Since 1974, Seattle and King County has been known as the best place to have a heart attack. In 2013, the survival rate for someone in King County who suffered a witnessed cardiac arrest and presented with the shockable rhythms of ventricular tachycardia or ventricular fibrillation reached 62 percent, and patients found in pulseless electrical activity or asystole had a remarkable resuscitation rate of 21percent. Unfortunately, the cardiac survival rates in other cities are often in the single digits.
My most recent ACLS refresher, while working at Yosemite National, was taught by Tod Levesh and James Kellogg, two King County Medic One paramedics.
Here are 10 tips from Levesh and Kellogg shared on how we can increase cardiac arrest survival.
1. Approach every cardiac arrest patient with a positive attitude
People survive cardiac arrest! Yes, even a patient in PEA or asystole has a chance. However, some EMS providers fall into the trap of reducing their expectations when encountering those rhythms that have expected lower survivability. Remember: you are the patient’s best hope for survival. The statistics may say that resuscitation likelihood is low, but your positive attitude and astute medical practice will make a difference.
2. Think several steps ahead
A cardiac arrest is a dynamic scenario. Cardiac rhythms change during a resuscitation, requiring different treatments. Furthermore, the needs of a resuscitated patient are far different from the needs of a patient in cardiac arrest.
As you work the patient, predict what may be needed 4 to 6 minutes in the future. Steps that greatly enhance the efficiency of your call include preplanning your move to the transporting unit, drawing up a few medications to have on standby, staging airway management equipment or personnel for extricating the patient. Thinking just a little bit ahead can help you avoid unnecessary delays.
3. Swallow your pride and put first things first
As ALS providers, we are very proud of our ability to initiate advanced procedures and give a host of medications. And rightfully so! This is a big responsibility. BUT, we need to be honest with ourselves.
The biggest contributor to a successful resuscitation is NOT those medications and advanced airways of which we are so fond. In fact, the most important thing we can provide to our patients is quality BLS care — compressions, ventilations and defibrillation. ALS procedures should rarely interrupt or disturb these functions. If you see an ALS activity delaying a BLS skill, gauge the importance of the ALS skill. Nine times out of ten, ALS can wait.
4. Train with realism
We often practice CPR scenarios where time is “accelerated”. Resist this urge. Work the simulated arrest in real time. Perform full two-minute CPR cycles on the manikin. Just like real life, care can’t be provided until an IV is established.
When training for a pediatric arrest use the Broselow tape or other pediatric medication job aids. Then draw up a 0.01 mg/kg dose of Epi 1:10,000. These training actions breed competence and confidence on real calls.
5. Avoid tunnel vision
EMS providers tend to become distracted by the skills aspect of a cardiac arrest, including AED use, airway management, intravenous access, rhythm interpretation, and so on. We all have areas of our practice that need improvement, and it can be easy to get sidetracked by one or more of these problem areas during a real call. That’s why it’s important to always remember that it’s your job as the lead provider to guide the resuscitation. You can’t do that when you are attempting your fifth IV or airway. Stay in the present, and keep those skills-related blinders off.
6. Communicate calmly to the team
A successful resuscitation is only possible when you communicate effectively. As the lead provider on a high-stress call, you set the tone for the other personnel. If you bark orders and communicate haphazardly, the resuscitation will rapidly fall apart. Instead, try to maintain a calm demeanor, making polite requests of your crew members and family/bystanders. You’ll be surprised how much more smoothly the call will go. Family members will offer up critical pieces of information, crew members will respond quickly and effectively, and you will come across as the confident and competent medical provider that you strive to be.
7. Debrief every cardiac arrest
This can be a tough pill for some to swallow, but nobody will ever run a perfect resuscitation. There will always be events that could have been avoided and better approaches to specific issues. Unfortunately, these specifics are often forgotten as we move on to other calls. That’s why it’s so important to get everyone who contributed to the resuscitation together as soon as possible. Have everyone discuss their actions, and have them provide feedback on what worked and what did not. Work hard to incorporate the lessons learned into your next CPR response.
8. Follow up
As you run a resuscitation, you should always work to establish the cause, or etiology, of your patient’s cardiac arrest. Many mnemonics exist for this, because it’s critical to remember that many causes of arrest are reversible! But this isn’t where your job ends.
Once the patient is in the ER, follow up to determine the ultimate diagnosis. If the resuscitation was unsuccessful, follow up with the medical examiner. This kind of medical feedback allows you to compare your care and clinical judgment to the medical reality. Without this step, we are left to constantly guess, and we will never become excellent clinicians.
9. Leverage technology for quality improvement
Many of these steps can be incorporated into your care immediately. However, the use of technology in a cardiac arrest QI process requires a system-wide commitment. Most modern cardiac monitors have the ability to record such eye-opening metrics as compression fraction — the actual amount of time that CPR was performed during a resuscitation, the length of pauses during compressions, and the adequacy of compression rate and depth.
Systems that provide this information to their crews report seeing dramatic improvements in cardiac arrest survival. While you may not be able to get these technical capabilities immediately, you can work towards their implementation. Talk to your service director and medical director.
10. Learn from others
Medicine is a complex field. Treatments, underlying science, and best practices of care are constantly in flux. In order to stay on top of it all, you need to approach medicine with an open mind. Much can be learned from your partners, crew members, nurses, and physicians.
Studying other systems and their approaches may provide insight into a new way for your units to respond and treat patients more effectively. As you work to incorporate these various insights into your practice, the quality of the care you provide will constantly improve. The Resuscitation Academy provides resources and training.
Share your tips!
Got a great tip to improve cardiac arrest survival? Comment below and if I use your tip in a follow-up article I will send you a signed copy of my book, Lights & Sirens: The Education of a Paramedic.
Tod Levesh and James Kellogg work as paramedics for King County Medic One and teach continuing medical education classes across the country. For more information, please visit GoInTheKnow.com.
