Tag: BLS

CPR for Dummies: How to Save a Life

One of the peculiarities of EMS education — and as a byproduct, of EMS practice and culture — is that we spend the majority of our time focusing on the minority of our calls. Think about it: your textbook has pages and pages devoted to ruptured aortic aneurysms, placentas previa, and mid-femur fractures — and when’s the last time you saw one of those? But scarcely a paragraph is given to the routine transfer, the drunk asleep on the sidewalk, or the MVC with minimal injuries. Call it an inverted pyramid: the most important stuff is low-volume, the most common stuff is pretty easy.

Whatever. The point is, at the very apex of this pyramid is the cardiac arrest. In its purest form, cardiac arrest is exactly why EMS exists. It couldn’t be higher stakes — as a disease, it’s absolutely certain to be life-threatening — and it’s terribly time sensitive, but the potential exists for a total cure if everything goes well.

Unfortunately, like many low-probability calls, we don’t get a great deal of experience with these — even less if your shift isn’t dedicated to emergencies. And when we don’t get much experience with something, that’s when training needs to fill in the gaps.

CPR and BLS resuscitation can seem like a confusing topic, especially given the frequent and seemingly arbitrary changes to the guidelines. The truth is, though, that it’s only gotten simpler and simpler — and you don’t need to follow the research (read: be a giant nerd like me) in order to know exactly what to do. Here’s the short, stripped-down, painless rules for how to save a life.

 

Push and Zap

Basically, after around sixty years of research on resuscitation, there are only two things that we know for sure help people survive cardiac arrest: chest compressions and defibrillation.

Literally, just those two things. Oh, there’s other stuff — ventilation, drugs, devices — that seem to help briefly, but so far nothing else has been proven to get someone’s heart beating again and let them walk out of the hospital with a working brain. Now, some of those other things do seem like pretty good ideas, and in many cases we started doing them before we knew if they’d really help or not, so we’re still doing them because people are used to it; it’s part of our training, and it’ll take some extra-compelling evidence to make us actually stop doing that stuff. But still, the story so far: chest compressions and defibrillation definitely help people survive, and that’s it.

What this means is that they should be your number one priority. If your patient is in cardiac arrest, that’s what they need. Other stuff? It may or may not be helpful; if you have the chance, or the personnel, and it doesn’t interfere with chest compressions and defibrillation, then you could go ahead and do it. It might help. But delaying or stopping the big two for that other stuff is like making a thirsty man wait for a drink of water while you comb his hair.

 

Early, Hard, Fast, Uninterrupted, and Full Recoil

Okay, so, chest compressions. Easy enough. Anyone can do ’em, all you need is your hands, just jump in there and push.

However, that’s not quite the whole story: the quality of compressions matters a great deal. We are literally pumping blood here; we are creating mechanical pressure to replace the squeezing of the heart. Just like you can wriggle a bicycle pump ineffectually without making much progress on inflating your tires, so too can you make goofy movements on someone’s chest without providing much perfusion. Even at its best, CPR only provides weak circulation compared to a real heartbeat; if you give poor CPR that’s even worse.

So here are the key components:

  • Early: Compressions should be initiated as soon as possible after arrest. That means, if I go down now, ideally you’ll start pushing on my chest as soon as I hit the ground. Typically that’s not possible, but mere seconds really do matter here; the longer there’s no circulation, the more tissue is endangered (all tissue, but particularly the vulnerable heart and brain), and the less likely that defibrillation will be successful — or if it is, the more likely there will be permanent complications.
  • Hard: Good chest compressions are a violent, aggressive act. We now recommend a depth of at least 2 inches in adults, which if you examine a mannequin (or fellow human) is remarkably deep. (Yes, “at least” means that going deeper is fine; compressions that are “too deep” are rarely seen in real life.) This isn’t a gentle cardiac massage, it’s not the mellow bouncing you usually see in movies, it’s a deep, powerful, oscillating thrust. It should tire you out, which is why we recommend changing personnel frequently; even when you think you’re still doing well after a few minutes, you’re probably not.
  • Fast: The recommended rate is now “at least” 100 compressions per minute. Since nobody knows what this means without a metronome, I highly recommend “musical pacing,” or using the beat of a well-known song to learn the rate. Stayin’ Alive by the Bee Gees is the classic; I like Queen’s Another One Bites the Dust myself. Again, 100 is an “at least” rate, so faster is better than slower. Admittedly, if you go extremely fast the heart won’t have time to fill between squeezes, but most “ludicrous speed!” CPR tends to have poor depth, and self-regulates anyway once you get tired.
  • Uninterrupted: Just like it’s essential to begin compressions as soon as possible, it’s equally essential to stop them for nothing. It’s not just that every moment you spend off the chest is “dead time” in which no blood is circulating; it’s worse than that. Chest compressions need to generate some “momentum” in order to create enough pressure to perfuse the heart; several consecutive compressions are needed before you’re really moving much blood at all. If you keep stopping — and studies show that everyone stops far more than they realize, to fiddle with one thing or another — you’re wasting those gains as soon as you’ve achieved them. Maximizing this “compression fraction” should be a primary goal; once you get on that chest, don’t stop for anything else unless it’s literally more important than circulating blood.
  • Full recoil: Among otherwise skilled rescuers, one of the most common errors is failing to allow for full recoil of the chest. In other words, you press down deeply, but rather than releasing fully, you start the next compression before you’ve come all the way up. This shortens the stroke of the pump just as much as if you were giving shallow compressions, and for several complex reasons (in particular the loss of preload) can reduce circulation in other ways too. We do this one particularly when we start to get tired, and begin to leaaaan forward to rest on the chest.

Defibrillation

It’s really as simple as this: once the heart’s entered fibrillation (or to a lesser extent a pulseless V-tach), the only plausible way to fix it is with electricity. These people are not going to “come to”; they are not going to have a Baywatch moment where they cough out water and wake up, even if you give them great CPR. They have an intractable problem, and the cure for it is an electric shock. Defibrillation is life-saving.

For most of us, this means using an AED, the automated devices you see everywhere from airports to ambulances. The reason they’re everywhere is because their use is time-sensitive, and if you drop dead ten miles from the nearest one, it might as well be ten light-years. No matter where you are, compressions must be performed to buy you time, and a defibrillator must be found to shock you back. If both don’t happen quickly, you will probably stay dead forever.

There are argument about some of the technical aspects of defibrillation, such as pad placement and waveform, but so far none of these details have proven to be very important. What is important is that you shock early, and get ready to shock without interfering with those compressions. Whenever possible, while one person gives compressions, someone else should clear off the chest by cutting or pulling the shirt from under the compressor’s hands, place the pads around them, and start the AED’s cycle. For many models of AED, there will be a period of several seconds while it walks you through voice prompts (telling you to stay calm, call for help, etc; these devices are designed to be usable by laypersons with no training), which should be ignored while you continue your CPR.

Once the AED tells that it’s analyzing the rhythm, you will need to stop compressions; this is the computer’s opportunity to decide whether the patient can be shocked or not, and interfering with this will just delay the process. If it doesn’t advise a shock, get back on the chest; you may have better luck later. If it does advise a shock, get back on the chest anyway! It’ll need to charge first, which may take quite a few seconds, and remember — every second matters. (Just make sure the whole team’s on the same page here, so that nobody pushes “Shock” until you’re clear.)

As soon as the AED announces that it’s ready to shock, everyone should be ready: cleared from the patient and prepared to shock. In a coordinated fashion, the compressor should clear the chest, the shock should be delivered, and he should immediately resume compressions with a pause of only a second or two. Rinse, lather, repeat.

When do you stop this process? When someone much smarter than you says to stop; or when the patient demonstrates clear signs of life (such as movement, breathing, or improved skin signs — or for the medics, a spike in end-tidal CO2). Don’t keep stopping to palpate pulses and otherwise fiddle with the patient. Like a soufflé or a Schroedinger’s cat, you must have faith in the process here, because checking on the process will assuredly cause it to fail.

 

It Ain’t Rocket Science

People, there are other details to this process, which is why they make us take CPR classes and carry the little cards around. And in 2015, there might be some new ideas on how we can do it best. Research continues apace in the countless EMS systems around the world that are experimenting with different technologies, techniques, and methods to improve survival. That’s how we’ve come from 1–2% survival rates to the 50%+ that a few cities now enjoy. It’s slow going, but it’s going.

