Cardiac Arrest Prehospital vs. Hospital

[mycrofft]

How about, "yes, but..."

"in nice conditions with a MD attending"?

I wonder after my rant what proportion of field arrests are CAD=>cardiac ischemia versus all other sorts, or even a breakdown by cause? Or breakdown by etiology of arrests that recover? How common is the need for a pericardial tap?

 

[Shishkabob]

"in nice conditions with a MD attending"?

Ah, but if we are expected to be able to do the skills on the living, and we are within our ability to cease resuscitation in the field, both without doctors present, why must one be present for the practice?

 

[medicsb]

Which brings the question up, would you advocate a Paramedic doing the same thing (practice a rarely used skill on a patient that loosely fits) when it's going to be an arrest you know you're going to call, such as doing a needle decompression on a blunt traumatic arrest, or a cric on an arrest with facial trauma?

I know you asked veneficus this question, but I feel inclined to respond as it's something I've given though to in the past. I personally would advocate for it on the grounds of utilitarian ethics (e.g. "end justify the means", producing "the greatest good for the greatest number"), though I do so with caution as a utilitarian approach to justifying procedures possibly lends itself to a slippery-slope situation. (For sure, the utilitarian approach is not applicable to all or even most aspects of medicine.)

However, I would only advocate for such practice in situations where "live" patient practice is rare and not easily simulated. I don't know if needle decompression is something that should be done on actual patients for "practice" as the procedure can easily be practiced on simulators. I'd argue that proper identification of landmarks and thus placement in the correct position is probably more difficult (I think I recent study showed that even physicians place the need in the wrong place pretty frequently). Darting a pt. during a code is not likely at all to help as you will not know if you placed it in the correct place unless you have a way to follow up. Cricothyrotomy can be practiced on animal analogues, which is better than the manikins and probably cheaper (pig tracheas don't cost very much to get from a butcher; they might even be free from some).

I actually think intubation is one procedure that should be practiced on "live" patients when possible. With many EMS systems abandoning ETI for cardiac arrest, when will a medic actually ever intubate an actual patient in those systems? Considering that most medic ETIs have been performed on CA patients, probably 2/3-3/4 of ETIs are no longer performed. So, ultimately, I think if you're not intubating CA patients, then you should NOT be intubating anyone, ever. However, I would agree that some patients might actually benefit from ETI. So, how would I suggest that a medic get live practice? In the OR, if you can get it, which most can't, unfortunately. After that the only alternative is CA patients. But, I only think it should be done after good CPR has been applied and is failing at some point down the line. Obviously, in ROSC patients ETI can be attempted. But if you're getting near the end or you're 15-20 minutes into the resuscitation, why not remove the King/Combitube/LMA/whatever and attempt a tube? It is practice that could benefit other patients down the line and thus I think it is reasonable and ethically sound if the procedure is limited to a small number of medics (in order to concentrate the procedural experience).

 

[Veneficus]

I know you asked veneficus this question, but I feel inclined to respond as it's something I've given though to in the past. I personally would advocate for it on the grounds of utilitarian ethics (e.g. "end justify the means", producing "the greatest good for the greatest number"), though I do so with caution as a utilitarian approach to justifying procedures possibly lends itself to a slippery-slope situation. (For sure, the utilitarian approach is not applicable to all or even most aspects of medicine.)

However, I would only advocate for such practice in situations where "live" patient practice is rare and not easily simulated. I don't know if needle decompression is something that should be done on actual patients for "practice" as the procedure can easily be practiced on simulators. I'd argue that proper identification of landmarks and thus placement in the correct position is probably more difficult (I think I recent study showed that even physicians place the need in the wrong place pretty frequently). Darting a pt. during a code is not likely at all to help as you will not know if you placed it in the correct place unless you have a way to follow up. Cricothyrotomy can be practiced on animal analogues, which is better than the manikins and probably cheaper (pig tracheas don't cost very much to get from a butcher; they might even be free from some).

I actually think intubation is one procedure that should be practiced on "live" patients when possible. With many EMS systems abandoning ETI for cardiac arrest, when will a medic actually ever intubate an actual patient in those systems? Considering that most medic ETIs have been performed on CA patients, probably 2/3-3/4 of ETIs are no longer performed. So, ultimately, I think if you're not intubating CA patients, then you should NOT be intubating anyone, ever. However, I would agree that some patients might actually benefit from ETI. So, how would I suggest that a medic get live practice? In the OR, if you can get it, which most can't, unfortunately. After that the only alternative is CA patients. But, I only think it should be done after good CPR has been applied and is failing at some point down the line. Obviously, in ROSC patients ETI can be attempted. But if you're getting near the end or you're 15-20 minutes into the resuscitation, why not remove the King/Combitube/LMA/whatever and attempt a tube? It is practice that could benefit other patients down the line and thus I think it is reasonable and ethically sound if the procedure is limited to a small number of medics (in order to concentrate the procedural experience).

I do not agree nor disagree with the practice of using the recently deceased for procedure practice. (in other words I haven't given it the amount of thought required)

I just acknowledge that the practice exists.