compressions aren't deep enough, you're leaning on the chest a lot, and you've slowed down noticeably.
I have worked as a tech in a couple of hospitals. I am used to being the one doing compressions for the whole code with a bunch of people watching A bunch of people who do not mind offering criticism.
I would like to play with this machine. ;-)
At four minutes, you generally just suck, period.
Like I haven't heard that before.
I'm cool with swapping out every two minutes. In my mind, the smoothness of the code is all in the choreography anyway.
Checking the rhythm can be done in the time window where you're giving two breaths.
Defibrillation can be done in the ten-second window you have for a pulse check and compressor switch, just be sure everyone understands what "CLEAR" means.
Do we really need to pause compressions for pulse checks with waveform capnography?
What happened to the research on hand-on defibrillation?
Pulse checks (if indicated by the rhythm check), defibrillation and intubation at the 2-minute mark during the compressor switch, meds at the one minute mark, and everything's hunky dory: a defib 60 seconds after giving the med, every med (if you alternate vasopressors and selective cardiotoxins, er antiarrhythmics), and the shock delivered within a few seconds of ceasing compressions.
Epinephrine is not the most potent cardiotoxin on the planet, but it is the most potent cardiotoxin we use. Why do you have to make such a big deal about amiodarone? ;-)
And since I'm a stand-back, big-picture, non-interventional, direct-the-work-of-others medic, I tend to have someone else do the compressions anyway. *grin*
I prefer to demonstrate things the way I want them done. People respond differently to requests, when they know I will get in there and do the stuff myself.
Adam,
ReplyDeleteI have heard of similar demonstrations to determine how effective compressions are. It's too bad we all can't afford those awesome Autopulse devices. I would like to see some studies on them. I have heard stories about ROSC patients waking up and talking... until the Autopulse was removed; can you imagine?
Those are wonderful anecdotes, but I don't think there have been studies yet showing that this expensive thoracic NIBP machine leads to more people surviving once the machine is turned off.
Those are wonderful anecdotes, but I don't think there have been studies yet showing that this expensive thoracic NIBP machine leads to more people surviving once the machine is turned off.
ReplyDeleteCorrect, but I don't doubt there will be a few. The machine provides pretty damn good CPR as far as I can tell. Yes it's expensive, but how much do we pay for all those ALS treatments that don't do anything? Obviously more research needs to be done, as is most often the case.
RM, I can always count on you to get these controversial topics going. Great comments on this post on your page.
Those are wonderful anecdotes, but I don't think there have been studies yet showing that this expensive thoracic NIBP machine leads to more people surviving once the machine is turned off.
ReplyDeleteCorrect, but I don't doubt there will be a few. The machine provides pretty damn good CPR as far as I can tell. Yes it's expensive, but how much do we pay for all those ALS treatments that don't do anything? Obviously more research needs to be done, as is most often the case.
I am less optimistic. If this is the wonderful treatment that so many claim it is, why isn't the research showing a benefit?
It is supposed to be simple and easy to apply, so operator error should not be a problem.
It is supposed to provide just right compressions.
So, where are the survivors?
RM, I can always count on you to get these controversial topics going. Great comments on this post on your page.
Thank you.
I was not expecting so much controversy or so many and such long comments.
I was not expecting so much controversy or so many and such long comments.
ReplyDeleteIts all in the titles.
How about a post entitled 'So what the hell are Paramedics good for anyway ?'. It seems like all I read is 'we can't do this well' or 'we can't do that well'. What the hell am I spending one and a half years of my life in school and a major amount of $for ? Sounds like I'd be better off staying an Intermediate. Way to boost morale, guys.
ReplyDeleteAnonymous -
ReplyDeleteThis cuts to the heart of the problem. It's not about us.
Tom
Anonymous,
ReplyDeleteDid you read the information? I believe you are missing the point. SOMETIMES less is more. In EMS most of the time less is more. I believe the best thing you can learn in paramedic school is advanced assessment skills. If you are becoming a paramedic so you can do all the cool stuff, maybe you should rethink things. Although it wasn't long ago when I was in school anxiously awaiting my first tube. Our job isn't defined by the drugs we give or intubations we get; it's moreso defined by realizing when not to do that stuff based on experience and KNOWLEDGE.
Good luck to you, read my letter to the new guy.
Don't preach to me with pithy little one liners. You know what I mean, and I'm QUITE sure that when you were going through the pain that is Medic school, you'd have been disheartened to learn that half of what you learn doesn't apparently mean sh*t.
ReplyDeleteI'm just sick of half of the blog posts I read being on some inflammatory topic such as this. Let's have some pride in our profession, and what we CAN do. Let's make it better, not bring it down.