But the best methods won’t matter if you don’t use them, and a lot of effort has been given to make our current methods truly simple. You literally can’t go wrong if you give great compressions and defibrillate as soon as possible. You can certainly go wrong if you forget that those are the two most important, life-saving measures — but you’d never forget that, would you?

Push and zap, folks. It’s so easy, an EMT can do it.

Differentiating Syncope: A Few Pearls

Syncope. To a fresh-faced student, it’s a snappy word for fainting. To someone with experience, it’s a heavy sigh, because we take a lot of calls for “syncope” and most of them are no big deal. But to a veteran provider, syncope is a deep, dark diagnostic hole—because syncope can be caused by countless different disorders, and although some are benign, a few of them are deadly.

Comprehensive diagnosis and treatment of syncope deserves its own dedicated series, and one of these days we’ll try and work through it from A to Z. Every etiology is unique and has its own distinct pathophysiology, presentation, and treatment considerations. Syncope sucks.

But for now, we’ll just talk about a few take-home pearls that can pay dividends in the everyday management of your next syncope call. We don’t support simplistic rules of thumb ’round these parts, but sometimes 95% of the work can be done by 5% of the know-how, and that’s just fine.

Here are a few dead-simple roadsigns to help guide you through the most common and most important causes of syncope.

 

Did they pass out and fall, or did they fall and then pass out?

Syncope means that somebody passed out and fell down. It doesn’t mean that they fell down and then lost consciousness. If they tripped on an oil can, fell over and smacked their head on a rock, they may have blacked out, but there’s no mystery there—it’s a simple trauma call.

So, our first step should be to take the raw he passed out and sift it into a more precise description. One problem is that people who lose consciousness often have a poor or unreliable memory of those events, so they may not always be helpful; this is why it’s nice to have witnesses who can tell the story. Of course, witnesses aren’t always reliable either.

 

Okay, so what do they remember?

To the extent that the patient remembers it, how do they describe the event?

A prodrome is an early, sometimes subtle set of symptoms that warn of a problem developing. Prodromes are our friend, because although they can be very brief or non-obvious, when present they can help indicate what happened. So, ask! It’s the O in OPQRST, and it’s the E in SAMPLE, so it’s the beginning and end of our patient history—no excuses!

Vasovagal syncope is one of the most common causes of syncope, involving a transient drop in blood pressure, and vasovagal syncope is usually preceded by a prodrome. If you’ve never had the experience of standing up too fast and getting briefly faint, here’s the gist: you become light-headed, your vision blurs or darkens, you feel weak, you may stumble, and finally you go down. There may also be broad neurological symptoms, such as visual disturbances (“seeing spots”), strange sensations, shaking, and more. (Basically, your brain isn’t getting enough oxygen, so odd stuff happens.)

How about seizures? Many seizures are preceded by a prodrome known as an “aura,” which can manifest as various unusual neurological abnormalities; read more in our piece on seizures. Did the patient truly lose consciousness, or do they claim that they remained somewhat aware? In a simple partial seizure, the patient will remain aware of their surroundings (although these often don’t cause a “syncopal” collapse); in most others they will experience a gap in consciousness.

Syncope caused by cardiac arrhythmias, such as a run of V-tach or a Stokes-Adams attack, will sometimes be preceded by a palpable sensation of weakness, or palpitations  (“fluttering”) in the chest. However, in many cases there will be no warning whatsoever.

 

What did the witnesses see?

It’s one thing to hear about a prodrome from the patient, but you may get a different story from the bystanders.

What did they see before he went down? Did he become absent, demonstrate tics or tonic immobility, perhaps complain of an aura? Did he demonstrate obvious clonic jerking of the muscles or urinary incontinence? If he’s acting normally now, was there a period after the event where he demonstrated sluggish activity or unusual behavior, consistent with a post-ictal period? These are all suggestive of a seizure.

Were his eyes open or closed for the duration? Closed is typical of classic syncope, such as a vagal event; open is more appropriate for a seizure. If open, were they rolled back? This also suggests seizure.

Did the patient say, do, or complain of anything before or after the event, which he may no longer recall? Dizziness, headache, chest pain?

Did he stumble, lean against something, or seem to become dizzy? After he went down, did he regain consciousness almost immediately? These are suggestive of vasovagal; once a horizontal position is reached, perfusion to the brain is restored and the problem resolves. If he remained unconscious for a prolonged period while prone—or his initial episode occurred while already seated or reclined—this is highly unusual for vasovagal.

Was he walking and moving normally, in no distress, when he suddenly collapsed like a marionette with its strings cut, hitting the ground with no attempt to protect himself? This is strongly suggestive of a cardiac event and these patients should be considered high-risk for sudden death.

 

Is there a suggestive history or surrounding circumstances?

Sometimes, the chain of events or the patient’s medical history may suggest an etiology.

Is there a known history of a seizure disorder like epilepsy? How about diabetes? (Take a blood sugar if you’re capable of it; in my book, everybody with an altered mental status is diabetic.) Do they have often pass out or become light-headed?

Have they been eating and drinking as normal? Have they had the flu, and been unable to keep down fluids for the past two days? Were they partying all night? Vomiting? Are they a marathon runner who collapsed in 110 degree weather? Dehydration is a common cause of syncope, particularly in the young, healthy population.

Is there a known condition which may have neurological or metabolic involvement? Cancer with metastases to the brain? A recent infection? A congenital heart condition, such as Long QT, hypertrophic cardiomyopathy, or Brugada? For that matter, are they currently drunk or using drugs? If they take psychotropic or other medications, are they compliant with these, or could there have been an under- or over-dose?

Has there been any recent trauma, such as a fall, motor vehicle collision, or assault with injury?

Have there been repeated lapses in and out of consciousness, rather than a single event? This is an ominous sign suggesting a significant problem.

 

Are there frank clinical signs that suggest a diagnosis?

This is less likely to be useful than the history, but it can help rule in or rule out major, acute emergencies.

Cardiac abnormalities may manifest with irregular pulses, and active decompensation may be revealed in the blood pressure. Whenever possible these patients should receive ECG monitoring, including a 12-lead. Orthostatic vital signs can be considered if vagal, orthostatic, or hypovolemic etiologies are suggested.

All syncope patients, including suspected seizures, should get a neurological workup, particularly a Cincinatti Stroke Scale.

Respiratory adequacy, including pulse oximetry where available, should be assessed.

Evaluate the abdomen for signs of hemorrhage, and inquire about blood in the stool or emesis as well.

Live from Prospect St: The Reluctant Tumble (conclusion)

Previously part 1 and part 2

Being reluctant to force Joe into an undesired ambulance ride, the crew contacted their supervisor. He arrived, evaluated the patient, agreed with their conclusions, and called Dr. Scrubs to discuss the matter. He was unable to dissuade the doctor from his decision.

The crew and supervisor approached Joe together and informed him of the circumstances; although all parties agreed that he should rightly be able to refuse transport, they felt they had been overruled by a higher authority, and if he would not come voluntarily they would be forced to compel him. Under this duress, Joe finally agreed to be transported, loudly and vocally protesting.

He was taken to his preferred hospital and care was handed off to staff with a full description of the situation. Less than 30 minutes later, another crew was sent back to the hospital to return Joe home; the attending ED physician had deemed his involuntary hold to be invalid and inappropriate, and refused to hold him against his will. No further evaluation was performed.

The encounter was documented extensively and quality improvement measures involving EMS and the base physician are expected.

 

Discussion

This case was not medically complicated, but it involved some difficult issues of consent and risk. Let’s look at the medicine and then at the wrinkles.

Medical Considerations

We were dispatched for a chief complaint of a fall — a very common mechanism of injury. When evaluating the fall, what should our main concerns be?

First, we should examine the mechanism itself. How far was the fall? In this case, as it often is, the fall was from a standing height, and from a standstill (i.e. not propelled while running, stumbling while breakdancing, etc.). This is often seen as the dividing line for significant versus non-significant falls; in many areas, falls from standing height or greater are considered an indication for spinal immobilization. (Other areas say greater than standing height; 3x standing height or more; or other numbers.) The elderly in particular are considered at higher risk for spinal injury, due to weakened bones and tighter ligamentous connections between vertebrae.

