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PHARM Podcast 018 – Prehospital cardiac arrest management with Paramedic Chris Watford

Tune in to hear Chris tell us about prehospital cardiac arrest!

Hi folks!

Chris is a paramedic in 3 EMS services in North Carolina!

He has a great blog. Check it out here!

He is associate editor for a EMS blog on EKG/ECG learning.

In the interview we discuss prehospital therapeutic hypothermia, CPR (BLS and ALS), prehospital RSI and airway management, pit crew concept of OHCA management and EMS providers.

Stay safe and enjoy the interview

Minh

Now on to the Podcast

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5 Comments Post a comment
  1. Hi folks
    A paramedic from my home state sent me some interesting historical perspective feedback on prehospital defibrillation and CPR. I wanted to share it with their consent.
    Quote begins now
    “Ive been in this business since the early 1980s. Im one of the old guys who had the misfortune to be around before defibrillators were introduced around 1987/88. I did my manual course in 1988, and my first defibrillation resulted in a successful save after the patient spent a week in Intensive Care in what was a very touch and go experience for her.
    Ive noticed that the latest rescusitation procedures are emphasising the importance of compressions over early defibrillation. I sometimes wonder if history is being ignored. Before defibrillators came on board, it was my experience that all our cardiac arrest patients remained in cardiac arrest even in the ED after we had transported them there. All we could do back then was CPR with minimal scene time, and transport to ED with CPR in progress, the emphasis on minimal scene time, uninterrupted CPR and early transport to a facility with ALS capabilities.
    I never seen a return of output with such rudimentary procedures. With the introduction of defibrillators, the change was very abrupt, quite an experience for me. Suddenly we were seeing people being transported to hospital with an output for the first time, and also seeing people actually survive out of hospital cardiac arrests. Prehospital defibrillation has been one of the most important steps taken in my experience and opinion. In my opinion therefore, I see it very important that there is no delay to give at least one countershock as early as possible so as to have this done as close to the time of actual arrest as possible. My concern is that when we walk in the door at a cardiac arrest scene, we can never exactly be sure when they actually went into arrest, and an indicator for me is to see coarse VF on arrival. My feeling is that this rhythm should be shocked as soon as possible. In our early days, CPR was started simultaneaously, and only stopped to confirm the rhythm and lack of pulse before giving a countershock, then cpr immediately recommenced as they rarely had an output with the rhthm change, needed some cpr till the ventricles caught up and an output was detected. Often I found that output would occur after moving the patient off the floor….I often wonder if the physical movement of the patient off the floor and onto a stretcher caused some shifting of fluids within the body and maybe primed the heart in some way.
    Our first prehospital defibrillation here in Qld was before they were introduced on road. The only facility that had defibrillaors at that time was the paramedic training facility as they roled out the courses. They had a paramedic actually arrest on top of a manniquin during his CPR assessment. He was immediately given a countershock and this resulted in a rapid reversion with spontaneous output, and he rapidly regained consciousness, and not long after had coronary bypass surgery, and then decided it was time to retire. He certainly picked the right time to have a cardiac arrest.
    In the above early experiences, they were all adult arrests due to medical causes. I didnt work in a coastal environment at that time, but later I worked for a period on the Gold Coast where we had a lot of paediatric immersions. With these I did notice that very often we would arrive on scene to find the child breathing with an output following bystander CPR. Unfortunately there is probably no way to know if the child was actually in cardiac arrest when CPR was commenced, but one can only assume that they were, and that such cases have a more favourable outcome with CPR only.
    Anyway, I thought Id just throw in some historical experiences regarding this debate. Im certain you are closer to those who are researching new ways of doing things, and I think its important that we dont forget just wht impact defibrillation had in terms of successful outcomes. I have noticed that the Qld Ambulance service recently reintroduced one countershock to a shockable rhthm upon arrival and commencement of simultaneous cpr.
    A pattern Im noticing in teh area where I now operate, is that most are in asystole on arrival, and cant really work out why this is so, possibly related to the patient being found too late. Other towns may be different, but here it could also be the distances we have to travel. Many of these are in the younger age groups, close to 50 or 60 as compared to the ones I mentioned aearlier that were probably up around 70-80 years old. I often wonder if the old ones have more collateral circulation due to prexisting cardiac pathology, and hence have a better chance at surviving an arrest with proper interventions, but a lot of this is just thoughts with no real clinical knowledge of such stuff. One example that brought this to mind is a paramedic in his 30s arrested in a swimming pool some years ago with paramedics all around him. They were on an air attendants course and were all doing swimming training in the moring at the hotel they were staying at, prior to going to classes. This guy received immediate excelent CPR from his colleagues,and was defibrillated within 10 minutes of teh arrest, but did not survive or have a return of spontaneous circulation from memory. Its then that I often wondered about whethter the older patients had more collateral vessels than the younger patient. Anyway, just a thought.”
    Quote ends

    June 9, 2012
    • They bring up an interesting point about “compressions first” or “analyze first” and interestingly enough the literature to date seems to find either approach is fine in systems with high quality CPR.

      What they bring up, albeit indirectly, is a big caveat for most of our current cardiac arrest literature is potentially there is a subgroup of patients who benefit from doing it another way. We just don’t have the numbers or the data to know until we spend more time studying cardiac arrest.

      This is where the CARES registry or groups like the ROC come into play. As services move to 100% data acquisition of each arrest, we’ll be able to control for more independent variables and actually perform useful subgroup analysis to say who benefits the most from each treatment.

      Great to hear the historical perspective on cardiac arrest care!

      June 9, 2012
  2. I should add that I misspoke (an astute listener gave me a poke) when I said New Hanover EMS borrowed from the Wake County model of cardiac arrest care. NH based their pit crew/hypothermia model after Seattle Medic One, Dr. Tober’s Collier County system, and Dr. Ornato’s Richmond Ambulance Authority.

    You know, it’s a good sign when there are enough high performing systems to confuse who you’re modeled after :)

    June 23, 2012
  3. Javier Benítez #

    Hi,

    Really enjoyed this podcast. Chris is a great guy and is adding so much education online. I think he brings an important point which most often gets put on the back burner in medicine. I’m referring to group dynamics, I love the fact you guys got to talk about the “Pit Crew” model. I find it ironic that medicine is borrowing from other industries, when it should probably be the other way around. Atul Gawande has addressed this with his book “The Checklist Manifesto”. We can learn lots on what this or that drug does, when to do this or that procedure, but if we don’t prepare appropriately and do not know how to lead a team or be a functional member of a team all that we know would not make a difference due to poor execution.

    Minh, I know you are aware of how important this aspect is because you have addressed it with previous guests in your podcast and on previous lectures. I just wanted to accentuate the importance of group dynamics and that it should be something we talk about more often.

    Thanks,

    Javier

    July 22, 2012

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