Not preaching. When I read this post I don't focus on what we can't do, despite the title. I focus on what we can do. What we can do is learn from the research and apply it. All the authors of this blog are well educated advocates of this profession. We are trying to improve our profession, not complain about it. We wouldn't waste our time if we didn't have a passion for the job that is paramedicine. We welcome your opinions, but I still think your misunderstanding our intent. I'm sure RM will explain his position on his post, but I am almost certain he doesn't think we CANT resuscitate. I'm pretty sure his stance is that we can do a better job of it if we listen to the evidence. If you are new at this job you are going to be hearing a lot of opinions. You will realize that the paramedic you will become is actually bits and pieces of every medic you have worked with.
ReplyDeletePs. I'm not patronizing you.
Anonymous,
ReplyDeleteHow about a post entitled 'So what the hell are Paramedics good for anyway ?'.
I'm easing in to that post. I don't want to rush things. ;-)
It seems like all I read is 'we can't do this well' or 'we can't do that well'.
There are many things that EMS does not do well. I am trying to improve the situation, rather than ignore it and hope that the Good Fairy will come along, wave her wand, and make it all better.
What the hell am I spending one and a half years of my life in school and a major amount of $for ?
Well, if you are doing it because you like doing something that does not work, I suggest that you switch to homeopathy, acupuncture, reiki, . . . , they will be glad to have you. You do not have to worry about any of your colleagues trying to improve patient care, because it is all placebo therapy.
I do not believe that EMS is placebo therapy.
We need to eliminate the things that don't work, not erect mausoleums to them.
Sounds like I'd be better off staying an Intermediate. Way to boost morale, guys.
If you want a morale boost, there is a nice story about medics sexually abusing patients, here. Emergency Medicine News:Volume 31(7)July 2009p 1, 27.
You can write a letter complaining that this is not important. Forget the patients, this is about the medics. If a few little girls need to take one for the team, maybe even take on the whole team, that's OK.
On the other hand, I am just being critical of care that kills/prevents resuscitation of patients. I should keep my keyboard to myself.
Do you want to do this because it helps patients, or because it feels good to drive fast, make noise, and act important. I don't think you would be so upset, if you did not want to do what is best for the patients.
Our job is to provide excellent care to the patients. If we cannot do that, we might as well be selling fast food.
The medics are not the job.
The patients are the job.
Tom B,
ReplyDeleteAnonymous -
This cuts to the heart of the problem. It's not about us.
Tom
If it isn't expected to help the patient, it probably shouldn't be done.
If it is being done just so we feel good about ourselves, it definitely shouldn't be done.
Adam,
ReplyDeleteI agree.
Many times the most important thing I do is hold the patient's hand. That does not make what I do unimportant.
Airway management is not about intubation.
Airway management is much more about knowing when not to intubate the patient.
"I'm just sick of half of the blog posts I read being on some inflammatory topic such as this. Let's have some pride in our profession, and what we CAN do. Let's make it better, not bring it down."
ReplyDeleteThe point of these posts, after better patient care, is pride in our profession.
If we don't take an objective look at what we do right and what we do wrong, then what kind of profession is it going to be when you finally enter it?
I'm not being patronizing, either, but half of the reason we're mired in the past is the "rah rah, we're medics! attitude.
News flash: You're entering a profession in flux, and the level of certification you seek is coming under increased scrutiny as to whether it is actually necessary at all.
And if we don't start acknowledging the reason for that scrutiny, and addressing those problems ourselves, within our profession, then the solution, such as it is, will come from outside EMS.
Is that what you want?
It's up to you to find your own morale booster. Your motivation can only be found within yourself.
Me, I find my morale boosted whenever I find medics bold enough to say, "We suck at this. Let's find a way to do it better."
Anonymous,
ReplyDeleteDon't preach to me with pithy little one liners.
I tried preaching with blog posts, but that didn't work. You really shouldn't criticize my approach, I put a lot into these posts, and . . . and think of my morale. ;-)
You know what I mean, and I'm QUITE sure that when you were going through the pain that is Medic school, you'd have been disheartened to learn that half of what you learn doesn't apparently mean sh*t.
I was disappointed to learn that some of what I was being taught was nonsense.
I did not let that get me down.
I resolved to learn as much as I could about how to be the best paramedic I could be.
I continue to be disappointed by the amount of nonsense that is taught.
Being a good paramedic is not about saying, Oh, yes doctor. Whatever you say doctor. I am a paramedic of little brain and never question orders, because that would be disloyal. Please pat me on the head and my morale will be boosted. Shall I fetch the paper and your slippers?
I'm just sick of half of the blog posts I read being on some inflammatory topic such as this. Let's have some pride in our profession, and what we CAN do. Let's make it better, not bring it down.