Typically, a blow to the head with loss of consciousness is also considered high risk for spinal injury. This is under the assumption that a blow with enough force to cause LOC may also have enough force to damage the spine. These considerations are all valid, but should only be seen as some of the many factors involved in stratifying risk; they must be considered alongside other elements like the physical assessment. In some systems, you may be forced to immobilize based on mechanism without other considerations. In others, you may be allowed to rule out immobilization based on certain findings, most of which Joe has; for instance, he denies neck or back pain or tenderness, denies peripheral parasthesias (numbness or tingling) or weakness, ambulated well, turns his head, and has no confounding factors like a distracting injury or altered mental status. In any case, the post-fall presentation was so benign that risk seemed low, and given the patient’s overall reluctance it is highly unlikely that he would have consented to a collar and board.

The use of warfarin (trade name Coumadin), on the other hand, does significantly increase the risk of intracranial hemorrhage (ICH), especially after blunt trauma to the head. Although again, Joe’s assessment was very reassuring — normal vitals, no complaints, and a baseline neurological status — it is very possible for ICH to have a delayed onset of presentation. The best example of this is the subdural hematoma, where cases of moderate severity sometimes take hours or days to develop, due to the venous rather than arterial source of bleeding. This delay is particularly common in the elderly, where (possibly due to shrinking of the gray matter, which leaves additional room for blood to collect before pressure begins compressing the brain) a classic scenario is the fall with a blow to the head, no complaints for hours afterward, and then sudden deterioration. Some sources state that 60% of geriatric fall patients who experience LOC from a blow to the head will eventually die as a result. Since in this case, we were delayed on scene for quite some time, there would be value in ongoing and repeated assessments of symptoms, neurological status, and vital signs while we waited around.

The patient’s pupils were unusual in appearance, which can be an indicator of brain herniation; however, this syndrome typically presents with one very large and round pupil. An irregularly shaped pupil as we saw here is more indicative of a structural defect, the most common of which is probably cataract surgery, which can leave the pupil off-round.

An incomplete medical history is common in scene calls involving the elderly. However, many do carry med lists, and in most cases you can reconstruct the majority of the patient’s diagnoses based on their medications. In this case, we found digoxin (or digitalis), which is almost always used to control atrial fibrillation; this is consistent with the patient’s irregular pulse, and with the warfarin, which helps prevent A-fib induced clots. Metformin (Glucophage) is an antidiabetic that helps control glucose levels. Citalopram (Celexa) is a common antidepressant of the SSRI type. Advair (fluticasone and salmeterol) is a preventative asthma/COPD inhaler combining a steroid with a long-acting beta agonist; it is used regularly to minimize flare-ups and is not a rescue inhaler. Omeprazole (Prilosec) is used for gastroesophageal reflux disease (GERD), aka heartburn. Ibuprofen is a non-steroidal anti-inflammatory (NSAID) used for pain relief and reduction of inflammation.

As VinceD noted in the comments, one essential question in any fall — and indeed in almost any traumatic event — is what caused it. Here we have a somewhat vague account which suggests a mechanical fall, i.e. tripping or loss of balance; this is not necessarily benign, as a history of repeated mechanical falls suggests deteriorating coordination or strength, but it is usually not indicative of an acute medical problem. However, many elderly patients (and some of the younger ones, too) will attribute any fall to tripping, so this claim should be taken with a grain of salt. It helps to have a witness to the event, as we do here, although witnesses are not always reliable either. In any case, what we want to know is: what happened just before the fall? Was the patient simply walking and tripped on a rug? Did he have seizure-like activity? Was he standing normally when he suddenly lost muscle tone and collapsed? Did he complain of feeling faint or dizzy? Was he exerting himself or straining on the toilet? Things happen for a reason.

 

Ethical and Legal Considerations

The bigger question is whether it’s okay for Joe to refuse transportation.

This is an odd question, because ordinarily we assume that people are free to go where they want, and calling 911 (or having it called for them) does not surrender this right. However, there is an attitude among those with a duty to act, such as healthcare providers and public safety officers, that individuals who are not cognitively able to understand their situation and make decisions in their best interest need to be protected from their own impaired judgment. This is equivalent to taking your friend’s keys so he won’t drive drunk, under the assumption that he wouldn’t want to drive drunk were he making sensible decisions. The legal term is implied consent, the same principle by which we transport children, drunks, and unconscious people.

How do we know if somebody is unable to make their own decisions? There is not an obvious line. For many providers, their rule of thumb is the old “A&Ox4”: if someone knows who they are, where they are, when it is, and what’s going on, then they are alert and oriented and capable of making decisions. Of course, this is only one piece of the mental puzzle. Social workers, psychiatrists, and other specialists have a full battery of tests that can help further reveal cognitive capacity. Can you perform these in the field? It’s probably more than you’re likely to do, although you might perform something simple like the MMSE. But some basic questions that highlight the patient’s judgment can help supplement your routine assessment — questions like, “Suppose you were at the mall when you started to smell smoke and heard the fire alarm. What would you do?” where any rational response is acceptable.

It’s important for the patient to be able to demonstrate that they understand what’s going on. Even someone with ordinary mental competence — unless they’re a fellow knowledgable healthcare professional — needs to be informed (to the best ability of the provider) of the possible risks and consequences of refusing care. In this case, it would involve giving them some description of the above possibilities (spinal fracture, head bleed, etc.), and ideally having the patient then relate them back to you, demonstrating good comprehension of those facts. The base physician’s view that Joe hadn’t fully demonstrated this understanding was a key part of his decision that he needed to be transported against his will.

Other important points are to ensure that the patient knows that refusal doesn’t preclude future care (“if you change your mind, you can always call back”); and that the ability of the providers to evaluate the patient on scene is at best limited. Any implication that you know what’s really happening to the patient or can definitively rule in or rule out any medical problem is unwise and legally risky. In fact, even suggesting possibilities or probabilities can be problematic if you’re wrong; on the other hand, failing to do so can leave them uninformed, so this can be a Catch 22. Your best bet is to outline some basic possibilities, carefully inform them of the limits of your training and resources, and be smart enough that you generally know what you’re talking about in the first place.

One complication in this case is the presence of someone who claims to be Joe’s health care proxy. A proxy (closely linked to the idea of a durable power of attorney) is a person whom, while of sound mind, you designate to make decisions for you if at a later time you are not of sound mind. Crucially, if you are still capable of decision-making, a proxy does not have the ability to override you; their role is to act on your behalf when you cannot. In other words, the decision of Joe’s proxy is only relevant if we do find (or in some areas, if an authority such as a judge has decided) that he’s incompetent to refuse or consent to treatment; thus, her presence does not necessarily alter the basic dilemma.

In this case, the physician’s attitude was that the problem was primarily medical: does the patient need emergency department evaluation to rule out dangerous processes? Medically, he does. However, the first question actually needs to be: Is the patient capable of evaluating risk and making decisions in his own best interest? If he is, then he is technically “allowed” to decide whatever he wants. Even a clearly dying man can refuse medical care based on religious views, personal preference, or any reason whatsoever (although barring a proxy or advanced directive, once he’s unconscious he can usually be treated under implied consent). This is different from the person who actively tries to take his own life; for philosophical reasons we view this as different from passively allowing oneself to die for lack of medical treatment. We prevent people from committing suicide but allow them to refuse medical care.

Realistically, although this fundamental right does not change, it’s fair to consider the surrounding medical circumstances to help decide how pressing and high-risk the matter is. In this case the doctor clearly felt that the risk was so high that it required going to extraordinary lengths, including overruling the patient’s own decisions and potentially even harming him, to ensure that a dangerous situation wasn’t “missed” — in short, that the ends justified the means. Dr. House is famous for this approach.

