JEMS State of the Science 2009

The Journal of Emergency Medical Services (JEMS) has a great supplement for download on their website. Called "State of the Science 2009," the 32-page insert has great articles on CPR, the changing roles of MS, lasix, and beta-blockers, the wide spread use of field 12-leads, research into hypothermic induction in a cardiac arrest, and other topics. You can find it on the JEMS website here. Look for the Download This Supplement link near the bottom of the page.

ACLS Update

Today I took my ACLS update and I did my PALS update about two weeks ago. I'm now sure that a person's success at ACLS and running through the scenarios is inversely proportional to a person's pay scale. In other words, the more your get paid, the worse you do at ACLS.

To illustrate my point:

My group today for recertifications consisted of an ER physician, multiple nurses, and 3 paramedics. The worst performer of the group was the ER physician--he overlooked the BLS survey (the look, listen, and feel), didn't know drug dosages, and had to refer multiple times to his pocket guide to double check the algorhythm.

The ICU, CCU, and ER nurses in my group performed slightly better. About half remembered the BLS survey, although some would skip steps (such as not checking a pulse and jumping from giving breaths to starting compressions). Most of the nurses had trouble identifying the heart rythms, which I guess is understandable. The majority of the nurses had a firm grasp of what drugs to give when, although they seemed a little iffy on dosages.

By far, the best performers at the skill stations were the paramedics. The medics were on top of the BLS survery, made smooth transitions from assessments to treatments, knew the heart ryhtms without questions, and knew the algorithms by heart.

Now, I'm not trying to say that medics know better than nurses and physicians, but I think that with the way the ACLS course is taught, it creates an environment for medics to do better. The course starts with the BLS assessment and CPR, followed by field interventions, and skills that are performed by medics on a very regular basis. Conversely, many of the nurses in my classes had no prior training in field assessment skills, or more technical skills such as intubation or needle decompression. Many of the nurses were unsure of their roles and stated multiple times, "well, the doctor normally would do that," or "I'd call for the doctor."

Doctors, on the other hand, aren't expected to perform CPR in a clinical setting, or be the ones to start the IVs or push the drugs. They often aren't expected to be the ones to perform the BLS assessment (as an example, one of the physicians in my class was an oral surgeon).

Medics practice these skills on a daily or weekly basis, incorporating the BLS survey, ALS skills and interventions, and transportation and turnover into all of their patient contacts. Nurses and doctors don't have the beginning-to-end exposure that medics in the field do and can therefore lack the same skill set. Many of the nurses in my class talked about how the patients they see on a daily basis already have an IV or airway established, how the diagnosis and treatment has already been determined, in other words, much of the guess work is already been done for them.

So the other medic students and I spent over three hours (or our six hour day) this morning going over the CPR video (a skill that we should already come to class proficient in). We then watched corny DVD videos of nurses, doctors, and EMTs perform the cardiac arrest algorithms (all of which were done with far too much urgency and energy to seem realistic or reassuring). After this we performed basic airway adjuncts like the OPA and non-rebreather masks (skills that we learned in EMT-Basic school and should be proficient in). We spent only 1 hour of our 6 hour day practicing the "mega-code" scenarios. So I have to wonder, where is the "Advanced" in Advanced Cardiac Life Support? My partners and I wanted only to do our scenario and take our test--get in and out in an hour. Really, the science and skills hadn't changed in 2 years. These are the 2005 guidelines, right?

Ideally, I'd love it if ACLS was taught in such a way that it focused on the skill level of the providers. ACLS for paramedics would focus more on the core cardiac arrest cases. ACLS for basic level providers would focus on core CPR skills and basic science. ACLS for nurses would focus on in-hospital interventions and working as part of a team with a doctor in the lead. ACLS for doctors would focus on the more tertiary aspects of cardiac arrest management, identifying and correcting causes of cardiac arrest that can't necessarily be identified or corrected in the field.