I am not trying to bring EMS down.
I am trying to improve EMS, so that our pride in EMS is justified.
Nathaniel Hawthorne wrote dark stories about people acting less than ideally. When asked why, he answered that this is what he writes, that he would like to be able to write happy cheerful stories as some of his contemporaries did, but happy and cheerful not what he does well.
This is what I write. That is one of the reasons for the wistful smiley face.
There is also a misquote that is attributed to many people. All that is needed for evil to triumph, is for enough good men to do nothing.
I am not good at doing nothing.
When I am engaged in benign neglect, it only looks as if I am doing nothing. I am still reassessing and looking for signs of change.
AD,
ReplyDeleteAnd if we don't start acknowledging the reason for that scrutiny, and addressing those problems ourselves, within our profession, then the solution, such as it is, will come from outside EMS.
Is that what you want?
This is true.
If we can't change things, it may be what we need.
It's up to you to find your own morale booster. Your motivation can only be found within yourself.
Me, I find my morale boosted whenever I find medics bold enough to say, "We suck at this. Let's find a way to do it better."
That's easy for you to say. Here I am telling people, "We suck at this. Let's find a way to do it better," and you tell him he has to find his own morale booster. ;-)
Where's a nice cheerful ParaCynic, when you need him?
Oddly enough, trying to become the best Medic I can be is exactly what I'm doing by coming here in the first place. For the record, I find many of your blog posts interesting, well written and educational. For that, I thank you (all of you).
ReplyDeleteI'm just greatly frustrated at putting in such effort to get somewhere, and then feeling like the goalposts are about to be moved. It would be nice to get the opportunity to actually practice the skill of intubation after spending 50 hours in the OR to learn it, before it gets yanked off of my protocol. I'm not saying that I'll intubate just because I can, but after putting in the effort to learn, I'd like to be allowed to demonstrate that I can (if the situation calls for it).
I apologize for the rant, I'm just going through one of those 'what the hell' moments. I'll have to formulate some thoughts and put them in an email, rather than a comment.
Anonymous, if you made it all the way through paramedic class without a "what the hell" moment, I'd be worried about you or the quality of your class.
ReplyDeleteThe goalposts aren't being moved so much as they're being narrowed. And hopefully you will get to practice the skill of intubation, when it's necessary and prudent.
By framing the debate here, hopefully we're showing that paramedics themselves have some say in what instances are reasonable and prudent.
At least, that's the goal.
Anonymous,
ReplyDeleteOddly enough, trying to become the best Medic I can be is exactly what I'm doing by coming here in the first place. For the record, I find many of your blog posts interesting, well written and educational. For that, I thank you (all of you).
Thank you. as I stated earlier, I expect that you are here to keep getting better. In EMS we are not always good at the warm fuzzy educational method.
I'm just greatly frustrated at putting in such effort to get somewhere, and then feeling like the goalposts are about to be moved. It would be nice to get the opportunity to actually practice the skill of intubation after spending 50 hours in the OR to learn it, before it gets yanked off of my protocol. I'm not saying that I'll intubate just because I can, but after putting in the effort to learn, I'd like to be allowed to demonstrate that I can (if the situation calls for it).
That is understandable.
I do not think that intubation should be eliminated as a paramedic skill.
I think that we need to limit intubation to situations where it may provide a benefit.
I think that the research is showing that cardiac arrest is not one of those situations most of the time.
I think that we will need to work even more at continuing education/remediation to deal with the lack of frequent use.
That is already a problem. I think that the biggest part of that problem is the fire departments requiring that everyone become a paramedic. That is not the way to provide quality care. It isn't much different from when Canada decided to call everyone in EMS paramedics.
We have a bunch of BLS people running around with paramedic written on their patch, but with no experience and without hope of acquiring experience. We need to limit the number of medics, so that they are able to maintain skills.
You wouldn't want to be treated by a surgeon, who only operates once a month. That would be crazy, but we have systems where a medic may be the lead medic on only one unstable patient in a month, or one every two months. The skills go away more quickly than that.
You will probably find the highest concentration of excellent medics in the places that limit the number of medics. Medic One, Boston, Hennepin County, . . . .
I apologize for the rant,
Like I never rant? It comes with the territory.
I'm just going through one of those 'what the hell' moments. I'll have to formulate some thoughts and put them in an email, rather than a comment.
Nothing wrong with that.
Anonymous,
ReplyDeleteI'm just greatly frustrated at putting in such effort to get somewhere, and then feeling like the goalposts are about to be moved.
It's a funny thing about those goalposts, before you know it you are the one positioning them.
By the way, nothing changes more than medicine; especially prehospital medicine. We are still the toddler.