Legally, in most areas EMS providers are seen as operating under the bailiwick and legal authority of their medical director, and online medical control is an extension of this authority. In other words, within reason we are bound by the orders of medical control. The details of this relationship vary, and are not always fully explored. For an example, consider this true story from 1997 in New Jersey:

A North Bergen dual-medic crew is dispatched to a pregnant, full term female in cardiac arrest. Downtime is unknown, and they work the code for a number of minutes without response. Determining that the mother is likely unsalvageable, and concerned for the health of the fetus, they contact medical control. After a “joint decision” the base physician verbally talks them through performing an emergency C-section on scene. They deliver and successfully resuscitate the fetus, and both patients are transported. The mother is declared dead soon afterwards, but the infant lives for a number of days before dying in the hospital. In the aftermath, the paramedics are cited for violating their scope of practice, and their licenses to practice are revoked in the state of New Jersey. The physician is forced to undergo remediation training to maintain his medical control privileges.

Is the moral that acting in the patient’s best interest is not always a defense against liability? Maybe. Is the moral that medical control cannot authorize you to perform otherwise illegal acts? Maybe. Is the moral that we should protect ourselves before the patient? I don’t know about that, but it’s something to think about. In this case, the course for Joe that seems most ethical to me — allowing the patient to make his own decisions — also lets us avoid potential liability for battering and kidnapping. However, it does force us to refuse a direct order from medical control. Invoking our supervisor gives us a bigger boat either way, and would be a big help to protect us from trouble coming from our employer, one of the most likely sources. It’s also true that, while we may have believed that Joe was competent, he is at least somewhat diminished, so we’re less than completely confident. Nobody wants to put themselves on the line by taking a stand, only to be proven wrong.

Fortunately in this case we were able to avoid getting violent at all, but it was a near thing. If it did prove necessary, it should have been done with ample manpower and many hands; in some areas chemical sedation by paramedics may also be authorized. And I would certainly not recommend acting without the doctor’s signature on a legal document.

With everything viewed in retrospect, the situation would have been much more easily resolved had the doctor not been involved in the process. At the same time, however, if a simple refusal had been accepted, and CQI later went over the call — especially if Joe experienced a bad outcome — the crew would have been in a difficult place.

No matter what, such a situation is highly unusual, flush with liability, and should be thoroughly documented in all respects.

Live from Prospect St: The Reluctant Tumble (part 2)

You kneel beside Joe and ask, “So, would you like to go to the hospital?”

“No!” he vociferously replies — a theme that will be repeated often over the next few minutes.

You explain the risks — that given his anticoagulation (Coumadin), and given that he struck his head and seemingly lost consciousness, there is a non-trivial possibility of bleeding into or around his brain. That although he feels well now, it’s not impossible for such a problem to develop insidiously and not manifest with symptoms until it’s too late. That you can take him to the hospital of his choice, in total comfort, he can receive some quick tests, and if nothing is wrong he’ll be back home before he knows it.

Joe wants to hear none of this. He just came out of the hospital, enjoyed it not at all, and that was just the latest episode in a long series of hospitalizations. “They ruined my hip” on one occasion, he opines, and he’s already been fooled before by “home before he knows it.” No sir; he’s not going anywhere.

You try, your partner tries, the neighbors try, the proxy tries. No way, no how.

Well, okay. But this is not the sort of incident to just brush aside, and you’re well aware of the risk inherent to patients refusing transport, particularly in a risky circumstances like this. So you pick up your phone and hit your hotkey for medical control.

“Needletown Hospital; this is Dr. Scrubs. How can I help you?”

“Hi doc, this is Maverick from Poketown BLS 48. We’re on scene with a high risk refusal.”

You fill him in with the story. He asks a couple questions, then requests to speak with Joe, and finally talks to the proxy for a few minutes. When the phone gets back to you, Dr. Scrubs informs you that he really thinks Joe needs to go.

Well, okay. You dive back in, bolstered with a physician’s opinion, and attempt to get Joe on board the hospital train. He’s not having it. The whole entourage keeps hammering away at him, but he’s simply not budging.

You call back Dr. Scrubs, bringing him up to speed. “We’re making no headway here. He just doesn’t want to go.”

He asks to speak to Joe, and the sounds of his best MD magic come wafting over the speaker, but Joe just has less and less polite things to say, until finally he comes out with, “You’ll have to handcuff me before I’m going anywhere! And just go ahead and try it!” He hangs up on the doctor.

You call back. “I gotta tell you, doc, I don’t see us convincing this guy. If you tell me that we must take him, then I’ll take him, but I think we’d have to do violence to him and start a battle royale here. Is that what you want?”

Dr. Scrubs replies, “Well, I think he needs to be seen, and it sounds like his proxy does too. I’d like to hear your opinion.”

You pause, then carefully say, “I do not think that it would be inappropriate to leave him, although obviously it would be preferable if he came in. I don’t know that I’d make the same decision, but I might, and I don’t see the situation as so high-risk as to justify anything really extreme.”

“Head injury, on Coumadin, loss of consciousness, you don’t think he needs to be seen?”

“We obviously can’t clear him here. But he’s stone normal by our assessment from every angle, and he’s not going to be left alone.”

“Well, I don’t think that’s a great idea. And he wasn’t really able to logically explain to me the risks of his decision. Anyway, his proxy agrees, so I’m not sure if I see the problem.”

“Doc, the problem is that although he does have someone here who says she’s his health care proxy, by our assessment he is at this time totally oriented, competent, and exercising sound judgment. So I’m not really comfortable kidnapping him, unless you want to sign a Section [your state’s involuntary mental health process, for those who are a danger to themselves or others].”

“Sure, I’ll do that. I can fax it to your dispatch and to the receiving hospital.”

“So you want us to tackle him?”

“Do what you have to do.”

You hang up the phone and look around. Police have left the scene, but could be easily recalled. Joe sits before you, a 79-year-old in fair condition, but no Evander Holyfield.

What do you do?

What are the legal considerations?

What are the ethical considerations?

Live from Prospect St: The Reluctant Tumble

It’s 9:00PM on a Wednesday, and you’re the tech on A48, a dual-EMT, transporting BLS ambulance. You are the 911 coverage for Poketown, a midsize urban area; ALS is available for intercept as needed. You carry fingerstick glucometry, activated charcoal, glucose, aspirin, and epinephrine.

You are just starting to yawn when a tone hums from the radio, and a voice declaims:

“Ambulance 8, take the response to 91 Eastbrook Rd. That’s priority 1 to 9-1 Eastbrook Road in Poketown, apartment 710, for the fall.”

You acknowledge, flip your lights on, and head that way. This is an apartment block in the middle of town that you know well.

You arrive to find Poketown Fire and Police already on scene. You load your bags into the stretcher, plus a backboard, and head into the elevators, which are so small you have to fold the cot to fit inside; you wonder how you’re going to fit the patient if you end up boarding them.

You arrive at the apartment to find an elderly man sitting in his wheelchair, accompanied by neighbors and friends, including a young woman who describes herself as his healthcare proxy. He greets you cheerfully, telling you that he’s Joe, 79 years old. He was walking around the apartment with his walker when he brushed against the refrigerator and fell backwards; his proxy tried to catch him but failed, and he hit the ground. He denies falling, then denies hitting his head, saying he landed on his butt, then finally agrees that he hit his butt then his head; his proxy, however, tells you he fell straight back like a board and struck the posterior of his head on the ground. She says his eyes rolled back for a few seconds and he seemed unconscious, after which he quickly came around and moved himself to his chair. She was alarmed and called 911 immediately after; the fall was about 15 minutes ago.

He presents as fluidly conversational, friendly, and fully oriented. He is slightly hard of hearing, speaks in a loud voice, and doesn’t always understand your questions the first time around, but he’s generally “with it” and remembers the full chain of events that led him here. He jokes around with you and the firefighters and offers to marry you to one of his daughters, who has “lots of money.” You tell him you wouldn’t know what to do with it.

