Making Requests for Protocol Changes

[Bieber]

Every ALS patient, yes. If I performed an ALS intervention it becomes an ALS call. I think this is good practice, because I know from experience that we find at least as many clinical signs by mistake than we do on purpose. This is true for all levels of medicine. I understand you are just starting out as a paramedic, but it shouldn't take you long to realize that our most powerful tool is DILIGENCE. You have absolutely no good reason to omit ECG monitoring on these patients. The tools are right at your fingertips, you've got the time. Cast a wide net and I absolutely promise you will catch some fish.

Well, there's your problem right there, you're still thinking in the archaic mindset of BLS and ALS. Instead of trying to divide patients into two groups and decide that they automatically need all "ALS" interventions, why not treat patients according to what their medical condition necessitates? Everything else is just dumbing down medicine so that undereducated providers can scrape by. Diligence doesn't mean throwing every tool we have at every patient who meets the "catch all" BLS and ALS divisions.

Sounds like you are out to re-write ATLS based on the information you obtained in CPR class. Doesn't that strike you as ridiculous? Pericardiocentesis is the definitive treatment for cardiac tamponade, performed only by physicians, and as you said, you have very little resources to make that diagnosis in the field. That all equals up to a patient who ought to be transported.

By the way, trauma is only ONE of the possible causes of tamponade...

You haven't answered my question. Unless you're advocating transporting all code blues so that they can rule in/out tamponade, you still haven't told me how we're supposed to determine whether the patient is a candidate for pericardiocentesis. Furthermore, prehospital ultrasound exists and could become more prevalent in the coming years--which makes pericardiocentesis possible for EMS personnel.

Not only are you wrong (I've seen several of the scenarios you describe actually happen), but your point is based in the fallacy that you understand the perimeters by which these physicians make decisions. You don't. That's not an insult, it's just the truth.

Like I said, transporting a traumatic arrest that had no vital signs upon arrival is kind of like beating a dead horse. Secondly, while surgical intervention may be possible, again, to crack the chest, you've got to stop CPR. For some patients it may be appropriate, but that number I suspect is very small.

And what is this assumption based on? Are you planning on eliminating chest tubes from ATLS also?

http://www.resusme.em.extrememember.com/wp-content/uploads/2011/01/patients-in-prehospital-traumatic-cardiac-arrest-Chest-decompression-during-the-resuscitation-of-1.pdf

Why would I call for eliminating chest tubes? They're a vital continuation to needle chest decompression, in fact there's no reason why we couldn't be performing them in the field; studies have shown that there's no significant difference in the efficacy or success of the procedure between physicians and paramedics.

Wrong again. An i-STAT is point of care testing that takes only minutes. Also, treatment of hyperkalemia does not stop at calcium. Are you really sure that you know exactly what resources the hospital has to offer these patients? Sure enough to decide concretely that nothing more can be done?

So, after running the code on scene with good quality CPR and IV medications, you're going to have an extended period of poor CPR during transport, more extended periods of poor CPR during the transfer of care, more delays (every one of those mere "minutes" counts in cardiac arrest, you know) during the transfer of care, delays waiting on the i-STAT and then--THEN--finally, if we find out that the patient is hyperkalemic, assuming that the patient hasn't already been treated for hyperkalemia by the paramedics, they can give him or her some... what, exactly? Insulin? Takes a while to start working. Glucose? That can be given in the field. Diuretics? Gonna take a while too. Kionex? Hours to DAYS, even. Not to mention there's some debate over whether or not it's even helpful, not to mention it comes with a risk of colon necrosis (somewhat moot in the case of cardiac arrest, but if it's not useful then you're just tacking on complications). Sure that maybe good CPR with limited interruptions along with calcium, sodium bicarb, and maybe even some glucose isn't going to give that patient the best possible chance at survival?

LOL once again you fail to realize that there is a whole world out there of which you are not a part. Active internal rewarming STARTS with warm saline. It does not stop there, not even close. Not to mention that hypothermic arrests may benefit from extended resuscitation. How long do you plan to work these patients in the field before you decide the cause is hopeless? Maybe you should just transport.

I'm well aware of other rewarming techniques, and I agree that hypothermic patients may represent one of those subsets of patients that may benefit from transport to the hospital. Technically, additional rewarming techniques aren't unfeasible for us to do, but I think those techniques will be a long time coming.

Damn right you aren't an expert. That's the whole point. Also, I said "PEA" and not "PE." Ahem.

Excuse me, I misunderstood what you meant. Let me correct what I said: you know we can do ultrasound in the field, right? And bringing ultrasound to the patient as opposed to the patient to ultrasound is most certainly going to increase what little chance of survival those patients have.

[usalsfyre]

Fiznat, I don't know your education level, but your making arguments that sound suspiciously close to "if it saves one patient...". That, quite simply, doesn't fly. The fact is the science supports terminating resuscitation on the vast majority of arrest in the field prior to transport. No lesser an authority on resuscitation than ILCOR recognizes this.

