Thursday, December 8, 2011

BLS for Cardiac Arrest, Part I

Rogue Medic has been setting MY world on fire for the past couple of years, but his most recent series of posts regarding management of cardiac arrest being a BLS skill has gotten a tremendous reaction. Go read the original post here and then follow it up with the evidence here. Rogue is one of those bloggers whose word is more or less unimpeachable. He never posts anything he isn't prepared to defend, and he has the evidence to back up his contentions. I aspire to someday have as much of a handle on my profession as him.

Likewise, Kelly Grayson has blogged on more than one occasion about EMS' insistence on being dragged into modern medicine, kicking and screaming. Here in Chicago, it's not uncommon to see signs declaring "The Chicago Fire Department: 150 years of tradition unimpeded by progress," and that's an apt description of the current state of EMS in many areas. Change "150" to "40" and you're not far off. In particular, AD's entreaties of our profession to think of ourselves as more than a patch and a skill set are what have led me to the conclusion that paramedicine will never truly evolve as a profession until we are willing to focus less on what we DO and being to embrace and focus on what we KNOW.

Research has proven time and again that the only interventions that have been shown to increase survival to neurologically intact discharge are early CPR and early defibrillation. As Rogue notes, ACLS even acknowledges that the majority of its guidelines have not been proven effective in improving the rate of survival to neurologically intact discharge, yet they continue to include aggressive drug therapy, advanced airway management, and the use of selective cardio-toxins such as Lidocaine and Amiodarone in their guidelines for treatment of cardiac arrest. There is no evidence supporting these treatments, and the AHA even tells you that up front, yet we continue to do these things to patients. At some point, we as a profession need to stand up and embrace evidence-based medicine. Continuing to administer "treatments" to patients that have not been proven to be of benefit is not "treatment" at all, nor medicine, as Rogue points out.

As far as cardiac arrest is concerned, our protocols will tell us to do many different things, sometimes entirely different courses of "treatment," depending on what we see on the monitor, but only high-quality CPR and early defibrillation have actually been proven effective in increasing the only statistic that matters, which is survival to neurologically intact discharge. In fact, the high doses of epinepherine we administer may in fact be doing more damage, particularly in the case of cardiac arrest due to AMI, which is probably the most common cause of cardiac arrest. The use of those selective cardiotoxins can cause stable dysrhythmiass to deteriorate into unstable dysrhythmias. As Rogue quite rightly pointed out, we can't just go along with what our protocols tell us to do, and we can't even stop short at integrating local protocol with AHA guidelines with what we know will work. We as a profession cannot possibly expect to be taken seriously if we don't begin to advocate for what is best for the PATIENT based on solid, verifiable evidence.

In my response to Rogue's post, I commented on the need for Paramedics, as a professional group, to begin to integrate our protocols (which oftentimes dictate what we MUST do) with what the research and the evidence have shown we SHOULD do. My position was that everybody has their protocols, we all have to follow them, and that supersedes everything else, including our mothers, but that we should find ways to integrate what our protocols tell us we MUST do with what the research tells us we SHOULD do. That's no longer my position. 

My position is now that we, as a profession, need to begin advocating for protocols that are in line with research, rather than in line with ACLS guidelines, or in line with tradition, or that are in line with theory. We need more evidence-based medicine in paramedicine. In responding to Rogue's post, I unknowingly painted myself into a corner, equivocating on the evidence while continuing to hide behind my protocols as a reason to abuse patients. I need to begin bringing this evidence to the attention of my medical director, and trying to convince him that we shouldn't doing things that haven't been proven to work.

Much of EMS over the years was based on logic and assumption rather than evidence. When my dad became a paramedic, first-line interventions for cardiac arrest included pushing two amps of bicarb and three stacked defibrillations prior to beginning CPR. This is laughable now, but what we are currently doing may be laughable in the future. Let's get off this train and begin thinking about things rather than blindly following our SMOs as though we are monkeys trained to push a button when a light flashes.

We need to use the evidence to convince our medical directors to allow us to stop abusing patients with "treatments" that don't work and "medicine" that may be more harmful than nothing at all. 

To be continued, as Rogue says... and many thanks to him for inspiring this kind of thought. 

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