Physically, he seems well, with no notable trauma. There is a small lump on his occiput which may or may not be baseline (hey, heads have funny shapes), but he denies any pain or tenderness there. He also denies pain or tenderness of the neck or back, and in fact denies everything, saying he’s just fine. A “lifeline” bracelet is present on his right wrist. His vitals show:

Skin: Slightly cool in the feet, some ecchymosis throughout, otherwise dry and unremarkable.
Pulse: Weak, slightly irregularly irregular radial pulses at 78
BP: 110/70
RR: 16 and unlabored
BGL: 124

Your physical exam notes no other gross trauma. His left pupil is large and abnormal in shape; he states that he has bilateral cataracts. His right pupil is round, slightly small, and somewhat reactive. His eyes track in all directions with no major nystagmus. His lungs are clear bilaterally. He demonstrates equal CSM in all extremities, and no facial droop, arm drift, or speech slurring. A full neuro exam notes no deficits. He denies chest pain, dyspnea, nausea/vomiting, general weakness or dizziness, peripheral weakness or parasthesias (numbness/tingling), or any other complaints. During your exam, he actually gets up and ambulates back and forth across the room with his walker, moving slowly but well with no major gait disturbances.

While you talk, your partner is examining the medication list provided by his proxy. It includes:

  • Digoxin
  • Metformin
  • Citalopam
  • Advair
  • Omeprazole
  • Coumadin
  • Ibuprofen

His full medical history is otherwise not readily available. He does state that he was just released from the hospital two days ago, after a 5-day stay for diverticulitis. He is allergic to morphine.

What is your general impression of this patient’s priority?
What do you think is going on? What are you worried could be going on?
What is your next step?

Some Things to Say (part 2)

 

Chest pain. It’s our favorite thing to ask about and maybe our favorite thing to find. Never more does EMS get its chance to shine than when diagnosing the acute MI, and chest pain is how we start down that path. In many cases, everyone from the vomiting drunk to the elderly broken hip gets asked about their chest.

But next time you throw in, “Any chest pain?”, consider this. Not only do many heart attacks fail to present with chest pain at all, even among those that do, the specific symptoms may not amount to what your patient considers “pain.”

Pain means different things to different people. What I call pain, you might call discomfort, and my girlfriend might call a funny feeling. Tightness, palpitations, burning. Trying to list it all would leave you on scene for 20 minutes with a thesaurus, but if you don’t find the right words, then the answer you get might simply be “no.” And you’ll miss the big one.

The solution is in one magic phrase:

 

How does your chest feel?

I learned this gem from Captain Kent Scarna of Boston EMS, and it joins the ranks of the most useful assessment tricks out there. Because despite all the ambiguity in the chest, this one pretty much captures it all. If there’s frank pain, the patient will tell you all about it. But if there’s fluttering, itching, a feeling like they just ate a canary, this invokes that too. As a diagnostic screening, it is appropriately vague. There is a time and a place for direct questions, but when it comes to chest pain, starting off open-ended is the way to go.

How does your chest feel? Fine, it feels fine. Okay then. If you’re truly concerned you can follow up to confirm — “No pain or discomfort?” — but there’s no need to break out the Webster’s. It’s sensitive but specific; it casts a wide net, but it still unpacks fully. What else could we want?

More things to say in part 3

The Art of the Transfer (part 2)

Continued from part 1…

One of the best types of transfer for educating yourself is a discharge from a hospital, or in some cases from a nursing home or rehab.

It doesn’t matter where they’re going; what matters is where they’re coming from. Because your patient’s leaving a prolonged stay in skilled medical care, they should come with a whole bevy of paperwork and documentation chronicling their course of care. And you get to read it!

He presented to the ED with X symptoms. Was worked up with Y tests, and awarded Z diagnosis. Was admitted for A, B, and C treatments, and is now being discharged in Q condition.

Now if you ever get a patient with X symptoms, you have a great idea of what’s going to happen to them at the ED; you’ll know the leading diagnostic possibilities in their differential; and you can guess the types of treatment they’re going to receive. Did you learn this stuff in EMT class? I sure didn’t; for many of us, once the patient hits the door of the hospital, they’re no longer of interest. But that’s not how it works — you’re part of a sequence of care, not a one-act play, and if you don’t understand what happens later, you can’t make effective decisions now. Even something as simple as explaining to the patient what’s going to happen once they arrive at the ED is impossible if you don’t have a clue yourself. “We walk in the door… and then magic happens!”

Moreover, once you enter that patient’s room, you get to assess and communicate with that very same patient you just read about in the chart. You can say, “Ah, so this is what that disease process looks like”; you get to feel the pulse fixed at 60 by a pacemaker, listen to the lungs filled with fluid in the CHFer, and examine the scar made by a recent craniectomy. This is like getting the answer to a quiz, then learning the question. In the future, if you hear those crackling breath sounds, you’ll know what they mean, because you’ve heard the same thing in patients whose diagnosis you already knew. Remember, in the field we often never learn the answers; we make best-guesses and presumptive diagnoses, but unless we’re able to follow up later on their eventual diagnosis, we may never know if we were right. The discharge is your chance to get in at the other end of the process and put it all together.

You also get to organize your mental categories of disease. Coming out of class, you’ve learned a litany of human ailment that runs from A to Z; and whatever order you learned it in is probably the order you remember it in, except for some important, life-threatening illnesses that received special attention. But in real life, facing a real patient, the diagnosis probably isn’t the first one in the textbook, and it’s probably not the most deadly zebra; it’s probably the most common disease, because that’s what common means. Transporting a hundred patients helps you understand what’s common. You do need to remember that shortness of breath can be caused by a pulmonary embolism, but you’re coming from the wrong direction if it’s the first thing on your mind when you meet a gasping patient, because it’s just not as likely as other possibilities. Discharging a few dozen people with COPD will help rearrange this for you.

How about meds? People come out of the hospital on lots of them. Diligently reading those charts will help you learn which ones are used for which diseases, and if you make an effort, you can start to memorize their names and connect generic with trade names. And you’ll read Coumadin and then meet the elderly lady with bruises all over, complaining about how she gets cold so easily. Connecting the dots, connecting the dots.

If you’re enterprising, you can practice analyzing EKGs, interpreting labs, and reading imaging reports. It’s all in there, and it’s all part of the patient’s medical care. And no matter how distant something might be from your own scope of practice, as long is it involves the same human beings you’re treating and transporting for the same problems, then more knowledge will make you a better EMT.

More on transfers in part 3…

The Art of the Transfer (part 1)

One of the problems with EMS today is that it involves a bait-and-switch.

From the outside, it’s not widely understood what the work involves. There’s a vague idea about flashing lights and saving lives, but that’s about all the public knows. So, enterprising young men and women take the class, get the training, find a job, and quickly discover that EMS from day to day isn’t quite what they had in mind.

Nowhere is this more apparent than for the EMT-B. For him, in many areas, most or all of the available work involves not emergency 911 response, but non-emergent patient transfers. Patients travel from home to hemodialysis centers, from nursing homes to doctor’s offices, or from hospitals to rehab facilities. Sometimes these are patients who need oxygen therapy or airway management; sometimes they are medically unstable and need close monitoring (although these patients often travel by ALS); but most often, they’re simply people who can’t easily stand or walk. If due to age or disability you’re unable to climb into a car or shuttle, and can’t safely transfer yourself to and from a wheelchair or sit in it, then you need to travel from place to place in a bed — and ambulances are the only traveling “bedmobiles” out there. Well, ambulances and hearses.

Routine transfers can get old. Real old. Maybe you’re looking for excitement. Maybe you’re looking to make a difference. Maybe you just want to use your skills or activate some neurons. Whatever the case, it’s easy to feel like bringing an endless parade of old people to their eye appointments is neither “emergency” nor “medical” even if it is a service.

Nevertheless, for many of us it’s an unavoidable part of our day. So it’s worth making the most of it.

 

A Classroom in the Ambulance

Transfers might be boring. But boring’s a good way to start out. There’s no better way to learn how to be an EMT.

My first job in this business was in a system doing 911 coverage almost exclusively. This seemed like a great opportunity, especially in an area (Northern California) where EMTs in the private sector were rarely able to work emergencies.

In retrospect, though, it was the wrong way to start. I walked in the door with absolutely no idea of how to do this job, and was immediately thrown into the field with no learning curve. I was expected to assist the medic, drive the ambulance, check the equipment, manage communications, and of course handle any BLS care. This was fresh out of EMT class, where I had no idea how to do any of that, and most of what I did know is not what was needed. And guess what? Every call was an emergency. Admittedly most “emergencies” are not exactly world-ending, but there were still stakes involved, which meant that being useless was bad for the patient, bad for my medic, and bad for me — because with the pressure on, it was difficult to relax and make the necessary “learning mistakes.”

