MonkeyArrow
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Can you cite your source?
What do you typically do in a Transport EMT job?
- Thread starter Lannel
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Huh? Cite his source that having two providers work a code while stationary is better than having one try to in a moving ambulance?
One provider provides high quality continuous compressions while the second hooks up the monitor and delivers a shock. After that shock, provider 2 starts compressions while provider 1 moves up to the airway (I believe we're assuming BLS for this scenario, but correct me if I'm wrong). At this point, it's fairly easy to switch roles every shock between both providers, and some sort of help (ALS, fire, or police) should be there any second since you're in an urban setting. I'm trying to understand your thought process here, but I feel like I'm missing something.
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I think we should probably ask that of you. Everyone here is advocating for doing what the AHA teaches: two rescuer CPR is more effective than single rescuer. Seems fairly obvious.
If you don't believe that CPR is ineffective in a moving ambulance
http://www.ncbi.nlm.nih.gov/pubmed/23178870
http://www.ncbi.nlm.nih.gov/pubmed/10114069
Sorry your argument makes no sense and is not based on anything but your own assumptions that are just frankly out there.
MonkeyArrow
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The first study that you cited states that there is no difference in mean chest compression depth between scene, in ambulance, or emergency department, evidence against your (collective) claim that CPR in the back of the ambulance is ineffective compared to scene.
EDIT: In variability indexes, the transport figures were in the middle for both depth and rate, meaning that they were not the worst. Note, the two comparatives are on scene and in the emergency department, both of which you advocate over in ambulance.
As to the second, it is literally a two sentence abstract from 1991 that seems to have no full get that I can read.
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http://www.ncbi.nlm.nih.gov/pubmed/23425006
http://www.ncbi.nlm.nih.gov/pubmed/10155415
The second one showing that only 45% of compressions were effective in a moving ambulance that was operated in a non-emergent manner.
Meanwhile, we will await research showing that hauling *** to the hospital while doing single rescuer CPR is a good idea.
http://www.ncbi.nlm.nih.gov/pubmed/10155415
The second one showing that only 45% of compressions were effective in a moving ambulance that was operated in a non-emergent manner.
Meanwhile, we will await research showing that hauling *** to the hospital while doing single rescuer CPR is a good idea.
MonkeyArrow
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I give you:
http://www.ncbi.nlm.nih.gov/pubmed/17276575
95% efficiency compared to CPR performed on scene.
Funny, why would you even include the first if it is not germane to the discussion (or to your point, at least)? It has no control group (scene compression). Actually, while the technically calculated rate of correct compressions is at 67%, the compression rate is on par with guidelines and the mean compression depth is .3 mm shy of the recommended rate. I'll take that. The second link was published in 1995. That's 20 years ago. I surely hope that our measuring metrics for CPR efficacy have improved since then.
Honestly, quickly leafing through PubMed myself, I see no conclusive studies. The second link that you cited showed decreased efficacy (albeit, study done in 1995), whereas the link I cited showed 5% decrease in quality in ambulance (performed in 2005, published 2007). Therefore, I think that a new, mega RCT or at least a meta-anaylsis of all the studies needs to be done to reach a conclusive decision. However, I do still believe that I am at least justified in holding the opinion that I have.
http://www.ncbi.nlm.nih.gov/pubmed/17276575
95% efficiency compared to CPR performed on scene.
Funny, why would you even include the first if it is not germane to the discussion (or to your point, at least)? It has no control group (scene compression). Actually, while the technically calculated rate of correct compressions is at 67%, the compression rate is on par with guidelines and the mean compression depth is .3 mm shy of the recommended rate. I'll take that. The second link was published in 1995. That's 20 years ago. I surely hope that our measuring metrics for CPR efficacy have improved since then.
Honestly, quickly leafing through PubMed myself, I see no conclusive studies. The second link that you cited showed decreased efficacy (albeit, study done in 1995), whereas the link I cited showed 5% decrease in quality in ambulance (performed in 2005, published 2007). Therefore, I think that a new, mega RCT or at least a meta-anaylsis of all the studies needs to be done to reach a conclusive decision. However, I do still believe that I am at least justified in holding the opinion that I have.
