NO CPR is better than moving CPR...true or false?

[Brandon O]

Bringing up a good point of what to you use as a standard measurement of a good EMS system. In some ways I would argue that patient complaints or satisfaction ratings would be the best measurement. If the patients feel they should have had better medical care they will complain. If you run a system with good medical care and EXCELLENT customer service, you deserve to be recognized for that. 95%+ of our calls are customer service calls, not excellence in medical care calls.

No doubt. At the same time, of course, you don't want to write off the rare true emergency (nor the slightly less acute patient who still needs appropriate care in order to optimize their outcome). The fact that they're a small portion of the overall volume doesn't change the fact that, fundamentally, they're the reason EMS exists. Otherwise we'd be running a taxi service staffed by professional person-picker-uppers and hand-holders.

When you visit the mechanic, you want somebody who isn't a douche, but also who fixes your car right. You only understand how to grade one of those, but you need both.

 

[KellyBracket]

Bringing up a good point of what to you use as a standard measurement of a good EMS system. In some ways I would argue that patient complaints or satisfaction ratings would be the best measurement. If the patients feel they should have had better medical care they will complain. If you run a system with good medical care and EXCELLENT customer service, you deserve to be recognized for that. 95%+ of our calls are customer service calls, not excellence in medical care calls.

"Customer service" gets short shrift in EMS, but it's going to be a fact of life soon enough (see How do patients view our care? for a recent discussion of this topic). It's already a fact of life in the rest of medicine.

But this shouldn't be much of a big deal. Whether it's doctors, nurses, or paramedics, I have found that the better, smarter, and technically superior health-care workers are usually the best at customer service, and vice-versa. Heck, they're usually just good people!

 

[Brandon O]

Whether it's doctors, nurses, or paramedics, I have found that the better, smarter, and technically superior health-care workers are usually the best at customer service, and vice-versa. Heck, they're usually just good people!

I agree to some extent, but it also goes the other way. There are technically competent burnouts, and there are warm and fuzzy humanistic types who think rivaroxaban is an '80s hair metal band. If you want both, you have to select for and cultivate both.

 

[mycrofft]

I am not so sure it is that bad.

The only proven interventions to work are cpr and defib.

Hypothermia I think would add something, but it is not exactly wide spread in EMS use.

PROMPT EARLY AND CORRECT CPR and defib. Which indicates a "cloud" ("Crowd"?) of trained and updated laypersons willing to acitvate the ARC's "Chain of Survival" (prompt/early recognition, 911 activation, CPR/AED, and ALS arrival).

I thought of an ALS function which helps survival and recovery: advanced airway management (versus NPA, OPA, and head tilt/chin lift alone).

 

[mycrofft]

No doubt. At the same time, of course, you don't want to write off the rare true emergency (nor the slightly less acute patient who still needs appropriate care in order to optimize their outcome). The fact that they're a small portion of the overall volume doesn't change the fact that, fundamentally, they're the reason EMS exists. Otherwise we'd be running a taxi service staffed by professional person-picker-uppers and hand-holders.

When you visit the mechanic, you want somebody who isn't a douche, but also who fixes your car right. You only understand how to grade one of those, but you need both.

AMEN. Yeah most MI aren't going to make it through the week or overnight even if they get to the hospital with a pulse, but there are thing besides MI"s happening out there.

 

[mycrofft]

"Customer service" gets short shrift in EMS, but it's going to be a fact of life soon enough (see How do patients view our care? for a recent discussion of this topic). It's already a fact of life in the rest of medicine.

But this shouldn't be much of a big deal. Whether it's doctors, nurses, or paramedics, I have found that the better, smarter, and technically superior health-care workers are usually the best at customer service, and vice-versa. Heck, they're usually just good people!

(Accents care of Mycrofft).
The cowboy/battlefield rescue culture needs to be toned down. Just because PEMS is important doesn't mean we have to come in shouting and running and yanking and cutting and all that jazz.

 

[EpiEMS]

I thought of an ALS function which helps survival and recovery: advanced airway management (versus NPA, OPA, and head tilt/chin lift alone).

I'm not sure if we can necessarily say that. I can't imagine it hurts, assuming advanced airway management is done rapidly and without interrupting CPR and defib, but there seems to be lots of data saying that ETI is harmful.

Viz.: http://www.osuem.com/downloads/advanced_airway_ohca_aem_2010_pgy1.pdf

"Even after multivariable adjustment for age, sex, site of arrest, bystander CPR, witnessed arrest, and rhythm on paramedic arrival, the OR for survival to hospital discharge for BVM versus ETI was 4.5 (95% confidence interval [CI] = 2.3–8.9; p<0.0001)."

Pretty good-sized study, too. I would've liked to see them not mix the EOA and CombiTube patients, but I suppose since they're both rescue airways, it's sensible.

Another study with similar results (same journal as above): http://www.osuem.com/downloads/prehospital_eti_ohca_aem_2010_pgy2.pdf

Recent study with similar results from Japan (in JAMA): http://jama.jamanetwork.com/article.aspx?articleid=1557712#qundefined

 

[mycrofft]

Any studies about the effects of aspiration of vomitus, blood, teeth, broken bits of Yankauer suction tips, etc. a cuff supposedly prevents?

