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.
>
>
>
--- This message has been thoroughly scanned by and is certified virus free by MacAce.net. --- avgxmacgbh
|