The drugs don’t work…….. but early BLS and electricity can!

Interesting day on Thursday. Attended the Edinburgh Cardiac Arrest Symposium. Well strictly speaking I didn’t actually “attend” it. Instead I logged on to a live webcast from the venue and watched the presentations from the comfort of my own home.

Advantages? Well it saved me getting up at 0430 for the early train to Edinburgh and at the end of the meeting could just take the dog for a walk in the woods instead of having a 3 hour train journey home to look forward to. OK missed going to the pub too. Disadvantages? Well couldn’t actually network in person. However that was probably more than offset by the animated discussion on Twitter with members of the audience and those following the webcast from the UK, Ireland, Canada, USA and Australia which was still carrying on 6 hours + after the meeting ended.

So what did we learn? Well perhaps most importantly Edinburgh’s 3RU prehospital cardiac arrest team have significantly improved outcomes following OOHCA in Edinburgh which, if it could be repeated across Scotland, would result in 300 lives saved per year. That’s a pretty good return. Estimates for my own area (Grampian) are in the region of 100 lives saved per year. And as someone who works with cardiologists and cardiac surgeons on a day to day basis I know from first hand experience the elation, relief and joy which follows the successful resuscitation and treatment of a OOHCA patient, and the sheer despair, grief and devastation which can follow an unsuccessful resuscitation. As Colin Robertson said in the final session at #EdOHCA sudden death from cardiac arrest deprives families of so much. But large swathes of Scotland come under the “remote and rural” banner which may make an urban model such as the Edinburgh one difficult to replicate country wide but we have to look into ways of trying to make that happen.

We learnt how “truth” changes as more medical evidence collects and how the rate of truth change is increasing. How absolute truths held at one time have now changed. Apparently there used to be evidence that blowing smoke up the rectum could be used to revive the apparently dead. Imagine trying that now. In the same way absolute truths such as the use of hypothermia post-OOHCA are now being revised – the recent TTM paper has shown no difference in outcomes at 33 or 36 degrees. But even then that doesn’t mean don’t cool patients – both groups were cooled with carefully controlled temperatures, Alternatively consider 33C and 36C as “just as good” but so if having problems at 33C can go higher. Delay prognostication for at least 72 hours then use multiple tools – CT, EEG, repeat neuro examination.

How about other interventions? Recently published studies haven’t shown improvements in outcome in those who received mechanical (Lucas or Autopulse) compressions compared to manual compression. But then again it hasn’t shown a decrease in survival and doesn’t cause harm. However it seems to make perfect sense, doesn’t it. Guaranteed chest compressions from a compressor who will never tire and who can continue to provide excellent quality CPR as the casualty is carried downstairs or transferred to hospital surely has to be a good thing (the 3RU demo certainly made it look so). The ability to take the victim to the Cath Lab with excellent ongoing CPR which is only stopped at the moment of PCI balloon dilation or stent deployment must maximize chances of survival……surely? Simon Redwood, Interventional Cardiology Prof from London didn’t mince his words – all OOHCA patients deserve a cath and mechanical CPR devices should be available on every RRV.

So what really makes a difference. Convention will tell you that the “chain of survival” consists of early recognition of cardiac arrest, early institution of BLS, early defibrillation and good post-ROSC care. A lot of other stuff ends up thrown in there – Adrenaline, airway management, intubation or the use of SGA’s. But forget about the Adrenaline – as the Verve most famously sung “The Drugs Don’t Work”, and the OPALS study suggested that advanced airways do NOT save lives in OHCA. Bag Valve Mask (initially) doubles good outcomes. ALS tends to overemphasise their importance. The factors that really make the differences are:

[1] EMS dispatchers (who have to recognize that a cardiac arrest has occurred, dispatch the correct EMS resource and in many cases instruct untrained bystanders on how to do CPR over the phone (check out this link – http://www.sandpipertrust.org/gillians-story/ – great example of Scottish Ambulance Service dispatcher instructing bystanders)

[2] Good quality uninterrupted BLS

[3] Electricity

But good quality uninterrupted CPR is difficult to achieve with only 2 Responders and systems such as 3RU which can deliver a third trained responder to the scene can improve outcome. Add in extensive training, understanding of non-technical skills, recording of and feedback of performance………and boundless and unending enthusiasm…… and things can begin to change. We learnt about the new ABC mantra of treating cardiac arrests – Audit, Basics, Clever stuff. High risk industries succeed as they are preoccupied with failure, recognise human factors and the importance of non-technical skills so be redisigning health care systems you allow people to get it right with massive impacts on quality of care delivered.

