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where is the evidence that in hospital asystole or PEA do better than prehospital arrests? in my current trust outcomes for PEA and asystole are less than 3% to return of spontaneous circulation (which is a useless outcome measure anyway). this is because the arrest is the result of a slow deterioration in the physiological state and often irredeemable. the disease process in the community will be different as the event will often be acute (trauma, PE etc.) and this theoretically should be treatable. I will no doubt be unpopular for the following comment but I have nearly 2 years anaesthetic and critical care experience and still find muscle relaxants scary things in the acute setting and the idea of their use in the prehospital setting by people with less experience than me who will have the need to use them a lot less than me, and therefore clinical governance issues with skill retention will come into play even more scary. To compare the states with their trauma load to the UK with our case mix is not really a fair comparison at this time. I guess these comments will (in some cases) simply reinforce the notion that the medical community is too conservative but I feel these views should be debated or no progress will be made. Lewis -----Original Message----- From: Accident and Emergency Academic List [mailto:[log in to unmask]]On Behalf Of [log in to unmask] Sent: 04 December 2004 16:15 To: [log in to unmask] Subject: Re: Defining who will not survive out of hospital cardiac arrest In message <009d01c4da04$dac674e0$9d74353e@Souix> Michael Bjarkoy <[log in to unmask]> writes: > 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. > I disagree (now there's something unusual!!). Success rates increase with increased bystander CPR and increased access to early defibrillation - neither related to paramedic education. And not sure that an in-hosp education programme is the way to go ... ? And think that "ALS-only" calls is not the way to go either - what exactly is an ALS-only call? Some of the "minor" calls need far more experience to be left at home safely. No evidence that a second ALS staff member on a unit improves outcomes. ;) Cheers Anton -- This email has been electronically scanned using DynaComm i:mail filtering software. If you have any questions please email [log in to unmask] Tony Daniel Sam Shayer Information Security Team