Dallas is the place to gather today and tomorrow if you are like me and actually enjoy the most current thinking on pre-hospital medical practice coming at you like a fire hose from the very â€œeaglesâ€ of our business. Unfortunately, I am not there. Instead, I was standing a thousand miles away this morning in a dim light hallway peering into a bedroom where a large chested man had been pulled from his bed onto the floor and was surrounded by a team of EMS professionals efficiently working to bring him back to life. The call was a mutual-aid assistance request from a neighboring district and I was one of a handful of â€œtrained providersâ€ simply waiting my turn to begin compressions. We havenâ€™t justified the money in my county for mechanical CPR devices.
At the Gathering of Eagles conference in Dallas, the first lightning round of topics for this morning was scheduled as â€œResuscitating Resuscitation: New Technologies and Approaches for Achieving ROSCâ€. I wished desperately that I could have been walking down a hallway in that Texas hotel instead of standing in that local house between a husband and his wife.
Still, no matter where I am, I try to take in all the information I can and learn something from it. Here, I was limited to watching each fresh new rescuer dutifully assume the position for compressing our patientâ€™s chest. Why is the room always so small? The bed is always so close and the personal effects of a lifetime are always stacked neatly in the way. Worst of all, the patient never seems to resemble the size of the mannequins we use in practice. But what struck me most vividly this morning was watching the inconsistencies between each of these well-meaning rescuers. I even started a checklist in my mind of the failures I saw. It was that attitude that led to the mostÂ important failure, it was the fact that I could almost viscerally feel a lack of hope in that room.
Also lacking in the setting was anything to keep cadence for the compressions or the rescue breaths. The eagles were about to tell me that without a metronome, providers typically compress too fast. I saw exactly what they discovered, that rescuers could routinely hit a rate as high as 140 compressions per minute even though we know we need to stay in the range of 115 to 120. The idea that â€œmore is not betterâ€ is quite clear here and we need to build better muscle memory. I knew we were being good about limiting the pauses, but I would soon be reminded that our enemy is not that “we suckâ€, but that we are satisfied that we are doing â€œgood enough.â€ I learned from the Resuscitation Academy at EMS Today last year of the importance of going into every OHCA with the attitude that â€œeveryone survives.â€ However, my faith somehow still gets robbed.
In just a few hours, I would be reading notes from attendees in Dallas promoting the virtue of consistency in providing â€œworld-class manual CPR.â€ But at that moment, I didnâ€™t feel surrounded by â€œeagles.â€ The Eagles would tell us about places like Oklahoma City and Tulsa that use the â€œpit crewâ€ approach so everyone knows what they are doing. Weâ€™ve got that in place here when it comes to pushing drugs and managing airways, but the prevailing opinion here is still that compressions are just a brute force task to manually maintain circulation through the heart. I would also hear that Memphis, where each ambulance is equipped with a LUCAS device, is getting ROSC in 30% of arrests compared to 21% of arrests employingÂ manual CPR. Probably the same type of CPR that we were performing today.
What we needed to hear was more than just advice to minimize compression pauses, to slow them down, maintain compressions even while the AED is charging, and always remember the fundamentals! We needed the advice that helps us recognize thatÂ PEA is a health hazard when it is distracting us from focusing on compressions by spending too much time looking for that elusive pulse. I needed to know that only 15% of pulse checks are accurate when done within the AHA guideline of 10 seconds or that if you don’t have VF, even the AED can be a health hazard due to prolonged compression pauses for rhythm analysis.
We all need to be convinced that with the advent of LUCAS/ITD and easily applied ECMO/LVAD, we may not need to care as much about the condition of the heart as we should be concerned over the resuscitation of the brain. The Eagles are further suggesting that traditional â€œsupine CPRâ€ should soon become a thing of the past in favor of a 30-degree “heads-up” Gravity-Assisted CPR that promises to improve patient outcomes. As they explained today, standard CPR increases ICP and facilitates only low cerebral perfusion pressure. A trend which is reversed by elevating the patientâ€™s head up 30 degrees. We can also hope that someday we can be using ultrasound in the prehospital setting to determine optimal position of chest compressions. And itâ€™s not just compressions that need our attention, but to understand that positive pressure assisted ventilation actually decrease the coronary perfusion pressure.
What I learned today in both of the settings where I found myself is that there is no “silver bullet.” There is still much to learn and understand and it is only hard work and an interest to do better that will ultimately ensure aÂ future where everyone will have a better chance at survival!