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@MonkeyArrow. Have you ever performed compressions in a moving ambulance? I understand that your facility does a number of interventions that may or may not prove to be effective in cardiac arrest patients, but what are the first things they do for a cardiac arrest with a shockable rhythm? I'm going to go out on a limb here and guess they perform CPR at 30:2 or continuous with two rescuers as compressors rotate out, defibrillate shockable rhythms, and administer whatever medications the ED MD running the call decides (epinephrine, amiodarone, atropine, lidocaine, mag...).
All the other fancy stuff comes later or not at all. If we (BLS or ALS) witness a VF/VT arrest secondary to a medical cause in the field, we stand a very fair chance of treating the patient and achieving sustained ROSC with a darn good chance at a decent neurological outcome. I simply can't figure out why you would advocate any EMS unit upgrading to an emergent response with a witnessed arrest as the attending provider stands up and attempts to do horribly ineffective (secondary to experience and the majority of admittedly small scale studies available) manual compressions for 5 minutes without any attempt at electrical therapy during the time period in which the heart is most susceptible to conversion of VF back to a perfusing rhythm.
I love to deliver live and viable patients to the ED. I recognize the ED physician's knowledge, skill set, and tools vastly surpass my own. I understand the ED and remainder of the hospital offer numerous services and interventions to help my patients that I can't, but I think part of giving these patients the best chance at survival means working them where I find them and stopping to achieve ROSC on an arrest during transport.
All the other fancy stuff comes later or not at all. If we (BLS or ALS) witness a VF/VT arrest secondary to a medical cause in the field, we stand a very fair chance of treating the patient and achieving sustained ROSC with a darn good chance at a decent neurological outcome. I simply can't figure out why you would advocate any EMS unit upgrading to an emergent response with a witnessed arrest as the attending provider stands up and attempts to do horribly ineffective (secondary to experience and the majority of admittedly small scale studies available) manual compressions for 5 minutes without any attempt at electrical therapy during the time period in which the heart is most susceptible to conversion of VF back to a perfusing rhythm.
I love to deliver live and viable patients to the ED. I recognize the ED physician's knowledge, skill set, and tools vastly surpass my own. I understand the ED and remainder of the hospital offer numerous services and interventions to help my patients that I can't, but I think part of giving these patients the best chance at survival means working them where I find them and stopping to achieve ROSC on an arrest during transport.
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Seriously? Do you actually understand what you're saying?
You open by making a statement that is full of blatent contradictions, and continue to contradict yourself since it would appear that you recognize that single-person CPR doesn't work...yet you advocate it.
Now you want a study for "proof"...
How about this. Go to google scholar. Type in "effectiveness of CPR when moving." And read through the numerous links that come back. Like the ones that compare stationary vs moving CPR...compare how effective CPR is when in various positions...show how quickly people fatigue when in various positions...compare the effectiveness between standard or mechanical compressions while moving...
No. You aren't.
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Are you going to support it in any way?
MonkeyArrow
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@chaz90 Yes, my facility runs through all the standard code things first. The point about not being able to shock with 1 person CPR is ludicrous. Let me refer you to the AHA 1 person CPR arrest management algorithm, since that's what everyone seems to like. The first thing that you do in a witnessed adult arrest is call 911 and go get an AED if you're all alone. You are 911, and the AED is literally a yard away from you. Take the pads, put it on the patient. Charge and deliver a shock if it is a shockable rhythm. This literally takes me all of 20 seconds to do on my LP12/15.
Also, yes, I have done CPR in a moving ambulance. I was able to do it, who knows how effectively since I or my patient wasn't hooked up to the proper scientific instruments to test its efficacy. But, I'm still alive. No one died, or got injured. As to the delivery of viable patients, I wonder how long the scene time was before transport for those patients who never achieved ROSC. If you futz around on scene for 20 minutes before transporting, chances are going to be very low. However, back to the OP's question, if the arrest happens in the back of an ambulance already en route, time to hospital will be much shorter, I'm assuming. The folded 5 or 10 minutes of shocking an arrhythmia back into perfusion doesn't magically go away just because you are in an emergency department instead of on someone's living room floor.