My next job was in a service where almost 100% of our work was routine transfers. Although this could be mind-numbing, I quickly realized how much of a better learning environment it was. Because in nearly every case, the patient in front of me was not having any acute problem, my assessment could be a total blind-man’s fumble and there wouldn’t be any adverse results. That’s not to say that you’ll never be in a position to take action — but it’s rare.

On a 911 response, you’re the patient’s initial point of entry for the health care system. Before today, there was no problem, at least not from this particular episode. Now there’s something new that needs to be addressed, and you’re deciding how that will happen. The answer might be easy, but it’s still being made.

On a transfer, the patient’s course of care has already been planned and initiated. Their problems are diagnosed, their treatments are underway. Your responsibility isn’t to set anything into motion, but merely to ensure that there’s no deviation from the intended path. This requires learning the patient’s current baseline — which may be very sick — so you can note any new changes, and learning what their current plan is (perhaps a discharge back to their home, which will require a stair-chair carry to get inside), so you can facilitate it as best you can.

Take some vitals. Check pupils, feel skin, listen to breath sounds. Listen to their story. You’re doing these things as a matter of course, because you’re supposed to, in the midst of friendly chit-chat — but you’re also practicing all of your foundational skills. In the off chance of anything unusual, you’ll hopefully find it. But in the mean time, you’re turning yourself into a good EMT, so in the future when you do start running emergencies, you’ll be ready. Do more than you need to, because the time to figure out the tricks of taking a thigh blood pressure is when it doesn’t matter, not when it does.

To quote the biblical if crass House of God,

Look, Roy, these gomers have a terrific talent: they teach us medicine. You and I are going down there and, with my help, Anna O. is going to teach you more useful medical procedures in one hour than you could learn from a fragile young patient in a week. . . . You learn on the gomers, so that when some young person comes into the House of God dying . . . you know what to do, you do good, and you save them. (76)

Tune in next time for more on the fine, fine art of squeezing juicy goodness out of each transfer you get.

David Hiltz on Resuscitation

In mid-May, FDNY hosted an educational conference on the topic of resuscitation. Numerous invited speakers, including medical directors from many of the country’s largest EMS systems, discussed issues like current research trends, “pit crew” models for CPR, and optimizing systems of care for communities.

I attended with David Hiltz, a longtime paramedic who now works with the AHA. A lot of valuable ideas were shared that weekend, including some material that bears upon Dave’s own work. I asked him to discuss it with me, bringing to bear his perspectives as a field provider, an educator, and a longtime “bridge builder” for Sudden Cardiac Arrest continuity of care.

A disclaimer: David’s participation here is solely personal in nature, and none of his comments or opinions should be understood as being officially endorsed or approved by the American Heart Association.

Brandon Oto: Dave, for those not familiar with you and your work, can you introduce yourself briefly?

David Hiltz: I have been in the healthcare industry since 1984, and over time, working in hospital emergency departments and with EMS agencies, I developed an interest in resuscitation.  I have been on staff with the American Heart Association’s Emergency Cardiovascular Care Programs for over 13 years and during that time, I have had the good fortune of meeting some really brilliant and committed people from whom I have learned so much.

BO: You’re involved with the AHA’s HEARTSafe Communities initiative. Can you tell us about that? What are you and the AHA trying to do?

DH: To be correct, the HEARTSafe program does not really “belong” to anyone. Rather, it’s a concept for communities to use in improving recognition, response, care, and outcomes for cardiac arrest patients.

The HEARTSafe program is a population and criteria-based incentive program designed to advance systems change in accordance with the American Heart Association’s Chain of Survival. Individuals, businesses, public officials, and emergency responder agencies are asked to establish a cardiac arrest response system geared toward these criteria.

The primary goal of the HEARTSafe Communities program is to increase survival rates from out-of-hospital cardiac arrest.  Individual communities are asked to develop and implement lifesaving strategies that focus on coordinating local resources to prevent sudden cardiac arrest from becoming sudden cardiac death.

Half the men and women with serious coronary artery disease first learn about it in a dramatic way: sudden cardiac arrest.

Outcomes at this point depend on whether the collapse is witnessed, whether the bystanders are trained and willing to perform CPR, and whether the arrest has occurred in a system set up to allow the early arrival of needed resources and the timely execution of evidence-based interventions.

Many have recognized the need to improve community systems of emergency cardiovascular care in order to optimize patient survival. The “Chain of Survival” represents the current approach to improving recognition, response, and care.

Decades after its creation, this same systematic and coordinated approach remains the strongest recommendation the resuscitation community can make to save more people in out-of-hospital cardiac arrest. (Not that I have any business being a “representative of the collective opinion” of the resuscitation community!) The idea is simply to maximize each community’s resources by implementing appropriate measures and strategies to achieve the greatest attainable patient survival.

There are numerous systems around the world where the implementation of community-based measures has lead to improved outcomes for critical out-of-hospital patients. I believe that programs such as Heart Rescue and HEARTSafe Communities are valuable frameworks for any group looking to explore related strategies for improving survival and quality of life.

BO: This past May, you and I were able to attend a conference on Randall’s Island, hosted by FDNY and focusing on topics surrounding resuscitation. The main theme was a continuing reinforcement of the basic fundamentals of resuscitation by laypeople and BLS responders, especially the importance of early, ongoing, and high-quality CPR.

Several speakers made the particular point that improving bystander CPR rates is one of the most important and highest-value steps we can take to improve our survival rates; Dr. Chris Colwell described it as the low-hanging fruit of the Chain of Survival. Overall, Dr. Paul Hinchey suggested that we need to shift our priorities away from the clinical practices of professional rescuers and clinical centers, and towards the recruitment of the general population.

Based on your experience with HEARTSafe, what are the principal challenges to improving bystander CPR rates? Why haven’t we been able to accomplish this important and seemingly simple task in all of our communities?

DH: Let me first say how much I enjoyed attending the conference and spending time with old and new friends there.

Your questions are significant ones.  This statement from the Executive Summary of the 2010 American Heart Association Guidelines for CPR and ECC Science articulates the core issue at hand:

Although technology, such as that incorporated in automated external defibrillators (AEDs), has contributed to increased survival from cardiac arrest, no initial intervention can be delivered to the victim of cardiac arrest unless bystanders are ready, willing, and able to act.

Bystander CPR can dramatically improve survival from cardiac arrest, yet far less than half of victims receive this potentially lifesaving therapy. CPR is inexpensive, readily available, and can save lives. Based on what we know, increasing the rates of bystander-initiated CPR is critical to improving outcomes.

There are a number of theories regarding the hesitation of bystanders to perform CPR, even when adequately trained. Mouth-to-mouth breathing and concern about the transmission of infectious disease may explain reluctance among some. Another potential barrier to learning and performing bystander CPR has been the complexity of past resuscitation guidelines. This complexity may affect a citizen’s willingness to learn CPR skills, contribute to a failure of recall, or negatively impact confidence in their ability to perform during an emergency.

While “fear of failure” is often cited as a major barrier, some bystanders may also decline to perform CPR because of legal concerns, and are often not aware of their protections under Good Samaritan statutes. Many educators and clinicians continue to hear concerns such as, “What if I break a rib?”, “What if the person dies?”, and “Can’t I hurt someone with CPR?” Fears like these should not get in the way of helping another person in their ultimate time of need. Knowing and performing CPR should be thought of as a moral obligation and civic duty.

Widespread access to CPR education is another potential barrier.  In many cases, citizens need to make a concerted effort to identify and enroll in a CPR program.  For instance, many sources for CPR education focus their efforts on training healthcare providers and do not routinely offer appropriate courses for the general population. This should change.

The marketing surrounding CPR are also important.  My experience has been that despite our best intentions, CPR “advertisements” are often poorly conceived and send the wrong message.  Make no mistake, regardless of whether you are a hospital, an EMS agency, or a lone instructor, you are marketing and promoting CPR education.  If your “message” is not effective, people will not be interested.   Consider the following commonly seen messages promoting CPR.  Which do you think would be most effective in enlisting the public?

