When I got to the station, I asked the AIC (a good friend of mine) if he could show me around the rig and how everything operates. The more I saw, the more excited I got. This agency has a lot of the things that I think makes EMS a true medical operation: CPAP, Sam Splints, Broselow Bags, continuous capnography as a vital sign, several IO's, 12 leads with wireless transmission capability, an autopulse, and electronic PPCR's. The agency also has access to several Primary Stroke Centers and a Level I Trauma and Burn Center. There are also career paramedics somewhere in the county at all times. Truly cutting-edge technology and uses of resources. I got more and more excited the more I saw. It felt like Christmas with tons of new toys to play with!
I've been thinking a lot lately about all the new things coming out in EMS. Every convention and conference I go to there's always tables and tables of shiny new things. It's overwhelming and commercial. But, if you know how and where to look, some of those pretty things will really make a difference to EMS. There's several material things and protocols that I wish I could have (or that I wish I could have when I'm an ALS provider here in a few months):
CPAP
12 Lead EKG with Wireless Transmission
Coordinated Pediatric Bag (like a Broselow)
Capnography Monitoring as an ALS vital sign
Autopulse - Automatic CPR Compressions
Chest Seals
Thermometers
Infusion Pumps (yeah, right - but I wish!)
ResQPOD (Impedance Threshold Device and an AHA IIA recommendation)
Field Cath Lab Activation
RSI
Some kind of Induced Hypothermia Protocol
I believe, with proper training, that everything on that list could make a real difference in patient care. With 12 Leads and cath lab activation from the field, we could save the patient up to 45 minutes of ER time. Capnography monitoring can truly alert to patient changes and status. For more on this, please see one of the field experts - 10 Things Every Paramedic Should Know About Capnography. There are few sources that explain it better and simpler.
Autopulse, ResQPOD, and Induced Hypothermia go together a little bit. In EMS, we make great "saves" every day, but I am occasionally hesitant on playing God. If we bring someone back, I'm disheartened to think that they will most likely never get out of the hospital. Even if they do make it out of the hospital, will they ever recover from the save that we performed?
In most situations, of course, we are ethically bound to at least work a cardiac arrest to the best of our ability. And I say, if we're going to do it, we might as well do it right. SCA - Sudden Cardiac Arrest - is the leading cause of death in the US and Canada with most patients at least initially in Ventricular Fibrillation.* Good, deep, strong, and probably most importantly, continuous, CPR provides the best chance for survival. AHA Guidelines note that we should be compressing 100 times a minute to get optimal forward blood flow. Human observational studies show that interruptions of chest compressions are common - far too common - and NO compressions were provided for 24-49% of time in cardiac arrest. Obviously, naturally, studies have consequently shown that prolonged interruptions in compressions reduced the likelihood of ROSC (return of spontaneous circulation).** In short, AHA recommends interruptions only when absolutely needed - pulse checking, analyzing rhythm, defibrillation. Compressions should not be interrupted for gaining vascular access, intubation, medication administration, etc.
Autopulse is very new technology, and I'm sure there is research both for and against it (does anyone know if they're making bariatric autopulses yet?). However, in my opinion, at the very least it provides continuous deep compressions. The machine doesn't get tired. It doesn't stop to try to do something else. It even beeps and tells you when to provide ventilation. ResQPOD is a threshold device and prevents unneeded air in the abdomen. This is an AHA IIA recommendation, and it also flashes when it's time to ventilate. No need to make our patients alkalotic, folks. If they're at the point of needing a ResQPOD, they have enough problems to begin with!
Induced Hypothermia. See old posts for some of my prior discussion on this, and await a case study that's in progress. I am a huge, huge supporter of this therapy. I believe it saves lives and prevents long-lasting neurological deficit. My protocols are JUST loose enough for me to have the ability to fly out a patient if I feel it's needed. My local hospital facilities don't have hypothermia protocol. I've spent time learning the protocol of our local flight companies, and if the event ever prevents itself, I'll fly someone immediately if it meets their criteria. I wish we had some kind of protocol here to get the process started, even if it was only through cold packs or very mild cold saline. But when the hospital doesn't even have the therapy, why should we? Time to call that helicopter.
Chest seals and thermometers - would be nice. Not necessary, but a chest seal will operate better than a regular occlusive dressing any day, and it'd be nice to tell the hospital or a patient's family what their temperature is. Same with a Broselow Bag. I could calculate my own dosages and size my own ET tubes, but it would be so much easier, quicker, and less stressful to simply have a nice color-coded bag.
Infusion pumps - I've never seen even a little one less than several thousand dollars. The Dial-A-Flows have decreased my all encompassing desire for a pump prehospitally, but I'm still a little wary. One drop off of an infusion can be a 10-15% error in medication, and who wants to take that risk? Dopamine, Amiodirone, Lidocaine - all drugs I wouldn't want to miscalculate. I don't know one assistant that I believe would sit there and count drops in the middle of the night on the way to the hospital. A pump would be very beneficial.
Airway, airway, airway. Isn't that what's pounded in all of our heads starting with basic first aid and continuing all the way up to EMT-P? If we should concentrate most on the airway and breathing, we need the tools to do so. CPAP. RSI. Capnography. CPAP is something that's more and more common, and I'm surprised it hasn't made it's way to this area as prominently yet. First of all, CPAP reduces the need for RSI to begin with. There are very few complications or side effects, with the most common being anxiety due to the mask. It saves patients in severe respiratory distress from being intubated, or it at least holds the intubation off. It decreases the need for the sometimes dangerous and far too-oft misgiven pre-hospital drug - Lasix. You can hook up a nebulizer treatment. The machine is small. Why isn't every agency using this?! For a good article on pre-hospital CPAP, see: Prehospital Use of CPAP.
RSI is something a little more serious, and I think there would need to be significant, individualistic training to make this an option pre-hospitally. For those who are unaware, RSI essentially involves paralyzing and sedating (typically using succinylcholine and etomidate) a patient that still is somewhat breathing and has a gag reflex for the purpose of intubating them and breathing for them. It's a life-saving procedure, but it's obviously not without risks. In the heat of the moment, suppose a provider administers the medications and then for whatever reason can't intubate the patient? You've just killed someone. But with proper training, this would be very valuable protocol to have.
That's the end of my wish list and it's reasoning for today. Of course, I'd love a little teddy bear nebulizer for the kids - but that's not exactly going to help save any lives or do anything new, is it? :)
Standby at a structure fire this morning lasted well over 3 hours, and was still going strong when we left. I'm tired - going to sleep to dream about all these new toys that I want!
* Zheng ZJ, Croft JB, Giles WH, Mensah GA. Sudden cardiac death in the United States, 1989 to 1998. Circulation. 2001; 104: 2158–2163.
** Wik L, Kramer-Johansen J, Myklebust H, Sorebo H, Svensson L, Fellows B, Steen PA. Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. JAMA. 2005; 293: 299–304.
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