Archives for September 15, 2010

Response to: “Criticizing a Letter to Mom?”

I was not critizing the letter to mom, hell, I agreeed with you about the fact that, when ALS Interventions interfere with BASIC care, it’s bad juju. 

But, I have a question about one of your points.

When choosing to transport to the hospital, while performing compressions, just to transport to ALS –

ALS Kills Patients.

-I may just be tired, but are you saying that you’d rather “call it” on scene rather than attempt to work it?  I agree.  The 90 y/o patient who has every medical problem known to man who has been down for an unknown time, yeah, call it…but that 60 y/o who doesn’t have too many problems should be given every opportunity to pull through.  CPR in an ambulance isn’t exactly safe, but that discussion is for another time.

I agree with all of your other “ALS Kills Patients” points.

Unfortunately, most of the patients we work with for a cardiac arrest got there due to one of two things: Old age or crappy medical conditions.  Usually those two go hand in hand.  I am purposly leaving out pediatric cardiac arrests because I would just have to call you a heartless bastard if you didn’t give a kid every shot in the world, or traumatic arrests because, unless it’s a tamponade or a pneumothorax, they’d be dead no matter how many or few drugs we’d give ’em.

So, research is going to lean more towards getting a pulse back long enough for transport to the hospital just for them to die minutes/hours/days later, just because that’s the type of patient we get. If I saw that the patients who, by medical definition, should have survived, did not because of pushing Epi and Atropine and maybe some Lidocaine depending on the rhythm, then I’d throw out my medical kit on cardiac arrests and just stick to solely BLS.

Airway Adjuncts: It all depends on the patient and what happened.  Personally, I’d stick with them because we are never sure why they went unresponsive in the first place.  I agree; don’t stop compressions just to get the tube.  If you can get it in with bare minimum interruptions, cool, if not, just use the adjuncts.  I don’t need to assert the size of my testicles by getting a “true” intubation (If I had any).  An Airway is an airway, no matter how I got it.

Why 25%?  I am not sure on the true numbers of how many cardiac arrests fall under H/T Fixable.  I was trying to use “easy” numbers for the sake of conversation.  I am sure the precentage of them are probably higher or lower…

On the Airway front, the ever mindful AHA is now saying that compressions are better than worrying about the airway.  While no research has said that an adequate airway will guarentee a successful cardiac arrest, we need the oxygen in the blood that we’re circulating to go to the brain and other bodily organs.  Call me old fashioned or a “Kitchen Sink Medic”, but I’m going to keep establishing an Airway in all my arrest patients.  We don’t have all the fun tools to determine just why someone went into arrest, especially when a frantic family member isn’t able to give us an adequate description of what happened before they went unresponsive, I don’t know what happened! He was fine, then he just went out!

I unfortunately will have to vehelmently disagree with you on not establishing an Airway.  Until I see lots and lots of data to the contrary, and I’m not talking about the lack of compressions during the establisment of the airway, but that somehow, it’s bad to provide an airway, I’ll keep doing it.

About the EMS Save:

Sometimes, it happens.  No matter what we do, sometimes we can only get the heart going for a little longer, no matter what we do.   It’s only a distraction when you hear someone saying, “This one is just practice…” when the patient is very dead and shouldn’t be worked anyways.  If we only worked the people we knew from the start we could save, then no matter what we did, they’d live, then the arrest save rate would be nearly 100%.  Do we code a lot of people we shouldn’t? I can see how we do.  We need to get away from, “doing it for the family” and working it because of lack of protocol to call them.

As much as my younger, dumber, and less experienced self would be all over you because how dare you say that ACLS doesn’t save patients?!  The hospital is the one that kills’ em…I get them there with a pulse, they die because they’re dumb. My more experienced self can also say that, it’s a combination of everything.

It’s good debating with you like this, RM.  You make me flex my mental muscles that I may not get the chance to, and I hope we can do it again, if that is alright with you.  Thank you, once again.

~MT~