  • Get certified in CPR
  • Instruction in BLS for Healthcare Providers, CPR, First Aid, Bloodborne Pathogens, AED use, Emergency Oxygen Administration, Fire Safety, and Child & Babysitting Safety to the public and private sector
  • BLS every Wed or Sat
  • One quarter of Americans say they’ve been in a situation where someone needed CPR. If you were one of them, would you know what to do?
  • Is learning CPR important?  Just ask these people… she learned and he lived
  • There are 300,000 cases of cardiac arrest each year with 80% occurring in and around the home.  Only 5% survive.  Learn CPR.
  • The time to learn CPR was yesterday… tomorrow could be too late.

I highly recommend reading the book Made to Stick, by Chip and Dan Heath. We all want our ideas to be understood, remembered, and have a lasting impact; this book may help you to make your ideas more effective. They also discuss the concept of “The Curse of Knowledge,”  which is described as “knowing something too well, so that this knowledge actually inhibits our ability to communicate the essence of it to the audience.” This curse of knowledge can be seen in how we promote CPR to the public as well as in how we often deliver it!  I believe that the “curse of knowledge” is a villainous and self-defeating phenomenon that often shows up in our CPR training.

All of us in public safety should remain focused on broadening CPR education for the general public, and there are a number of new programs to help support this, such as the AHA’s “CPR Anytime for Family and Friends” kit and the advent of Hands Only CPR. The CPR Anytime kit makes it possible to deliver hands-on training to large groups of people in a matter of 20-30 minutes.  I am particularly supportive of this system, due to studies that demonstrated the  effectiveness of the kit being as good as the traditional three- to four-hour courses — 93% of trainees could still perform adequate chest compressions and successfully use an AED six months after learning it.

BO: It sounds like the answers to many of the current problems in addressing Sudden Cardiac Arrest are not medical in nature, but psychological. We’re moving away from questions like “what’s the ideal antiarrhythmic?” and towards questions like “how can we market CPR so people will learn it, teach it so they’ll remember it, and contextualize it so they’ll be willing to do it?”

The reason this shift is both possible and necessary is that there’s a tentative agreement in the literature that, to put it briefly, what works is the simple stuff. As Dr. Chris Colwell laid it out, when it comes to the good old ABCs, compressions are definitely important in arrest — but Airway and Breathing perhaps not so much, and the jury’s still out on exactly what role they should play. But we do know that early, consistent, deep chest compressions, at an appropriate rate, with minimal interruptions do make a difference, and it’s fortunate that this dovetails well with the “human interface” problem, where people have been telling us that bystander CPR was too complicated and scary. So the main goal now is to see how many people we can tag with this meme of “when someone looks dead, push on their chest” — and simpler memes work better.

But what about the role of EMS in this picture? On the one hand, we are trained professionals who have less room to complain about “scary complexity” in our care. On the other hand, we’re human beings too, and we seem to face some of the same problems as laymen — for instance, we bag too fast, we don’t push deep enough, and (as Dr. Paul Hinchey described) we have a nasty habit of interrupting our compressions for all sorts of reasons. Some people were predicting the 2010 AHA Guidelines would see a wholesale switch to compressions-only, even for healthcare providers. That didn’t happen, but is that the general direction we should be going? The clinical picture here isn’t clear — the literature has some support for minimally-interrupted compressions by EMS, but it seems unwise to start demanding that the BVM always stays in the cabinet when there’s no pulse. Respiratory etiologies of arrest — like drowning — make this clear enough. Still, as Dr. Paul Pepe said, would we rather have more oxygenated blood circulating less, or less oxygenated blood circulating more (with fewer interruptions to compressions to allow for breaths)? How far do you think we should take this trend of simplification in the professional setting? Does the “human element” mean that we need to cut things down on the professional side as well?

DH: I think that categorizing citizen CPR “issues” as psychological, psycho-social or as one of behavioral change is correct.

Existing education research suggests that attitudes and behaviors are different from cognitive knowledge and skills, and cannot be adequately addressed through discussion that is simply added or dropped into courses.  Perhaps future course design could better address these emotional perceptions. Ideally, the average citizen should want to know how to perform CPR and should feel comfortable about the idea of doing it in a real emergency, perhaps even before they ever give serious consideration to learning the skill itself. Increasing the number of people who are trained and willing to act is essential to improving the likelihood of survival.

EMS providers should be doing whatever is necessary to improve the quality of the resuscitation we provide. This will not be accomplished through initial training and education alone. Examining and optimizing our actual performance in the field is needed: improving resuscitation quality will require regular practice, real-world data collection, and an iterative process of measuring and improving.

Adding more sophisticated gadgets and more complex therapies may not yield the desired results, particularly if the fundamental problems have not been addressed.  This would support the general idea of simplification — but because of the diversity among EMS providers and agencies, it is difficult to make any broad statements.  Before adding “something else,” it may make sense to first ensure that we are doing the essentials well and consistently.

In addition to improving the quality of our own resuscitation, we as providers also have a unique opportunity to play a role in citizen CPR education.  I would even suggest that other public safety agencies, such as fire and police, share this responsibility as well.  If we truly believe that EMS is where public health and public safety intersect, then we should be making citizen engagement one of our priorities. There are a wide variety of “off the shelf” programs, products, and strategies that we can put into practice at the local level. Concepts like HEARTSafe Communities, HeartRescue, and other similar models for improving community response to cardiac arrest can provide guidance for implementation.

Desire and intellectualization alone are not enough to save lives.  Full implementation of the AHA recommendations will improve outcomes, but it requires the involvement of each provider, agency, and system to make resuscitation quality a priority and lead the effort to save lives.

BO: Paul Hinchey talked about CPR devices and adjuncts like the LUCAS and the Zoll AutoPulse. The current evidence seems to indicate that these devices are no more effective at increasing survival to discharge than perfect-quality manual CPR. However, when perfect-quality manual CPR is not possible, a mechanical device may have a role. In particular, Dr. Hinchey pointed out that if we begin to routinely accept codes directly into the cath lab for intra-arrest PCI, then transports prior to ROSC would become a valuable option in some situations, and due to the challenges of continuing CPR while packaging and transporting, mechanical devices might then come into their own.

This idea seems to mirror another idea involving “code drugs” like epinephrine and amiodarone. Currently there is no evidence that any of these drugs improve survival to hospital discharge — the only outcome that really matters. However, they may improve survival to hospital admission, and one argument for their continued use is that if we can keep people “alive” (neurologically intact and with a salvagable myocardium) until they get into the hospital, then perhaps later advanced care (such as catheterization, ECMO, therapeutic hypothermia, or other future remedies) might be able to get them back out again. In such cases, even an intervention that only supports part of the Chain of Survival might have ultimate value if something else can provide the last few links.

In any case, do you believe devices that “replace” the rescuer in providing the major components of CPR can have a role? Assume that, as have tentatively found, they do the job no better than an ideal human, but also no worse. With all the challenges we’re encountering in getting really consistent performance from our rescuers, are there some situations where we should simply cut our losses and turn the job over to a machine? Obviously this won’t always be possible — unless every citizen carries their own Thumper — but we could move towards a point where every EMS and first response unit carried such a device and made attaching it a priority.

DH: A variety of devices have been developed and promoted in an effort to enhance perfusion during cardiac arrest. Generally speaking, these devices require more personnel, training, and equipment, or apply only to specific settings. Although the idea of using technology to improve perfusion during arrest is indeed intriguing, I think it is important to remember that the application and use of these devices also has a potential to delay or interrupt CPR.  Since we do know that delays and interruptions negatively impact survival, agencies and rescuers choosing to use these devices need to be acutely aware of this downside, and take steps (such as appropriate training) to minimize potential interruptions in chest compressions and/or defibrillation.

To quote the current AHA-ECC and CPR Guidelines: “To date, no adjunct has consistently been shown to be superior to standard conventional (manual) CPR for out-of-hospital basic life support, and no device other than a defibrillator has consistently improved long-term survival from out-of-hospital cardiac arrest.”  Also, “Class IIb recommendations are identified by terms such as “can be considered” or “may be useful” or “usefulness/effectiveness is unknown or unclear or not well established.”