@triemal04 Yes. I'm fairly positive I understand what you are saying. Thanks for your concern. I typed in exactly what you told me to into the search engine which you mentioned. The studies that came up showed inconclusive results, as I noted in my previous posts as some said compression efficiency decreased while others said that it was very close to the baseline. Additionally, many studies have poor baseline performance, such as 52% on the floor, demonstrating a lack of proper training to begin with. The use of a mechanical device is not relevant here. No one is arguing that a human can outperform the LUCAS.
In fact, I do find it kind of funny that Tigger dropped the study point after I posted a study that showed the opposite results that you guys are claiming. Here is an excerpt from the same link that was in my last post, as none of you obviously cared to look at it:
RESULTS: Compared to resuscitation at the scene, efficiency of chest compressions during a helicopter flight was 86% and 95% in the moving ambulance 95%. There were no differences in secondary outcomes (time without chest compression, total number of incorrect hand position relative to total compressions, and total number of incorrect pressure release relative to total compressions).
CONCLUSIONS:
Resuscitation during transport is feasible and relatively efficient. There is some difference between the environments, but there is no relevant difference between helicopters and ambulances regarding the effectiveness of CPR.
I'm curious, if each of you had a LUCAS, would you transport your arrests?
Also, yes, I have done CPR in a moving ambulance. I was able to do it, who knows how effectively since I or my patient wasn't hooked up to the proper scientific instruments to test its efficacy. But, I'm still alive. No one died, or got injured. As to the delivery of viable patients, I wonder how long the scene time was before transport for those patients who never achieved ROSC. If you futz around on scene for 20 minutes before transporting, chances are going to be very low. However, back to the OP's question, if the arrest happens in the back of an ambulance already en route, time to hospital will be much shorter, I'm assuming. The folded 5 or 10 minutes of shocking an arrhythmia back into perfusion doesn't magically go away just because you are in an emergency department instead of on someone's living room floor.
@triemal04 Yes. I'm fairly positive I understand what you are saying. Thanks for your concern. I typed in exactly what you told me to into the search engine which you mentioned. The studies that came up showed inconclusive results, as I noted in my previous posts as some said compression efficiency decreased while others said that it was very close to the baseline. Additionally, many studies have poor baseline performance, such as 52% on the floor, demonstrating a lack of proper training to begin with. The use of a mechanical device is not relevant here. No one is arguing that a human can outperform the LUCAS.
In fact, I do find it kind of funny that Tigger dropped the study point after I posted a study that showed the opposite results that you guys are claiming. Here is an excerpt from the same link that was in my last post, as none of you obviously cared to look at it:
RESULTS: Compared to resuscitation at the scene, efficiency of chest compressions during a helicopter flight was 86% and 95% in the moving ambulance 95%. There were no differences in secondary outcomes (time without chest compression, total number of incorrect hand position relative to total compressions, and total number of incorrect pressure release relative to total compressions).
CONCLUSIONS:
Resuscitation during transport is feasible and relatively efficient. There is some difference between the environments, but there is no relevant difference between helicopters and ambulances regarding the effectiveness of CPR.
I'm curious, if each of you had a LUCAS, would you transport your arrests?
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I have a LUCAS. I continue to work my arrests on scene until termination of efforts or ROSC as the hospital offers only the same therapies I can for a patient that remains in cardiac arrest.
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Actually I posted additional studies.
Not to mention that "I'm still alive. No one died, or got injured." is a useless statement. One time you did something with these results. That means absolutely nothing. Especially since we know that transporting emergent significantly increases the ambulance's likelihood of being involved in an accident. And while an AMR operation in California did one tiny study showing no difference in CPR quality between seatbelted and standing providers in Type II vans, most of the time transporting a cardiac arrest involves no seatbelts for most providers. But hey, one time you did it and everything worked out, so that must always be true.
