Cardiac Arrest Thoughts

I’ve been doing this a long time — 15 years as a medic — and it amazes me how often I find new ways to do things or think about things.

I did another cardiac arrest yesterday. Fairly routine. Yet another nursing home hospital bed one legged diabetic dialysis patient pulseless, apneic, CPR in progress, first responders defib – No shock advised. Patient a full code. Done it many times before, so what was different?

1. My eyesight is getting worse. I’ve remarked on it before how I have to squint sometimes when I am trying to thread a 24 gauge catheter into a tiny vein. Yesterday I had trouble reading the lip line markers on the ET tube. The lighting wasn’t great and there was some thick mucus on the tube, but I couldn’t tell if the number at lip line was 21 or 23? I couldn’t make it out. I squinted harder, but still couldn’t see it clearly.

Also when the nurse handed me the W10, I was trying to read the medical history and again, I couldn’t read it. It is one thing to sit on an ambulance bench seat on a nice easy ride to the hospital and read a W10, but in the middle of a code when you are the only ALS provider, it is quite another. I have decided in the future what I will do is have the nurse stand by me while I am doing my code things and read the W10 aloud. Start with medical history and proceed through the medications. I have of necessity over the years learned to make use of nursing home staff on codes — yesterday they did a fine job with CPR and handing me what I asked for from my gear, that this is just a logical extension.

2. ETCO2 and cardiac arrest. I have also written about this extensively (See Post), but I continue to gain new insights. The clear utility of continuous capnography is a quick verification that your tube is good (you still have to listen to lung sounds because ETCO2 won’t detect a right mainstem). The other benefit is it can provide a glimpse into your patient’s survivability chances as well as measure how well CPR is being done. This woman had an ETC02 of 35 on intubation (with CPR), which suggested she was not as dead as she looked. She was initially in a PEA but after some epi went into v-fib. I shocked her a total of three times, then she went back to a PEA, which dwindled to asystole and then back and forth between PEA and asystole for the duration of the call. I don’t like to transport dead people, so I usually follow the 20 minute and out rule for patients in asystole, and under our new guidelines I can call medical control to cease resuscitation even on patients who have been in v-fib or PEA for a period of time if after 20 minutes, they remain pulseless. The problem here was we were getting such good ETCO2 readings. The patient stayed in the 20-30 range. What was most interesting was every time I gave her epi, the ETCO2 rose up to the 30’s. We never did get pulses back. My guess was a dopler would have showed a BP in the 50’s or 60’s during the epi effect. Anyway, I felt we had to bring her in.

Now in the past without ETCO2 to monitor the effectiveness of CPR many of us became rather casual in our efforts. The patient was dead and wasn’t coming back but was still alive enough that we had to work them. Now with ETCO2 measuring the effectiveness — basically, the better your CPR, the better the cardiac output, the higher the ETCO2 number — you are obligated to maintain maximum CPR efforts. As soon as you start to get lax, the monitor is going to tell you. 28, 27, 26, 25, better start pumping harder. 26, 27, 28. You stop CPR briefly to switch positions or administer a drug and your ETC02 is down to 18, 17, 16, 14. And it takes some pumping to get it back up into the mid 20’s.

I had just one partner yesterday so he drove, while a cop rode in the back with me, which leads to another thing I learned.

3. IOs — I love the EZ-IO. One legged diabetic, dialysis patient with me the only ALS responder, it’s a no brainer — I don’t even look for a peripheral vein, I just get out the drill. Brrrrrr. I have access in the tibia. But here’s the problem. In the past, I would have put in a line in the AC or an EJ, which would enable me to sit at the head and bag the patient while also administering drugs. I could do a code with just two people in the back. But now with the line just below the knee, no way. So, I’m trying to administer drugs and do CPR at the same time. That’s challenging. You stop CPR for a moment and the ETCO2 plummets because your circulation/pressure has just dropped to Zero. Epi and atropine push pretty easy and quick, but due to the patient’s history and down time, I decided to try some bicarb. Let me tell you bicarb is a bear to push through an IO. Its like pushing D50 through a 24. It is slow, so I’m doing one-handed CPR, and one handed bicarb pushing against the bristojet, all trying to maintain my balance as we go over the bumps in the road. Bottom line, I really need to get a third person in the back.

