Saturday, August 8, 2009
What, you ask, does SETTRAC stand for? SouthEast Texas Trauma Regional Advisory Council....that's a mouth full and that's where I spend all day Thursday learning and relearning current medical knowledge and interventions.
I thought I might share a few of the more interesting high points from that day of mentally thrilling lectures. Some of this information was already known to me from my own experience and some I learned at the conference. It's interesting to hear physicians and other medical experts discuss aspects of our profession that I have long suspected or believed to be true. I guess that means I'm on the right track!
1. During a cardiac arrest if the victim does not receive CPR or defibrillation (shock) prior to 5 minutes then their prognosis (success) of resusitation is very poor. By resusitation I mean they live to walk out of the hospital. And yet most of the public refuses to perform CPR, even on their own families! We don't usually arrive before 5 minutes because we're still subject to the laws of physics. The lights don't create wormholes or time dilations either. Crazy huh?
2. If a cardiac arrest patient receives CPR for over 4 minutes without spontaneous return of heartbeat and/or breathing then their prognosis is also very poor. Ever watch the Princess Bride? Remember the scene when they're trying to save the man in black? The wizard tells them that there are stages of death: Slightly dead is still mostly alive and mostly dead is still slightly alive. If a patient recieves CPR and further medical treatment in that Mostly alive stage than things can go well, but that Mostly dead stage tends to stay dead. Early and immediate intervation by everyone is known as the chain of survival, without that first link of CPR there's no chain.
3. Patients that are dead tend to remain dead. There is no coming back from dead beceause brain death begins to occur within 4-6 mins after breathing and heart rate has ceased. Even if the heart is started after that time the brain is non functional. (except in specific cases such as electrocution, drownings and cold environment situations)
4. The American Heart Association (the premier experts on heart health and research, google it!) determined in 1992 that cardiac arrests that showed no improvement during EMS resusciation on scene should be pronounced dead at the scene and NOT transported to the hospital. If a patient does not response in a very short amount of time then they won't respond. Their research has determined that once a cardiac patient becomes asystolic (flatline) their chance for successful resuscitation is less! than 1%. Dead is dead. The rest is window dressing for the family and high risk for the EMS crew and innocent traffic. God forbid that people learn how to accept death as a natural and sometimes more dignified state of being.
5. Someone that has been killed because of trauma such as a motor vehicle accident has a .08% of successful resusitation. Assuming that their injuries are compatiable with life; meaning that they still have their head and all their major organs in the anatomically correct locations. Every traumatic arrest (death due to massive injury) that I've worked has never survived. If it's enough to kill you out right then you're staying dead.
6. Tourniquets are really good for stopping massive bleeding. (the medical profession randomly decided years ago that tourniquets are bad). I've seen how our current methods for treating massive bleeding, which don't include tourniquets, don't work well if at all.
7. Unless the patient has a injury that is time sensitive, such as heart attack, then whether they arrive at the hospital in 10 mins or 30 mins won't change their outcome. And most patients don't have time sensitive injuries therefore EMS rarely needs to race with lights and sirens to the ER. Generally speaking racing to the hospital to save 2 minutes of transport time only increases the risk for accidents and doesn't change the patient's outcome what so ever; except in those very small percentage of time critical injuries. And yet everyone assumes that ambulances always drive emergency and get offended when we don't do that for their family member. We do that in less than 5% of our calls and we run over 25,000 a year right now
8. Unintentional injury is the number 1 cause of death for those 65 and younger. I've long believed that about 90% of the things that happen to people are due to their own poor planning, decision making or lack of forethought-that fits the unintentional injury stats. Next time you're doing something that includes an element of risk; stop and think about every step of your plan. Assuming you have a plan. Ask yourself- Is this really a smart way to do this? Do I really need to do this now? Had a guy fall 30 feet out of a tree years ago and shatter his neck causing full paralysis. He was trimming the tree AFTER DARK because he was 'almost done'. WTF? Would you allow your kid to do this? Then you probably shouldn't either.
WOW! My experience has confirmed these statements from the conference. In 16 years I've had 1 cardiac arrest patient walk out of the hospital. Just 1, and I've probably ran at least 1 cardiac arrest call a month for 16 years on average...so that's 192 patients and 1% of that is 1.92...so that's about right. That's not including the calls that the other medics have worked.
We also give false hope to families during cardiac arrests because everyone expects us to work miracles. But for all our education we have yet to equal God in the ability to control life and death. (Thank God for small favors!) We do all these treatments and race to the hospital just so the family can get a huge bill and be told all over again that their love one is STILL dead. These families tend to follow us to the hospital (which is illegal and very, very dangerous because they put their "magic" flashers on and think that this somehow protects them against red lights and they tail gate us through intersections even after we tell them not too. They rationalize that they're 'helping' their loved by doing this although I have yet to see what positive assistance tailgating an ambulance provides the patient since we don't allow them in the back with us anyhow.)
Most families already suspect that their loved has died and are upset but still rational. If we began approaching the situation as a -work at the scene or not- but declare death when death is confirmed then the families can began to deal with the reality in a more appropriate manner. Hope can be a torture when others know that hope is lost.
We have a saying in EMS. It's harsh but oh soo true. Most cardiac arrests are dubbed FPO - For Practice Only. This mean we realize immediately that this patient will not improve, that they've been Mostly Dead All Day and nothing we do will change that. But the thought is we don't want to upset the families or get sued and hey...we can always use the practice. So we toss in the kitchen sink, soak ourselves in sweat and drive like NASCAR champions to the ER (I admit it, driving emergency is a blast!). The family races behind us and coagulates in the ER- "Is he Okay? Is he breathing? Is he alive?" No, no and still no is your answer but at least we 'tried everything'. They thank us for trying (that part is rough when you're thinking FPO) then begin their temporarily delayed grief in the impersonal hospital.
The EMS walks out of the hospital and in the privacy of their ambulance shake their heads and say, "That was a good FPO code...let's get some lunch."