Just goes to show that there is a great deal to be discussed in paramedicine, and a good number of professionals scattered around the globe that are willing to participate in serious, constructive discussions.
For those who couldn’t make it, and for those wanting to review what was discussed, below a summary of topics, thoughts and trends with the occasional new nugget of information thrown in by Yours Truly:
First off, most discussion participants were located in the UK & Ireland, although we did have a few from North America too. We are aware of time zones and the difficult barriers they can be, we’re looking in to options of being more inclusive of antepodeans and other wonderful international folk.
General consensus was that the uptake and implementation of the newest resuscitation council guidelines amongst the paramedic services within the UK was quick, although it was noted that some staff were initially skeptical at the de-emphasis of advanced airway management. Once the backgrounds and reasons had been explained and the procedures had been in place for a while, these critical voices died down and the new guidelines were accepted well.
But do the guidelines work? Generally people felt that following the new guidelines resulted in a higher rate of ROSC (Return Of Spontaneous Circulation). Which could be an indicator of higher survival rates, but the real goal is survival with good neurological outcome, not just ROSC.
Everyone knows that “Practice makes perfect”, but with whom and how many of them do we practice with? The so called “pit-crew approach” was mentioned, where – similar to a pit stop in car racing – everyone on scene has a single and specialised role. Everyone knowing what to do and working as a team towards a common goal – survival of the patient – sounds like a good idea, although there has been no hard evidence as such supporting this approach.
An number wise? How many paramedic staff should be on scene during an active resuscitation? What is the balance between must-have and nice-to-have? The TOPCAT2 study suggests that a two people is not enough for a cardiac arrest, and that survival rates improve dramatically with 3 or more rescuers on scene. Dublin (Ireland) Fire Brigade sends a pump to back up an ambulance crew on a cardiac arrest call, similar to many US systems. But the actual sweet spot, the balance between enough brawn for chest compressions, enough medical staff for medical procedures, not too many people on scene to crowd the incident and also cost effectiveness – that is an answer that currently must be decided by each service individually.
On the topic of staff numbers, the TOPCAT2 study also showed that strong leadership during a cardiac arrest leads to improved outcomes. One designated paramedic would take a step back, and coordinate the resuscitation; making sure adequate compressions were being done, the drug regime was on time, airway was under control and so on. This supports the conclusion of an earlier paper by Simon Cooper, “Lighthouse Leadership“.
And if we can’t get more human helpers, how about technological aids that are available on the market? Not many paramedics have had experience with mechanical compression devices, but they were generally seen as a step in the right direction, with more scientific evidence on this topic expected within the next few months and years. Some comments so far was that the Physio Control LUCAS was easier to apply, whilst the Zoll AutoPulse has been known to cause friction burns to patients. This will be an interesting development to keep an eye on in my opinion.
Compression feedback devices were another tool mentioned. A good idea, needing some thought prior to implementation. Paramedics need to be open to being criticised by a machine, and special care must be taken with the audio feedback enabled (PUSH HARDER! PUSH DEEPER! PUSH FASTER!). Not something relatives ought to hear…
A few other topics were touched on: Ventricular Assist Devices were practically unheard of, ECMO is extremely rarely used for cardiac arrest patients, and continuous compressions during defibrillation is not a topic at any of the discussion participants services. All things I wouldn’t at all be surprised to see a fair bit of research coming our way in the near future.
At the end we all agreed that it boils down to results. Response, Organisation, Timing and Technology is useless if they do not contribute to a greater survival rate. And by that, I mean a person surviving with no or minimal neurological deficits. Severely brain damaged people are not our aim. Happy, healthy people are.
Outcomes…they are not published often. And if they are, comparing them is difficult as most services use different measuring tools. One registry mentioned was CARES in the USA; a start, but we need an internationally recognised registry, otherwise we may as well be comparing apples with oranges.
We ran out of time pretty quickly,the highly controversial topic of paramedic intubation was hardly touched upon (we could have probably gone for another three hours…), as well as therapeutic hypothermia, or terminating resuscitation on scene. Even after 75 minutes of discussion people just would not stop bringin up new ideas, topics and comments – love to see such an enthusiastic bunch!
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If you want to relive the experience, the #ParamedicABC twitter hashtag transcript of the discussion can be downloaded here.
The next discussion will be on Sunday the 3rd of March, 1900hrs GMT (London). Topic: Education.
In the meantime, please stay in touch via twitter, facebook & the web, and be good to each other!