But the AHA has their way of doing things and who are we to questions, other than the providers that render their standards of care.

Difficult Arrests

I've had a string of difficult cardiac arrests lately. Not difficult from a skills stand point (they all go smoothly enough) but difficult from a circumstances stand point. Last night we were dispatched to a cardiac arrest reported by PD on scene. Fire was dispatched at the same time and arrived on scene right behind us. I walked up the stairs to the 2nd story condo and found one of the local (and very well liked and respected) police officers along with a county sheriff or two.

"I just need you to do a verification for me," the local cop said. Now, I immediately slowed down at this point, going from a resuscitation mode to a confirmation mode. The local cop is one of the deputy medical examiners (DME), he would know what a dead body looks like better than most.

My partner and I entered the bathroom and found the elderly female patient lying on the floor next to the toilet. The cops, firemen, and husband all had to wait in the living room while my partner and I went about confirming the confirmation.

First thing I noticed is the cyanosis in the face and left arm (she was lying on her left side). She was pale centrally, but no dependent lividity. Her core is not quite warm, but not quite cool either. And in checking a carotid pulse, I find her to still be very warm at the neck and chest. "She's still viable," I tell my partner, "we're gonna have to work it."

We pull her to the living room and start working the arrest. Firemen start CPR, while I get to work on the airway and my partner is working on an IV. I start to ask questions and find out that PD was sent to investigation after dispatch had received some peculiar 911 calls from the husband. Due to some communication difficulties on the husband's part, the request for an ambulance never made it through dispatch.

The officers arrived and found the patient arrested in the bathroom, made the determination that it was a DBA, but called a cardiac arrest anyways. We arrive and begin working the code. The patient had been down for up to 20 minutes by the time we start CPR. The patient remains in asystole throughout the arrest, but we transport (as our protocols say we do) and call it at the hospital.

Here's where I have difficulty with this call--I don't know whether I need to be upset at the local cops or not. The communications problem that resulted in our delay aside, it seems to me that a DME should know how to check to see if the patient is still viable or not. The determination that the patient was still viable was (to me) pretty obvious and given that determination, we started working the code right away. The police are CPR trained, it's a job requirement. The DME knew enough to call this as a cardiac arrest, not a possible DBA. So I ask myself, should they have started CPR?

My supervisor had a good point about this; the cops' CPR training is primarily for themselves. They are not medical responders and can't be expected to act as such. They may not have had gloves or a pocket mask available to them for their protection. And their training is in recognizing dead versus alive, not viable versus non-viable arrest.

I'm still wrestling with this today. Do I need to, or am I expecting more than I should from the cops?

As a side note: I try to learn something from every call. From this one, I went into it with the wrong mind set. I allowed myself to slow down when the officer asked me to confirm. I know in the future to treat every cardiac arrest like a workable cardiac arrest until proven otherwise.

What I Get for Taking Vacation

It's been a hell of a week. I took a shift off on Tuesday to spend a few days away with my wife celebrating our 4th anniversary. I paid for it though, before and after.

The shift before my anni-vacation, my partner and I ran 5 calls before noon. One of which required cardioversion for SVT after two unsuccessful rounds of adenosine. In the middle of all this, dispatch is paging us that there are return medivans waiting at providence ER. We made three round trips to Portland that shift.

I had to paralyze and intubate a stroke patient while nervously waiting for additional personnel from rescue. We took him to Portland on a vent.

Upon returning from my anni-vacation, I had a first ever experience as a patient went from a 3rd degree block to cardiac arrest in front of me. I was setting up an oxygen mask and not looking at teh patient when a fireman said "I think he just went out on you!"

"No he didn't." I replied as I double checked the monitor leads (one of them had fallen off). It was then the patient went from pale to purple in 10 seconds. Fuck I thought.

"Code 99." My partner calls into the radio. Immediately this is followed by the FTO sitting at post "Medcom from Medic 3, does 1 need our assistance?"

