Hi Dave
I appreciate the asystole phenomenon for cardiac related problems are due to
poor response times. I intimated at this as "AMI arrested patients are
usually in VF in the first instance" but probably didn't reinforce that
patient degrade into asystole rapidly as I thought this was taken for
granted - I should never assume should I. Apologies for not making this
point clearer and glad that you picked up on it.
Different areas have different response times. Where I am based at present
(Falmouth, Cornwall) we are hitting our Cat As on average 92% of the time in
8 minutes and are indeed finding VF arrests and not PEA/Asystole. For areas
where the response time is over 8 minutes on a consistent basis I accept
that 'cardiac' asystole arrest is the rhythm that would be seen in the
majority of cases.
The focus of my posting was to identify the shortfall in education for
paramedics in areas which we may have a degree of success - arrests for
non-cardiac causes. To achieve this we need the tools and authority to do
the job and need to be specialists not generalists.
As a side issue, Dr.Michael Copass has stood down from the role as Med.Dir
for Medic One the county Medical director is now Mickey Eisenberg and KCM1's
medical director is Tom Rea. So there may be changes afoot in Seattle.
regards
Mike
----- Original Message -----
From: "dave.j.fletcher" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Saturday, December 04, 2004 6:38 PM
Subject: Re: Defining who will not survive out of hospital cardiac arrest
> Mike
> I think you will find that the majority of asystole we see in the
> community
> is the result of poor response times.
> An 8 minute call to arrival time is more specifically a call to monitoring
> time of 12 minutes. It's hardly surprising we see so little coarse VF on
> arrival!
> Regards
> Dave Fletcher
>
> --- Original Message -----
> From: "Michael Bjarkoy" <[log in to unmask]>
> To: <[log in to unmask]>
> Sent: Saturday, December 04, 2004 1:26 PM
> Subject: Re: Defining who will not survive out of hospital cardiac arrest
>
>
>> Hi Rowley
>> I have been thinking about this for a while and here are a few
>> observations.
>>
>> AMI arrested patients are usually in VF in the first instance. Non
>> shockable
>> arrests are often (but not always) due to other mechanical causes such as
>> trauma, OD, hypovolaemia (basically the 4 Hs and 4Ts).
>>
>> If we accept that in a hospital setting the patient has a better
>> prognosis
>> for the non-shockable side of the arrest flowchart than in a prehospital
>> setting we should not just accept that it is a fact of life (or death)
>> but
>> challenge the flaws in the system which allows this to be.
>>
>> Since the ambulance dispute in the late 1980s we have had to accept the
>> notion that there must be one paramedic on each ambulance. The result is
>> mediocrity in education and application of care. If look toward a system
>> (Medic One, Seattle) where success for non-shockable arrests are better
>> we
>> could learn some of valuable points.
>> 1. Educate paramedics along side physicians in hospital by experienced
>> physicians
>> 2. Reduce paramedics to less than 20% of the workforce
>> 3. Have 2 paramedics on a Medic Unit
>> 4. Release paramedics from protocols and guidelines and allow autonomous
>> practice
>> 5. Reduce the type of incidents that paramedics go to ALS only
>> 6. Give them the range of drug and invasive skill interventions that
>> reflect
>> an A&E dept
>> 7. Offer a comprehensive in hospital continuing education
>>
>> If the above is implemented then the success rates from out of hospital
>> arrests for non-VF/VT patients will increase.
>>
>> Now that is said, I do realise that it will never happen in the UK as
>> there
>> are too many political and medical reasons which would challenge this
>> concept.
>>
>> On my return from one of my exchanges to Seattle I was asked by a medical
>> director of an ambulance service what, if anything, I would like to see
>> implemented into the local ambulance service. I replied - paralytics for
>> airway management. The blood drained from the medical directors face as
>> he
>> stammered out the statement "I don't think we are currently politically
>> or
>> clinically ready for that sort of thing". To which I replied "Yes....
>> Seattle have only been doing this for 30years. I suppose its a bit too
>> soon
>> for us".
>> And there in lay the problem. The medical community are too conservative
>> here in the UK (and Europe) for such concepts and until it does change we
>> will never witness positive outcomes for such patients.
>>
>> Mike Bjarkoy
>>
>>
>> ----- Original Message -----
>> From: "Rowley Cottingham" <[log in to unmask]>
>> To: <[log in to unmask]>
>> Sent: Monday, November 22, 2004 9:06 PM
>> Subject: Defining who will not survive out of hospital cardiac arrest
>>
>>
>>> Ambulance paramedics in Sweden prospectively surveyed 38 750 out of
>>> hospital
>>> cardiac arrests from 1990 to 2001. In 16 712 patients who were in
>>> non-shockable
>>> rhythm (that is, not ventricular fibrillation) and in whom
>>> cardiopulmonary
>>> resuscitation was attempted before the paramedics' arrival, overall
>>> survival to one
>>> month was 1% compared with 8% in patients in a shockable rhythm. None of
>>> the
>>> non-shockable group survived if the arrest was at home and not
>>> witnessed, if there
>>> was no bystander cardiopulmonary resuscitation, and if it took more than
>>> 12 minutes
>>> for the ambulance to arrive. No patient over 80 survived when the delay
>>> was more
>>> than eight minutes. The authors say their findings provide evidence on
>>> which to
>>> base non-resuscitation protocols, and they note the possible adverse
>>> psychological
>>> impact on families of any such lack of action.
>>>
>>> Heart 2004;90: 1114-8
>>>
>>> Why was this not done here? And now it HAS been done will we implement
>>> it?
>>>
>>> Rowley.
>>>
>>>
>>>
>>
>>
>>
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>>
>
>
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