Hi Simon

Much of your post I agree with and a few weeks back tried very poorly to
champion the cause for better ALS education, skills and drugs. I was shot
down in flames so wont go down that line again.

I would argue that unless we go back to the days of dumping patient onto
stretchers and providing minimal prehospital treatment - the times from
collapse to A&E arrival is often in excess of 30 minutes. The outlook for
non perfusing patients in these circumstances is grim.

I realise A&E appreciate the difficulties in the field and that is why I
intimated that they continue resus sometimes for our benefit as well as
normal resus policy.

This compassion toward ambulance crews is appreciated a lot. But there is a
feeling sometimes of 'oh, why did they bother bringing in this asystolic
patient- what a waste of time' and I have heard often within a couple of
minutes of arrival - 'OK 30 minutes down, I think that is long enough lets
call it'.

It is for this reason I believe it is better to get a pulse back on these
patients before the load and go. 3 loops is an OK guidance, but I wouldn't
want it to be set in stone. It is in some services! If a policy such as 3
loops - load and go is written into local ambulance policy, fingers wag and
managers get very intimidatory when you don't go by the recommendations.

I prefer to treat a treatable rhythm on scene unless I believe the A&E dept
can offer better care. Sometimes I run, sometimes I stay and play and
sometimes I call it on scene.

Those who do best are usually those who get a ROSC - I am yet to be
convinced otherwise.

Mike


----- Original Message -----
From: "Simon Horne" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Sunday, January 16, 2005 9:42 PM
Subject: Re: Limiting Shocks


> Not sure I necessarily agree with the desire to achieve ROSC first. While
> good ALS en route must be very difficult (and believe me we in A&E do
> appreciate this), we have access to more diagnostic and treatment options
> than you do.  The half hearted attempt is more often limited by the
> reality
> of an unsurvivable blood gas pH/lactate/base excess combined with the
> knowledge that if an underperfused heart is going to come back, it does so
> early rather than 35 minutes on.
>
> The opposite side of this coin is that when (as we had last week) the
> arrest
> is secondary to a potassium of 7.8, this needs to be picked up on in order
> to be successfully treated.  Your (and my) guidelines do not include as
> standard the use of calcium gluconate or insulin for every arrested heart
> but do involve the correction of metabolic problems IF DETECTED.  While
> these are few and far between, you will not achieve ROSC on scene in these
> or similar patients and indeed by delaying transfer you may prevent us
> achieving it too.  Arguably any return we get is likely to be brief in the
> majority, but that's another issue.
>
> I think the three cycles on scene guide is as good a compromise as is
> likely.  If recently in VF, or with a rapidly corrected hypoxia, you will
> get results on scene.  If you don't get them soon though, then it may be
> possible to achieve more if you just cut and run.
>
> Si Horne
>
>
> -----Original Message-----
> From: Accident and Emergency Academic List
> [mailto:[log in to unmask]]On Behalf Of Michael Bjarkoy
> Sent: 16 January 2005 17:15
> To: [log in to unmask]
> Subject: Re: Limiting Shocks
>
>
> Hi Dave
> No limitation on this in Devon, Somerset and Cornwall as yet. However this
> is a dynamic profession we work in so next week it may all change!
>
> I would imagine the limitation is the paramedics perception of what can be
> achieved with the drugs s/he has.
>
> If you only have 6 Epi's and your running time to hospital is 9 minutes
> (for
> arguments sake) then you will probably perform 9 or so minutes on scene
> (3xEpis) resus, transfer to ambulance and then the perform another 9
> minutes
> resus en route to A&E (the other 3 Epi's).
>
> This may be the 'logic' which may limit on scene times - I do not
> necessarily hold this view. I would prefer to get the patient back into
> ROSC
> first and then transfer.
>
> I really dislike working hard on a patient and transferring to A&E before
> ROSC to be greeted with '... and how long has this patient been down?' -
> the
> A&E team make a half hearted (excuse the pun) attempt at further resus
> just
> to make the paramedics (who is collapsed in the corner sweating profusely)
> feel better for all his/her hard work.
>
> No, I prefer to get the patient back on scene, so the A&E team have a
> viable
> patient to work on.
>
> happy New Year Dave
>
> Mike
>
> ----- Original Message -----
> From: "dave.j.fletcher" <[log in to unmask]>
> To: <[log in to unmask]>
> Sent: Sunday, January 16, 2005 9:15 AM
> Subject: Limiting Shocks
>
>
>> Are the list aware of any local ambulance service limitations to the
>> number
>> defibrillator shocks that crews can make before they must 'run' to
>> hospital?
>> Regards
>> Dave Fletcher
>>
>>
>>
>
>
>
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