We can argue about anecdotal case reports all day long, the fact is the majority of these cases are not helped last ditch, off the wall treatments like trauma room thoracotomy and centisis. At some point you have to begin weighing the cost/benefit of possible accidents in transport and the greater cost associated with inhospital resuscitation with the non-existent (statistically speaking anyway) improvement in outcomes.

As far as anecdotal case reports go, I have never seen a chest opened in a trauma room for any other purpose than "let's try this" at academic centers. I've also never seen, or heard of, a patient that required a centisis surviving when the initial presentation was cardiac arrest. The ONE time I've heard of a patient surviving cardiac arrest from tampanode it was recognized prior to arrest during transport, and they were waiting with a needle.

I don't know if your a field provider who's uncomfortable with terminating resus or perhaps a med-student/resident physician who is biased towards your trade. Either way, this attitude places providers and the public at risk from unneeded priority transport, subjects the patient to unneeded procedures, and subjects their estate to useless cost. None of which is good policy, good medicine, or true patient advocacy.

[fiznat]

Fiznat, I don't know your education level, but your making arguments that sound suspiciously close to "if it saves one patient...". That, quite simply, doesn't fly.

Well not really. This argument has gotten a little bit beyond, I admit, but my main point is that advocating for "no transport on all cardiac arrests" is going too far. My opinion is that there needs to be a protocol that is a little bit more sensitive than that. The one we have where I work makes sense to me:

NO TRANSPORT: Rigor/lividity/asystole, decomposition, injuries incompatible with life (decapitation, transection, incineration, etc), persistent asystole following 20 minutes of ACLS

TRANSPORT: Hypothermic arrests, electrocution arrests, shockable rhythms, ROSC at any point, witnessed non traumatic arrests, etc

I have a bit of an issue when people bring up arguments like Bieber has, where the main point presupposes that we can predict what physicians will and won't do. I have a fair amount of education and experience, and the lesson that has been most important to me over those years has been to respect how little we really know. When Bieber suggests in a single post that we both eliminate facets of our assessment (ECG monitoring) increase our scope of practice ("primary care"), and skip going to the hospital, it sets off alarm bells.

[usalsfyre]

Fiznat, understand your position better and I agree with those thoughts...mostly. I WOULD argue that outside of electrocution and hypothermia, ANY cardiac arrest rhythm that has been unresponsive to ACLS (especially with an ETCO2

Edited April 9, 2011 by usalsfyre

[Bieber]

Well not really. This argument has gotten a little bit beyond, I admit, but my main point is that advocating for "no transport on all cardiac arrests" is going too far. My opinion is that there needs to be a protocol that is a little bit more sensitive than that. The one we have where I work makes sense to me:

NO TRANSPORT: Rigor/lividity/asystole, decomposition, injuries incompatible with life (decapitation, transection, incineration, etc), persistent asystole following 20 minutes of ACLS

TRANSPORT: Hypothermic arrests, electrocution arrests, shockable rhythms, ROSC at any point, witnessed non traumatic arrests, etc

I have a bit of an issue when people bring up arguments like Bieber has, where the main point presupposes that we can predict what physicians will and won't do. I have a fair amount of education and experience, and the lesson that has been most important to me over those years has been to respect how little we really know. When Bieber suggests in a single post that we both eliminate facets of our assessment (ECG monitoring) increase our scope of practice ("primary care"), and skip going to the hospital, it sets off alarm bells.

Who said anything about eliminating facets of our assessment? I'm calling for us to be wiser in our interventions, not to just simplify things down to "this must always be done, regardless of the situation!" for the sake of the lowest common denominator. I'm sorry if you don't think we need to expect more from our providers, and not just dumb things down to their level or maintain the overly ridiculous simplification of "BLS" and "ALS". I respect very much how little we know, which is why I don't think much of what I've suggested is possible unless we seriously rethink and readjust our educational standards, and why I have ALWAYS called for greatly increased educational standards for paramedics.

Furthermore, I agree that some code blues ought to be transported to the hospital, as I've said multiple times now. Why are you ignoring what I am saying? Instead of simply telling me "I don't know what treatments the hospital might possibly give", why don't you present some actual references that show exactly what those treatments are? You're right that we can't predict what every physician might do, but most follow a similar standard of care; something which every one of us can research through the miracle of literature. I think you're trying to bend my words and oversimplify my argument to try and justify yours; instead of that, why don't you address my issues directly, actually SHOW me where I'm wrong (because yes, I readily admit that I just might be) and give me more than just "well, you don't know what they might do! They could have some wonder cure that you've never heard about because it's a top secret that only physicians are privy to!"

I never said we shouldn't transport ALL codes, eliminate ECG monitoring for ALL patients, try to replace ALL primary care, or ALWAYS skip going to the hospital.