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Two Steps Forward, One Step Back

After much speculation, the American Heart Association released the 2010 ECC Guidelines last week.

And like past versions of the guidelines, there are some good things, and some recommendations that leave one scratching his head, wondering what dark, smelly orifice they pulled that idea from.

This year, it appears that AHA is afraid of the big, bad Nitroglyerin Boogeyman, too.

Either that, or they think that EMS providers are a bunch of booger eating morons incapable of utilizing Nitro safely, but are afraid to just come right out and say it. You’ve already read my view on the subject.

This if my fifth version of the guidelines to teach. I’ve taught and coordinated over 350 ACLS and PALS classes (I quit counting in 2006), a couple dozen instructor courses, and done God only knows how many CPR courses, instructor updates, monitoring and mentoring.

And in those 17 years spent doing this, I have come to believe two things:

1. Despite the stated emphasis on evidence-based medicine (and it strengthens with every new release), some recommendations make it into the guidelines based on no evidence whatsoever.

2. Somewhere in a dark basement at AHA headquarters, there is a little troll named Melvin whose job is to write stupid test questions and come up with ludicrous recommendations. Melvin wrote the test questions about Milrinone for the PALS course, and the oxyhemoglobin dissociation curve a couple of ACLS versions ago, and the Grand Prize Winner of stupid questions, whose correct answer required that providers turn off all oxygen delivery devices before defibrillating.

Just because you see something in an ACLS book doesn’t necessarily make it valid, folks.

Comments - Add Yours

  • Yoda The Medic

    Couldn’t agree more. Melvin should be horsedragged. My other favorite is the AED question (apply pads first vs turn on first) and I tell our students that I won’t punish them for some asshattitude from AHA.

  • 40lizard

    Its going to be interesting to see how these “new” guidelines shake out in the field especially for all of those that’s been doing “ABC’s” forever and a day! :)

    • Too Old To Work

      It’s going to be a big change and take a lot of effort from training, supervisors, and medical control to keep on people to follow the new protocols. CAB has been used in Europe since about 2000 with great success. It probably should have been adopted in 2005, but it was probably seen as too big a change.

  • JPINFV

    At least more people are starting to recognize that oxygen isn’t some wounder drug that will cure EVERYTHING. I’m personally surprised that there hasn’t been any EMS forum backlash against the “supplemental oxygen doesn’t help get RBCs past a blockage, so O2 isn’t really warranted in ACS” yet.

    • Anonymous

      ZOMFG!!! They said THAT?!?! They’re going to kill people!

      Next thing you know, they’ll be taking our non-rebreathers away, and we’ll be forced to use nasal cannulas! Oh, the huge manatee!

      • JPINFV

        Just in case anyone missed it as it was somewhat buried.

        “2010 (new): Supplementary oxygen is not needed for patients without evidence of respiratory distress if the oxyhemoglobin saturation is ≥94%. Morphine should be given with caution to patients with unstable angina.

        Why: Emergency medical services providers administer oxygen during the initial assessment of patients with suspected ACS. However, there is insufficient evidence to support its routine use in uncomplicated ACS. If the patient is dyspneic, is hypoxemic, or has obvious signs of heart failure, providers should titrate oxygen therapy to maintain oxyhemoglobin saturation ≥94%.”
        -PDF page 20
        http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadable/ucm_317350.pdf

        Wait… titrate? That’s a big science word, kinda of like explaining to an RN teaching an EMT refresher why her idea of putting hypotensive stroke patients both in shock position and semi-fowlers is a bad idea (and I was even willing to bypass the entire debate on whether trendelenburg/passive leg raising actually works).

        • Anonymous

          LOL. TOTWTYTR have been saying that about oxygen in ACS in our EMS Mythbusters lecture, and quoting the AHA guidelines on it, since 2005. I’m constantly amazed by the people who don’t read the book, and presume to know what the standards are.

        • Terigiordano

          I had an O2 sat of 93% yesterday….. the probe had fallen off of the patient. Let’s get out of the dark ages and start paying attention to how well they are ventilating and look at ETCO2 instead.