4. The patient’s husband was in the nursing home lobby. When I saw him, I do as I often have done in the past — have him come over and say something brief to his spouse. I do this to give them a chance to say goodbye. I tell them we are breathing for their spouse, but they may still be able to hear. And then the one says to the other, I love you, etc. I want them to have that moment, and it usually works out well. Yesterday, I did it, and the man told her heartfully he loved her and then we pushed on through the door and then behind us came an awful howling. A howling that did not abate. I could only picture the man on his knees crying out to the heavens.

It is hard to know what is right sometimes. Did I give him a chance to say goodbye? For him to know that his loved wife heard his words? Or did I give him an awful memory that he’ll never forget — a picture of his unresponsive wife on a board with a plastic tube sticking out of her mouth and people pounding on her chest?

They worked the patient in the ED for another twenty minutes. She had a recent admission for hyperkalemia so they gave more bicarb and then calcium, but to no avail.

14 Comments

  • brendan says:

    Sounds like it went as well as it could have, but I am curious- do you have the option of calling for more help?

  • hilinda says:

    I think you can never know whether you’ve given someone a last memory of their loved one with tubes and people doing CPR- but you CAN know that you gave them the chance to say whatever they might have needed to say, and that trumps the other.

  • PC says:

    Thanks for the kind comment hilinda.Brendan,yes, I can, but…it used to be I could reguarly call for other service members to respond from their homes, but this option has been out lately due to a paging system limbo.usually I don’t have to call because I have at least two partners (when I work in the suburbs)– either EMTs or MRTs ( a lessor category than EMT in this state).or I don’t have to call because I work the person and call them dead on the sceneso I am not automatically in the practice of calling for help.When I work in the city with a single partner, the first responders are usually there so I utilize them(they are FD so they are more able to go into the hospital than two police officers from the suburbs.in the past I have felt like I have managed asystole/pea codes just fine with two, but that was before the ETCO2 commentary on the quality of CPR, before the new emphasis on CPR. You could and should argue that I should have always concentrated on CPR, but it is what it is.The only backup I can get now is a commercial service, and they would be coming from ten or more minutes out. And unless they had a free medic, they wouldn’t get to bill (not that it should be my consideration)unless they sent a medic, and even then I’m not certain how that would work.In the past I have called them on codes, but only when I was working with an extremely weak partner.Had I to do this call over, I would have called for assistance. I should make it at least a rule on any vfib code to have a third person in the back. The most difficult part of doing a code without a skilled partner and extra hands is the moving of the patient from bed to ambulance while maintaining good CPR and a secure tube.Live and learn. After 15 years, I am still trying to perfect it.

  • Walt Trachim says:

    With you on the question of extra hands, Peter.Up in Manch we always get an engine or a truck company to respond for codes, and since Manchester Fire requires their personnel to be EMT-Basics at the very least (they have a number of Intermediates and at last count 5 Paramedics on the department) so we use them extensively. I have no problem grabbing up two of them to put in the back with me to do CPR and help me with whatever I need.It usually works out pretty well, especially when you’re trying to get multiple things done at once. The only problem I run into is that we have to get these guys to slow down – I know we’re doing 100/minute, but it has to be effective, but sometimes quantity and quality don’t go hand in hand. They are getting better, though (last code I worked with them was a save), and it is always good to have lots of help.

  • brendan says:

    I guess I’m lucky then. I rolled a truck by myself once (well, lots of times actually), and when I found one particular patient in arrest, I had 4 people onscene in less than 5 minutes. We can’t call it onscene though, so for us it’s pretty much a necessity to get more help. Even three-person crews will often re-tone for a driver.

  • Cheating Death says:

    As always, powerful stuff.We could all hope to not only work codes this well but with this much knowledge. You all inspire me to dig in a bit more!

  • Anonymous says:

    Peter I can definitely feel your agony on the level of not having enough hands to help when your the sole ALS provider on scene. As a new medic I’ve done a few codes and have always had help on scene usually another ALS truck. However one morning i stayed late and had an EMT-I partner who was bragging how he’s had 3 combi-tubes in the past 3 weeks. I advised him we would have none of that during this quick 3 hours together. 20 minutes later and 2 attempts at an ETT I was passing a combi-tube on a witnessed arrest w/ no ALS back up and a very new crew on scene. I remember my frustration in the back of the truck as I was attempting to do CPR and push med’s, and tried the two at once method to only be let down by the ETCO2 numbers I would get as I tired. Looking back the code went as well as it could have, but if I had that 3rd person there, perhaps it would have been more effective. As you know and preach the ETCO2 doesn’t lie when it comes to CPR effectiveness. But on a lighter note, how ’bout them EZ IO’s huh, I love the look on the firefighters and cops faces as I drill that thing in, can’t wait to see what other new toys they come up with