High-quality CPR is fundamental to the success of any “ACLS” type of intervention. We should place the highest priority on performing good chest compressions with adequate rate, depth and complete recoil. Interruptions in chest compressions and unintentional hyperventilation must be avoided. In particular, for patients with shockable rhythms, defibrillation should be delivered with minimal interruption in chest compressions.

To date, increased rates of ROSC associated with ACLS drug therapy have not translated into long-term survival benefit… but perhaps improved quality of CPR, combined with advances in post-resuscitation care, will provide additional insight regarding the role of drugs in optimizing outcomes.

I think it is also appropriate to consider the process of organ and tissue procurement in an effort to minimize waiting time and alleviate suffering for patients qualifying for organ transplant. In my opinion, there is room to improve efforts relating to the ethical procurement of organ and tissue donations.

Based on what I know, and in my opinion, mechanical devices can’t replace a rescuer in providing the major components of CPR.  They may have a role in certain circumstances and settings, but there is a clear and continued need for human hands on the chest. Adding a mechanical device will not, by itself, solve CPR quality issues. Additionally, without careful implementation, these devices could potentially hinder rather than help the CPR process.  Incorporating them is fine and could be very appropriate in certain settings, but caution and careful implementation is needed.

BO: Thanks for bringing that up; we often don’t think about CPR’s role in maintaining viable organs and tissue for transplant.

You mentioned post-resuscitation care. One of the points Dr. John Freese made is that, when it comes to practical implementation of post-ROSC therapeutic hypothermia protocols, we’ve found that starting hypothermia prior to ED arrival can be beneficial. This isn’t necessarily for clinical reasons, but instead because hypothermic therapy already initiated when the patient arrives at the hospital is very likely to be continued in the hospital — whereas if it is not yet initiated, the patient may or may not end up being cooled, depending on how aggressively and consistently that facility is applying a hypothermia protocol. In other words, field treatment in this case is playing an economic or policy role, by letting the EMS side say to the hospital side: “We’ve already started this beneficial therapy — you’re not going to terminate it, are you?” And in fact, if they’re still reluctant to get on board, it becomes reasonable for us to divert these patients to other facilities instead, applying further economic pressure.

This is an example of a change in the standard of care being pushed through by a “grassroots” type of influence, as opposed to a top-down fiat which may take much longer to occur (due to institutional inertia or financial concerns). Many of our readers may have experienced frustration with the slow pace of change in their own systems. You’ve done a lot of work with implementing large-scale adoption of new training and procedures in different communities; in your experience, what’s the best way to approach this? Is it top-down, by seeking buy-in from administrators and medical directors at the highest level, or is it from the trenches, by finding broad support for the initiative from clinical staff or even from the public?

DH: An interesting perspective and suggestion, Brandon. I think you did an excellent job of framing up the subject. Improving systems of care for stroke, STEMI, and cardiac arrest patients can be very complex, to say the least. Increasingly I am finding that EMS can play an essential role in developing an integrated systems approach to optimizing response, care, and outcomes.

Yes, Dr. Freese made a compelling suggestion concerning the implementation of EMS therapeutic hypothermia protocols, and his point about continuity of hypothermic therapy is one that I have also observed. This is a great example of a practice being “imported” from the out-of-hospital environment to the hospital setting.

It is difficult if not impossible to make a single recommendation that will hold true everywhere. However, EMS providers, leaders, and agencies will be integral components of any localized strategies of care.

Multi-party coalitions involving EMS field providers, representatives from local prehospital and hospital agencies, and emergency physicians as well as cardiologists can help coordinate strategies for improving cardiac arrest outcomes within a region. This can involve not only therapeutic hypothermia, but the entire spectrum of issues associated with a comprehensive system of care for these patients.

In order to effectively address the issues, such coalitions need a thorough and honest understanding of what is working and what is not. This requires an examination of all system components and how they interact. Each member’s input can help in defining and framing the overall issues, as well as in the development of strategies to yield life-saving results.

Unless a system is hopelessly obstinate,  changing and improving standards of care through a combination of “grassroots” influence as well as a top-down approach may yield the most desirable results. Indeed, in my experience, this has been the most effective means of implementing change. Programs like Mission: Lifeline, HEARTSafe, and Heart Rescue can also offer good frameworks for developing this type of process.

BO: Dave, it’s been a pleasure; I hope we can chat again soon. One of the best things the internet has done for EMS is to bring together widespread people with different ideas from different places, but with many of the same problems. My thanks to FDNY for hosting a great (and affordable!) conference, and to yourself for taking some time to discuss it.

Any parting words?

DH: The pleasure has been all mine!

Additional remarks:

  • An agency or system’s ability to resuscitate VF cardiac arrest can be an excellent indicator of its overall clinical quality.
  • There is no single change that will dramatically improve cardiac arrest survival. A combination of approaches, including improved recognition, willingness of citizens to perform CPR, telephone CPR (via EMD), rapid defibrillation strategies, really good BLS, and effective post-resuscitation care are all needed to truly move the “survival needle.”
  • Data collection and an iterative process of measurement and improvement is important in every system.
  • Desire alone is not enough to yield results.  Real effort is required to improve recognition and response. Public safety agencies, EMS included, are well positioned to take the lead in this drive for improvement.
  • Increased probability of citizen CPR, implementation of AHA guideline recommendations, and improved quality of resuscitation from all rescuers is what is needed in order to save lives.

Some Things to Say

We’re not idiots. Everyone knows how to communicate. You just flap your jaws and blow.

In this business, though, we often find that it’s not enough to communicate; we have to do it efficiently. Likewise, it’s not enough to ask the right questions eventually. We need to do it promptly, because we’re not going to be here all day.

Heck, never mind efficiency. Sometimes there’s just a right thing to say, and everything else is wrong things. As Mark Twain put it, it’s the difference between the lightning-bug and the lightning.

So when you find a good bunch of words, you hold onto it, because like a master key, it’ll come in handy again. Here are two little phrases that everyone should have in their toolbox.

 

Has anything been bothering you lately?

I borrow this from Thom Dick, who suggested instead “Have you been upset about anything lately?” This is good, but to my ear leans more toward psychological troubles — very legitimate, but perhaps not what you’re after.

The patient has chest pain. Okay. Abdominal pain. Difficulty breathing. Clicky elbow. Can’t pee. So you assess their complaint from every angle, real and metaphoric, and you see what there is to see about it. But what’s the context? Is this the final stage of a grab-bag of other problems? Before it was abdominal pain, was there nausea and discomfort? Have the past few days produced a gradually increasing malaise? Is that onset truly sudden, or were there precursors?

Forget all that. Did your cat just get run over? Is your insurance refusing your reimbursements? Did your medication run out last week and you haven’t been able to afford to refill it? Are you living on ramen noodles and water?

Has anything else been bothering you? We can’t list every malady, but this question encompasses them all, and it can reveal entire storylines you wouldn’t have learned without an open-ended query. Patients have a habit of not mentioning anything that doesn’t seem directly related to their chief complaint, but those blips can make or break a clinical picture. I never call a history complete without asking it once.

 

How can I help?

Patients have a lot of complaints. Sometimes it’s the very reason they called you. Sometimes it’s just a complaint. They’re sick. Stuff hurts. Feels bad. Has problems.

They may share these complaints with you. And you may be able to help. Chest pain, you say? Why, I have just the morphine for that!

The trouble is, sometimes we’re not sure if we can help. Or it doesn’t seem like we can. Chest pain’s one thing. But what can you do when they complain of feeling “awful”? What about an uncomfortable stretcher — sure, let me just grab the plush memory foam? Heck, on my BLS truck, we don’t even have the morphine. We’re not magicians here.

But if you’re drawing a blank, try the wild card: ask!

Hey, sorry you’re having problems. How can I help? Often they have a solution. They’ve dealt with their problems for longer than you have. Next time, maybe you’ll have that answer on tap. But you don’t have to know all the answers; you just have to be able to ask. Funny thing, too; even when you really can’t do anything, they’re glad you cared enough to try. Sure is better than just sitting there trying to ignore their whining.

How can I help? Hey — isn’t that our whole business? They give us textbooks on how we can help. But sometimes helping’s easier than a CPAP or a trauma alert. Sometimes we can cheat, because the answer’s up for grabs. You just gotta ask.

More at Some Things to Say (part 2)