          • http://roguemedic.com/ Rogue Medic

            Terigiordano,

            I agree that the waveform capnography is a much more important tool, but if we are trying to titrate the delivery of oxygen, the pulse oximetry will be better. Ventilation is more important than oxygenation, but we do need to pay some attention to both. In the OR, the first place to require waveform capnography, they also require pulse oximetry.

            If I had to choose, I would definitely go for waveform capnography over pulse oximetry, but I don’t have to choose.

            Unfortunately, plenty of people (including medical directors) will make the opposite choice

          • JPINFV

            Quick question. How does a disconnected pulse oximeter differ from a cardiac monitor that shows asystole when a lead is off or ‘ventricular tachycardia’ during CPR (artifact waveform)? Just because a tool doesn’t shut off when it becomes disconnected doesn’t change its value when used properly. Similarly (and serious question), can capnography tell us the status of hemoglobin saturation?

            Personally, I’ve always gotten the sense that pulse oximetery is made out to be a boogyman due to constant misuse (the proverbial ‘withholding O2 because of a normal SpO2 even when the patient is struggling to breath’ stories), not because it’s a bad tool or measures a useless parameter.

          • Too Old To Work

            You’d be surprised at the number of people who don’t pay attention to the state of their equipment, just the state of the numbers. I’ve had queries from the QA people because the “O2 sat looked low”. Never mind that the patient was otherwise fine, the numbers just didn’t look good on paper.

            That’s a big problem with modern medicine. Everyone is so busy looking at the numbers that a lot of them don’t actually look at the patient. I think that was the point Terigiordano was trying to make.

          • Too Old To Work

            My 02 sat runs anywhere from 95-97% all the time. I don’t smoke cigarettes and don’t have any respiratory disease that I know of. I also bike several times a week, so I don’t get short of breath easily. Yet there are some medics, nurses, and even doctors that would consider intubating me based solely on that number.

        • Too Old To Work

          Ooooo, titrate. Yeah, that’s a tough one because you have to use that highly complex pulse oximeter. It’s nice that they are not just relying on numbers, but actual assessment of the patient for respiratory distress. Amazingly, I think this is going to be one of the hardest changes to implement. We’ve all been taught since day one that O2 is like chicken soup. Can’t hurt, might help. Unteaching that is going to be difficult.

          I’ll be at refresher tomorrow morning, so I’ll see if I can find our medical director and ask her about it. As smart as she is, she’s been a proponent of the chicken soup school for a while.

      • Too Old To Work

        I’ve made it a mission over the past couple of years to get the BLS crews in my system using cannulas. Most of them have started to figure it out and I’m seeing more and more patients (appropriately) on NCs and not on Non rebreathers.

        Well, except for this one EMT. If you didn’t know me better, you’d suspect that I always tell her to do the opposite of what she thought I’d want just to screw with her head. But, you do know me better than that, right?

        • http://roguemedic.com/ Rogue Medic

          Whatever you do – Do not explore the exciting world of fast food order satisfaction!

          Go ahead, tell her. It’s worth a try. ;-)

  • Rone689

    “Despite the stated emphasis on evidence-based medicine” Quite possibly the way they get evidence is to stipulate a Black Box problem. When enough people are poking the box in the same way and everyone agrees that poking it that way hurts their fingers you obtain evidence that poking the box in that way hurts fingers. Next set of guidelines recommends not poking the box in that manner. Not wanting to waste said Black Box they stipulate that everyone kick the black box. This perplexes those of us that look at the black box and see that it is made of granite and weighs 50 lbs use our common sense and say, “You do it, I’ll watch.”

  • Erin1973

    Bravo. Well said! But I do believe the trolls name is Chuck :).

  • Easyduzit25

    I think the new guidelines for CPR are a step in the right direction FOR NON PROVIDERS ONLY….. as a provider i am still gonna drop a tube and do 30 and 2 because as we all know without proper ventilation the chances this patient is going to wake up are very slim. from what I have read Arizona started this study in order to get more people to attempt CPR it seems people were opting not to try CPR because they didnt want to do mouth to mouth. So as a public experiment over the last 5-10 years or so they pushed this compressions only CPR. i cannot Find the article but the raw numbers were funny like they went from 60 out of 100 people surviving and being discharged to like 110 out of 180 which was pretty hillarious to me because they pushed the variable up to get better results but like i said i cannot find the article anymore……the article i am speaking of was online before AHA came out with the new guidelines. So sorry about such a long rant but although the new guidelines are great for those without access to suplemental Oxygen and BVMs i would encourage anyone with an MFR or above to stick with the 30 and 2 because these are just GUIDELINES and guidelines are the lowest required actions, besides if you stick to just the guidelines for CPR as they are right now you may get lucky on a few but the mortality rate on your shift will be effected.