Not to mention I still do not understand how you can advocate for single provider CPR for any significant length of time. To say that the quality of compressions will decrease at the same rate with one and two provider CPR doesn't make sense. Two providers should be able to meet compression guidelines for eight minutes or however long you think it will take for more resources to arrive.
Not to mention that "I'm still alive. No one died, or got injured." is a useless statement. One time you did something with these results. That means absolutely nothing. Especially since we know that transporting emergent significantly increases the ambulance's likelihood of being involved in an accident. And while an AMR operation in California did one tiny study showing no difference in CPR quality between seatbelted and standing providers in Type II vans, most of the time transporting a cardiac arrest involves no seatbelts for most providers. But hey, one time you did it and everything worked out, so that must always be true.
Not to mention I still do not understand how you can advocate for single provider CPR for any significant length of time. To say that the quality of compressions will decrease at the same rate with one and two provider CPR doesn't make sense. Two providers should be able to meet compression guidelines for eight minutes or however long you think it will take for more resources to arrive.
We do have a LUCAS on each arrest, and no, we don't until we have ROSC. Also we have worked someone for over an hour and got them back and they are out and about walking today. You my friend are ridiculous.
I hope you understand that you are continuing to contradict yourself. Is it intentional? Because you used the reasoning that 2 people couldn't effectively provide compressions, ventilations, and defibrillation as a reason to not stop...and now you seem to be saying that 1 person can easily provide compressions and defibrillation. Huh...
Anyway. You clearly want to believe that what you are doing is appropriate despite all evidence to the contrary. And are unwilling to consider that you might be wrong, or even look at "proof" that you in fact are.
http://informahealthcare.com/doi/abs/10.1080/10903120500373108 Stable CPR=better CPR. Not inconclusive at all.
http://link.springer.com/article/10.1007/s00134-006-0273-8#page-1 Poor positioning=ineffective CPR. Not inconclusive at all.
http://www.koreamed.org/SearchBasic.php?RID=0082JKSEM/2009.20.4.343&DT=1 Moving, and poor positioning=ineffective CPR. Not inconclusive at all.
http://informahealthcare.com/doi/abs/10.3109/17482941.2012.735675 Moving CPR=ineffective CPR. Not inconclusive.
http://ajcc.aacnjournals.org/content/17/5/417.full Poor position=ineffective CPR. What a shocker...
http://www.biomedcentral.com/content/pdf/1757-7241-20-39.pdf Moving CPR=ineffective CPR. So shocking...
http://www.sciencedirect.com/science/article/pii/S0300957207003747 Moving CPR=ineffective CPR. I sense a trend...
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.1991.tb09554.x/epdf Single person CPR is bad. This actually was looking at ventilations, but if you actually read it there is enough in there to include it here.
There's more out there, but your mind is clearly closed.
For anyone else, some of those links will require you to actually read the study to be able to pull the pertinent info from it.
MonkeyArrow
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Glad to hear everyone is open to hearing different opinions and having an academic discussion.
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That's not the impression I'm trying to make at all. I'm very open to academic discussions, but I'm honestly struggling with what your position is here. I know you advocate transport of cardiac arrests, but I'm not seeing any of the evidence that you are that suggests it's beneficial in the slightest.
An academic discussion? That would require you to post some validation for your opinion. Because right now that's all it is; your opinion. You came up with one single piece of evidence, and a lot of contradictory statements. I can look back and see several people that have posted multiple different opinions and evidence to prove you wrong.
The ball is in your court right now.
Brandon O
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Well, people get excitable, as always. And it does sound like you're practicing in a unique environment if those intra-arrest interventions are available at your facilities. But let me make an argument that even in your case, you should at least do several minutes of CPR if a patient arrests en route.
My scenario -- let's keep this BLS as in the original example (doesn't change much if ALS IMO, but it confuses things):
1. Patient loses a pulse en route. Tech recognizes this and immediately begins compressions.
2. Driver calls for help, parks the truck somewhere safe, and comes into the patient compartment.
3. Driver finds AED, exposes patient, applies pads, runs it through the sequence until ready to analyze.
4. Tech stops compressions for the first time since pulse was lost, lifts off chest, immediately resumes compressions while AED charges (depending on device).