The 3RU demo was awesome. Within 2.5 minutes of 3RU’s arrival the airway was secured, mechanical CPR was in situ, shocks given, IV access established, ETCO2 monitored; and the 4H’s and 4T’s considered.

So how do we get this out to the rest of Scotland, particularly to the more remote areas? Plans are already afoot to try to replicate this model in parts of Grampian supported by BASICS Scotland (http://www.basics-scotland.org.uk/) and the Sandpiper Trust (http://www.sandpipertrust.org/).

Watch this space #EdOHCA #ruralhealth #savinglives #sandpipertrust #BASICSscotland

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A Saturday afternoon in November was approaching

“1st Announcer (Eric Idle) : And now it’s time for ‘Novel Writing’ which today comes from the west country from Dorset.

2nd Announcer (Michael Palin): (we hear the sound of a crowd in the background) Hello and welcome to Dorchester where a very good crowd has turned out to watch local boy Thomas Hardy write his new novel ‘The Return of the Native’ on this very pleasant July morning. This will be his eleventh novel and the fifth of the very popular Wessex novels. And here he comes! Here comes Hardy walking out toward his desk, he looks confident, he looks relaxed very much the man in form as he acknowledges this very good natured Bank Holiday crowd. And the crowd goes quiet now as Hardy settles himself down at the desk, body straight shoulders relaxed, pen held lightly but firmly in the right hand, he dips the pen in the ink (the announcer becomes excitied) and he’s off, its the first word, but it is not a word… oh no it’s a doodle way up on top of the left hand margin. It is a piece of meaningless scribble, and he’s signed his name underneath it. Oh dear what a disappointing start, but he is off again and here he goes the first word of Thomas Hardy’s new novel, at 10:35 on this very lovely morning, it’s three letters it’s the definate article and it’s THE, Dennis

Dennis (Graham Chapman) : Well this is true to form, no surprises there. He started five of his eleven novels to date with a definite article. We’ve had two of them with ‘IT’, there has been one ‘BUT’, two ‘AT’s, one ‘ON’ and a Delores. Oh that of course was never published.

2nd Announcer : I am sorry to interrupt you there Dennis, but he’s crossed it out. Thomas Hardy here on the first day of his new novel has crossed out the only word he has written so far and he is gazing off into space. Ohh! Oh dear he’s signed his name again.

Dennis: It looks like Tess of the D’Urbervilles all over again.

2nd Announcer : But he’s… No.. he’s down again and writing Dennis, he’s written THE again, he’s crossed it out again and he has written A and there is a second word coming up straight away, it is SAT, a sat, doesn’t make sense a sat, a Saturday, it is a SATURDAY and the crowd are loving it. They’re really enjoying this novel and it’s AFTERNOON, a Saturday afternoon, is a confident beggining and he is straight on to the next word and it is IN, a Saturday afternoon, IN, in, in, no, NOVEMBER, November’s spelt wrong, he has left out the second E, but he’s not going back it looks as though he is going for the sentence and it is the first verb coming up, the first verb of the novel and it is WAS,…. the crowd are going wild. A Saturday afternoon in November was, a long word here , appro, is it approval, ah no it’s APPROACHING, a Saturday afternoon in November was approaching and he has done the definate article THE again and he is writing fluently, easily with flowing strokes of the pen as he comes up to the middle of this first sentence and with this eleventh novel well underway and the prospect of a good days writing ahead, back to the studio.”

Well seems as good a start as any. Welcome to my blog which I hope is going to contain some personal reflection and opinion, a lot of #FOAMed and some links to some of the best critical care, echo and prehospital medicine blogs out there. Off to #EdOHCA symposium now but feel free to follow the chat on Twitter via @gasdoc2857