In the middle of applying defib pads, setting up for the intubation, and IV, I grab the handset. "Negative 3, fire is already on scene." I don't need another medic to drive 15 minutes from post to 'assist' me on a code when I'll be off scene in less than 10. (I have a problem with second ambulances responding as "back up," something I'll rant about later.)

That shift was rounded out with a transfer for gall stones at midnight. Something I truly considered a valuable use of my emergency medical skills.

Today, it continued with a trauma system entry from the memory ward at one of the local adult care facility. The patient fell outside and was in the rain for 10-20 minutes before the caretakers found him. He had a huge hematoma on the back of his head and was supposedly altered from his normal state of dementia. Turns out he had a subdural bleed as was a trauma transfer 30 minutes after arriving at the hospital.

And this afternoon, I took my second vent transfer of the week, an acute MI with complications. I just took a vacation, but really, I need another one.

Last Moments

This last shift, I responded to a reported seizure at a local care facility. I obtained a report from the staff and interviewed the patient. She looked pale, was slow to respond, and was weak. Nothing too unusual for this particular care home, most of the residents were here because they were truly sick. I put her on the monitor after feeling a very slow radial pulse and sure enough, she was in 3rd degree heart block. Very soon, I had a feeling my patient's heart was going to stop.





I had had a feeling to dispatch rescue when we were first assigned to the call and at this point, the engine crew walked in. I gave them the quick report and we went about starting an IV, getting the patient on oxygen, repeating vitals, and moving her to my cot. I held off on the Atropine because of the block, and considered pacing. She was stable, tolerating the rate well, with a good pressure, and so for the moment, I held off on the pacing (later, the ER doctor reassured me it was the right thing to do).

The nursing home is four blocks away from the ER, so I told my partner an easy code 1 return would be fine. I radioed my report, receiving a very emphatic and clipped NO! when I asked if there were any questions. We turned over the patient to the ER staff and bid the patient a good afternoon. My patient, 85 years old, had just spent some of her last moments with my partner and I.

A few shifts back, my partner and I had a candid discussion about how our patients often spend the last few waking moments of their lives. My company uses a Rapid Sequence Intubation (RSI) protocol to manage the airway in traumatic and medical cases when the patient is unable to maintain their it themselves. The procedure uses medications that cause sedation, retrograde amnesia, and paralysis to facilitate intubation. Sometimes, because of their condition, the patient dies and their last waking memory is some sweaty, adrenaline fueled paramedic looming over them saying "I'm going to put you to sleep now so I can take care of you."

This occurs frequently outside the realm of the RSI patient. We take a critical cardiac patient into our ambulance to be transported and they arrest during transit--again the Paramedic is the last person they see. We are cutting someone out of a mangled car, and they decline shortly after--the Paramedic and the firemen are the last people they see. A patient actively stroking, trying to tell their family I love you through a mouth that doesn't work, then finally hemorrhages in the ambulance--the Paramedic and his partner are the last people they see.

I've tried to take this to heart, realizing that often as the Paramedic, I am one of the few people to see a critical patient in their last minutes or hours of life. They can arrest on scene, in my ambulance, or at the ER after being turned over to the nurses and doctors. The patient may even have the prophetic impending sense of doom and know that their death is coming. As a Paramedic, my training is to prevent that, but I know that's it is often as much about factors outside my control as it is my skill level. So how would I want to be treated by a Paramedic in my last few minutes and hours?

I take this with me and use it to shape my attitude and relations towards my patients. I treat every patient with dignity and respect. I do my best to make sure they are comfortable on the cot and warm enough. And I try to reassure them that they'll be taken care of, whether it is their last moments or not.

My 85 year old arrested shortly after arrival in the ER. I had a feeling she would, so did the ER doctor and the nurses. Her heart would only tolerate a dysfunction like that for so long. My hope, for both her and her family, is that her last moments were as comfortable as they could be.