5. Once charged, crew coordinates defibrillation so that compressions are interrupted for less than a second while shock is applied.
6. Continue this process for at least several minutes.
In this scenario, no-flow time is almost zero, time-to-shock is as short as possible given the "surprise" circumstances, and this continues to be the pattern for the first several potential shocks. If no luck, if there's suspicion for a correctable cause, or perhaps if the first few attempts give a "no shock advised," transport could be resumed. ALS and other assistance can meet the crew at their location without difficulty and without interrupting the process.
Another scenario:
1. Patient loses pulse. Tech recognizes this and begins compressions while driver heads for hospital, bells on.
2. Tech either starts with compressions then takes a break to get the AED, or gets the AED first; either way there is no flow during the period of preparation and activation.
3. Tech must again interrupt compressions to personally apply shock. This is all while transport is ongoing, so precise back-and-forths are probably not as feasible (nor as safe), and compressions may not be as high quality.
4. Realistically, the truck will probably need to be stopped during AED analysis as well.
In this scenario, the patient probably arrives at definitive care earlier. However, the best shot for restoring a perfusing rhythm -- that is, immediately after arrest -- may be unsuccessful since it's inevitably going to be preceded and probably followed by a no-flow period. As time goes on (particularly if questionable or interrupted compressions continue), odds continue to drop, and no matter what awaits at the end of the trip it may be futile by then.
My view is that if I see a patient arrest, I have been thrown a set of delicate teacups to juggle, and I want the absolute best chance to set them back in the cupboard ASAP. That is both a logical and an evidence-based perspective. If I bobble them within those first minutes -- and running a complete code on my own in the back of an ambulance, even a BLS code, sounds like the definition of bobbling -- that may screw the pooch permanently, and it'll be my fault all the way. It's not like I can blame it on bystanders!
My scenario -- let's keep this BLS as in the original example (doesn't change much if ALS IMO, but it confuses things):
1. Patient loses a pulse en route. Tech recognizes this and immediately begins compressions.
2. Driver calls for help, parks the truck somewhere safe, and comes into the patient compartment.
3. Driver finds AED, exposes patient, applies pads, runs it through the sequence until ready to analyze.
4. Tech stops compressions for the first time since pulse was lost, lifts off chest, immediately resumes compressions while AED charges (depending on device).
5. Once charged, crew coordinates defibrillation so that compressions are interrupted for less than a second while shock is applied.
6. Continue this process for at least several minutes.
In this scenario, no-flow time is almost zero, time-to-shock is as short as possible given the "surprise" circumstances, and this continues to be the pattern for the first several potential shocks. If no luck, if there's suspicion for a correctable cause, or perhaps if the first few attempts give a "no shock advised," transport could be resumed. ALS and other assistance can meet the crew at their location without difficulty and without interrupting the process.
Another scenario:
1. Patient loses pulse. Tech recognizes this and begins compressions while driver heads for hospital, bells on.
2. Tech either starts with compressions then takes a break to get the AED, or gets the AED first; either way there is no flow during the period of preparation and activation.
3. Tech must again interrupt compressions to personally apply shock. This is all while transport is ongoing, so precise back-and-forths are probably not as feasible (nor as safe), and compressions may not be as high quality.
4. Realistically, the truck will probably need to be stopped during AED analysis as well.
In this scenario, the patient probably arrives at definitive care earlier. However, the best shot for restoring a perfusing rhythm -- that is, immediately after arrest -- may be unsuccessful since it's inevitably going to be preceded and probably followed by a no-flow period. As time goes on (particularly if questionable or interrupted compressions continue), odds continue to drop, and no matter what awaits at the end of the trip it may be futile by then.
My view is that if I see a patient arrest, I have been thrown a set of delicate teacups to juggle, and I want the absolute best chance to set them back in the cupboard ASAP. That is both a logical and an evidence-based perspective. If I bobble them within those first minutes -- and running a complete code on my own in the back of an ambulance, even a BLS code, sounds like the definition of bobbling -- that may screw the pooch permanently, and it'll be my fault all the way. It's not like I can blame it on bystanders!