    • Terigiordano

      Just a note to easyduzit25….. if you have “dropped a tube”, you shouldn’t be stopping compressions to give breaths, so therefor your 30:2 does not make sense. The point is uninterrupted chest compressions, for providers that can intubate, the ratio’s don’t matter….

    • CBEMT

      as a provider i am still gonna drop a tube and do 30 and 2 because as we all know without proper ventilation the chances this patient is going to wake up are very slim.

      And with too much, the chances are even slimmer. PLEASE tell me this is a typo, and that you’re not actually stopping compressions to ventilate with an advanced airway in place. I also hope you’re not placing the establishment of said airway as a priority.

      • Too Old To Work

        30:2 makes sense for mouth to mouth, but not much else. We ventilate between 8-12 times a minute, regardless of number of compressions. Then again we also use the ETCO2 for more than just tube confirmation.

        • http://roguemedic.com/ Rogue Medic

          But where is the evidence that ventilations improve survival to discharge?

          • Too Old To Work

            We don’t know if they do or they don’t. Compressions and electricity should be the first treatments for VF arrests, but other than that, we don’t know much. Well, we know that the longer VF goes on, the less likely survival is. There is some evidence that normoxic ventilation might be better than hyperoxic ventilation. We know that hyperventilation decreases survival.

            Finally, it’s possible that we should do some things until we get ROSC, then do other things once that is achieved.

            We also know that it’s hard to do studies on resuscitation methods.

          • http://roguemedic.com/ Rogue Medic

            We don’t know if they do or they don’t.

            Yet we cling to the What if . . . ? of a treatment that is a complete unknown in cardiac arrest. We do have evidence of ventilations leading to worse outcomes.

            There is some evidence that normoxic ventilation might be better than hyperoxic ventilation. We know that hyperventilation decreases survival.

            Is that because of the hyper, because of the ventilation, because of both, because of something else, or some other combination?

            Finally, it’s possible that we should do some things until we get ROSC, then do other things once that is achieved.

            Not just possible.

            We also know that it’s hard to do studies on resuscitation methods.

            Maybe it would be easier if we weren’t so committed to retaining treatments that lack evidence of benefit.Maybe it would be easier if we weren’t so committed to defending as standards of care, treatments that lack evidence of benefit.

  • Countryprideproducts

    We have seen a few years now where they teach cook book pt care, if they present with this c/c follow these steps ect. With that came 12 leads 15 leads, pulse ox, ect. What I am not seeing is quality secondary assessments and good history taking.. we need to go back to the days where we had thinking medics that could handle pressure make hard choices, and logically explain the reasons. When I went to MICT school we started with 50 in class and 10 went to state and maybe 7 would pass the first time.

  • usalsfyre

    Easyduzit25m

    The mortality rate on your shift will be affected, but not in a bad way…

    You can keep up with the old ways, but your in all likelyhood contributing to poor outcomes for these patients. The only interventions backed by science are high quality chest compressions and early defibrilation. Let me state that another way, THE ONLY INTERVENTIONS THAT MATTER ARE CHEST COMPRESSIONS AND DEFIB! Everything else is pure conjecture. Oxygen has been shown to cause harm (Association between arterial hyperoxia following resuscitation from cardiac arrest and in-hospital mortality.) and nobody has the requisite anatomy to put together a real study on ACLS interventions. So you can keep on with the old ways, but don’t expect any improvment in outcomes. Just because we learned it in school doesn’t make it so…

  • Stretch

    Sadly so true, about time Melvin got the boot, I sometimes fell the art of the questions is in figuring out what the question means, rather than the correct answer. Evidence based ? Depends on p factor and bias, don’t forget confounders. Sure what would we silly Pre-hospital providers know ?

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