  • VA FireMedic says:

    Insightful as always. I always liked the idea of giving family the option of saying goodbye, and its then their choice. I’ve had to make do with the people I have several times…I’ve had police officers drive, firefighters ride in the back and bystanders hold c-spine. Someone I work with was working in a VERY rural system with only him and his partner in the entire county, and they had an ATV accident and the patient’s friend bagged the patient all the way to the hospital. Not ideal, but it happens.We are just now placing EZ-IO’s in service, so I’m excited about getting to use one. As for EtCO2, the state is apparently mandating that we begin using it and so we should be getting that soon too. I’ve been reading your other blog (the capnography one) to learn more.No offense, but ever thought about reading glasses? I’m not even 21 yet and already have to wear contacts, so if you’ve made it this far you’re already very lucky!

  • Gertrude says:

    Wait a minute. You had a nursing home staff that knew how to do CPR, was helpful and present with the patient AND they had paper work? What planet do you work on and is there space for one more?

  • Erin says:

    Peter-You most certainly did do the right thing by taking a moment to let the patient’s family say good bye. So many times, especially with codes, we load and go without stopping to consider that there is distraught family nearby. What if it is the last time they see their family meber before officially being pronounced “dead.” You took the time to recognize that the patient is more than just a patient, they are most importantly a PERSON loved by others. By taking the small amount of time, you allowed the patient’s family what little bit of closure they could get. Even if they cry out in agnoy, your kindness means the world to them. I had a code a few weeks ago where a wife came home from church to her 70 year old husband slumped over at the table pulseless and apneic. It was unexpected and she was beside herself with grief. After we got him on the backboard, and just before we took him out of the house, I brought her over to her husband so she could kiss him good-bye. He died the next morning in the ICU. Our crew got a thank you note last week from the family for our care. In it they mentioned that they really appreciated how the patient’s wife was able to kiss him goodbye. So let that be a lesson to you to never question if something like that is the right thing to do…It shows that you have compassion no matter what the situation is.

  • Rogue Medic says:

    Yes, the anguished cry did begin after the husband told her he loved her. No, she was not looking as presentable as she might have liked. Neither of those makes it wrong to offer him the opportunity to say something to his wife. His reaction, as you went through the doors, probably would have been the same, if you had told him he may not say anything to her, or if you had just kept moving as if he were not there. I suspect that the geatest difference would be in the weeks, months, and years afterward. Studies of family presence at resuscitations in the hospital have shown that family members appreciate this opportunity – no matter how uncomfortable. You gave him the choice. He accepted. How much worse if he did not even have that?As for the CPR, I have long been saying that the only thing the ALS does is to interrupt CPR and give people excuses for poor CPR. These are not valid reasons for ALS. Still, I never imagined that insisting on excellent CPR would make as much difference as it has. Some places are reporting a tripling of the number of resuscitated people with working brains leaving the hospital. That is improvement.

  • Patrick W says:

    Peter, thanks for the insightful and thought-provoking blog post.I am surprised that you had such a difficult time pushing Bicarb through the EZ-IO. I have relatively limited experience with the IO (you have done more than I have), but I have found the IO to offer much less resistance than most IVs…certainly less than a 24g! The IO needle is a 15g, after all. Just curious, do you spike the bag directly to the IO or do you flush the line first? The only time I had any problems with resistance was when I hooked the bag straight to the IO without flushing the line with at least one saline flush first. I now flush all IOs with two 10cc flushes before spiking a bag and they all flow smoothly.

  • PC says:

    Patrick-I will have to try your suggestions. Gennerally though my problem isn’t pushing drugs through the IO — epi and atropine go easily. Bicarb is the one that has given me a problem. I’ve never done D50 through an IO so I can only imagine how hard that is. I’ve pushed Bicarb through an IV line and while not as easy as other, it is certainly much easier than D50, so I was surprised at the difficulty I have had with it in IOs. I’ll try the double flush and then report back next time I use it.Thanks again,Peter

  • Anonymous says:

    Four days ago, a paramedic saved the life of a very dear friend of mine who was in cardiac arrest. He even broke a couple of ribs, so hard did he have to work. Thank you, and all your colleagues, for the work that you do. Respects.English lady

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