BTW, as a longtime sufferer of nocturnal GERD, I can tell you about aspirating stomach contents; is no picnic and can make you generally sick, but not invariably fatal as they used to tell us in CPR and EMT classes...if you can sit up and cough long enough.

 

[Veneficus]

Any studies about the effects of aspiration of vomitus, blood, teeth, broken bits of Yankauer suction tips, etc. a cuff supposedly prevents?

BTW, as a longtime sufferer of nocturnal GERD, I can tell you about aspirating stomach contents; is no picnic and can make you generally sick, but not invariably fatal as they used to tell us in CPR and EMT classes...if you can sit up and cough long enough.

I think it is relative and in not all cases is the pathology clinically evident.

In a relatively healthy person, stomach acid/content in the lungs is not going to be acute life or death in most cases.

However, there exists the reasonable possibility for destruction of lung tissue.

Like any chronic destruction of tissue, there will be a period of compensation before the effects are clinically evident.

IN an acutely ill person (like cardiac arrest) you have a person with an obviously serious comorbidity. (otherwise they wouldn't be dead)

Many providers forget about the physiologic inflammatory response as a mechanism of illness/injury in the acute phase. (In all fairness treatment of this isextremely expensive and the results are not outstanding)

When you add inflammatory damage (including cellular swelling) + direct damage of stomach content + subsequent infection (like VAP) +supine position with reduced ability to clear secretions + somebody sticking a suction tube in this environment is where you are going to see the fatality numbers start to add up.

As I professed many times, a major problem in emergency medicine is an all or nothing mentality. There are many stages between living a normal life and dead. I think that al levels of emergency medicine really need to start catching on to that.

The days of spontaneous respiration and pulse being all that needs done are over. Cardiac arrest and other sick patients are not discharged home from the ED. Emergency care needs to be part of a continuity of care, not just lip service paid to it while they do their own thing in spite of everyone elses efforts.

 

[mycrofft]

The money shot for the thread. Lock 'er down.

"The days of spontaneous respiration and pulse being all that needs done are over. Cardiac arrest and other sick patients are not discharged home from the ED. Emergency care needs to be part of a continuity of care, not just lip service paid to it while they do their own thing in spite of everyone elses efforts."

 

[Veneficus]

The money shot for the thread. Lock 'er down.

"The days of spontaneous respiration and pulse being all that needs done are over. Cardiac arrest and other sick patients are not discharged home from the ED. Emergency care needs to be part of a continuity of care, not just lip service paid to it while they do their own thing in spite of everyone elses efforts."

What is wrong with that statement? It is true.

 

[mycrofft]

Not only is it true, it ought to be the masthead.

Each EMT and paramedic text ought to come with that as a bookmark.

Medical Directors at conventions ought to wake up with headaches, furry tongues, and that tattooed backwards on their foreheads so they see it first thing each morning in the mirror.

 

[Brandon O]

Just-published study that's relevant to this discussion. Thanks to Vince D for the heads-up.

http://www.ncbi.nlm.nih.gov/pubmed/23223106

 

[EpiEMS]

Just-published study that's relevant to this discussion. Thanks to Vince D for the heads-up.

http://www.ncbi.nlm.nih.gov/pubmed/23223106

I wonder if there's an EMS system that'd be willing to do this with similar mannequins -- looks like an interesting study design.

 

[ThirtyAndTwo]

I've heard the same, that you cannot do effective CPR in a moving ambulance. They have these things called "thumpers" that are some kind of device that does automatic compressions, I've never seen one but I'm thinking they probably hook onto the cot somehow, but anyway they are able to give good compressions in a moving ambulance.

 

[NomadicMedic]

I've heard the same, that you cannot do effective CPR in a moving ambulance. They have these things called "thumpers" that are some kind of device that does automatic compressions, I've never seen one but I'm thinking they probably hook onto the cot somehow, but anyway they are able to give good compressions in a moving ambulance.

Google "LUCAS 2" and "auto pulse". Those are the two main players in mechanical CPR devices.

 

[mycrofft]

Google "LUCAS 2" and "auto pulse". Those are the two main players in mechanical CPR devices.

See first two responses in this thread. Et al.

 

[CPRinProgress]

but if you cant revive the pt on scene are you supposed to transport or just pronounce them or transport them while you just stare at there body. decreased effectiveness cpr is better than no cpr and you can stand next to the stretcher while someone holds you and switch when you stop for the aed to analyze

 

[systemet]

but if you cant revive the pt on scene are you supposed to transport or just pronounce them or transport them while you just stare at there body. decreased effectiveness cpr is better than no cpr and you can stand next to the stretcher while someone holds you and switch when you stop for the aed to analyze

Call it. I try not to stare, it's rude.

 

[Rykielz]

Maybe this is what that nurse in Bakersfield, CA, who refused to do CPR after she called 9-1-1, was thinking.