This is a guest post from Rom Duckworth, paramedic and educator that follows-up on this post about my experience in the CIRC trial. If you want to guest post or review on this blog, check out the guidelines here.

CIRC Trial and IBP ALS

Having had the opportunity to attend the ACLS Guidelines roll-out in Chicago in October of 2010 I noticed something profound in both the recommendations and the research (though not the ACLS algorithms or course, but that is another topic). In the process of evaluating the science behind the guidelines four things became apparent to me.

1)     The overall scientific strength of the guidelines (not every recommendation, but the guidelines taken as a whole).

2)     The specificity of what works, what doesn’t, and what needs further evaluation.

3)     The difference in success rates between comparable EMS systems (rural to rural, urban to urban, etc.) throughout North America. Read as “room to improve”.

4)     Potential for the continuation of obsolete practices and paradigms among healthcare providers, even those attending regular BLS, ACLS and PALS recertification programs.

These four items led to me picturing an equation of:

(local implementation of guidelines) + (Time) = (Real Lives Saved)

This equation motivated me as an EMS Coordinator and educator in a small regional system to see what changes I could begin in my own service and then, hopefully, propagate throughout the rest of our region.

Initiative for Best Practices in ALS Education Program

I put together an education program that addressed the five areas of a systemic approach to improving resuscitation.

1)     Early CPR and Defib

2)     True high quality CPR

3)     Uninterrupted CPR

4)     Meaningful Medications

5)     Post ROSC Care

Unfortunately the project would be restricted not only by time and money, but it could also deviate only minimally from our current Regional Paramedic Protocols.

So in January of 2011, with more focus on the process than the name of the project we began the Initiative for Best Practices in ALS (IBP ALS). With the support of our department’s Chief and our Medical Director we placed our community-based ALS service as the hub of a program with five spokes.

1)     Early access to CPR and defibrillation was improved by providing community stakeholders with educational resources and grant materials as well as updating the training for ALL dispatchers and first responders in proper BLS.

2)     The quality and consistency of CPR was improved through education programs that emphasized the WHY (affective) of BLS as much as the HOW (psychomotor) in order to eliminate low quality and outdated BLS practices. We also stressed the importance of continuous EtCO2 as a tool to monitor effectiveness of CPR, airway management, and achievement of ROSC.

3)     In addition, our service worked to minimize interruptions of CPR through the use of mechanical CPR devices, automatic ventilators and a modified airway protocol.

4)     While we couldn’t move completely away from general administration of algorithm based medications during resuscitation, we did implement a drastic change (for us) to using Vasopressin and Amiodarone as “One-and-Done” meds rather than the “rinse and repeat” of epi-lido-epi-lido-epi-lido. We also emphasized medics evaluating and addressing the patient’s underlying problem through history and assessment, as opposed to primarily following an algorithm until arrival at ED was achieved.

5)     We put protocols and education in place for immediate-post ROSC BP maintenance, 12 lead acquisition and transmission and eventually, hypothermia.

Lessons Learned

As we wind up our first year of the program I’ve been surprised by some of the lessons learned.

1)     Trials and special programs give focus: Many participants in our IBP ALS program were invigorated just by the fact that our service was a part of something special.

2)     Direct Follow up: I too believe that face-to-face follow up after each call helps to improve the quality of care not just in the types of calls addressed in the project (for us, resuscitation) but positively affects all aspects of EMS care in the system.

3)     Rise of the machines: While some complain that machines haven’t proved to be the be-all, end-all of resuscitation, I can tell you for certain that in our system they have dramatically improved our ability to provide continuous, high-quality CPR.

4)     Save lives with your MIND, rather than your HANDS: If I had to choose the central concept of the IBP ALS program, this is it right here. Do I believe that we’ll save more lives because Vasopressin is such a great drug? Nope. But I DO believe that paramedics will save more lives when they’re focusing on evaluating and addressing correctable problems, rather than just watching the clock for the next “rinse and repeat” med administration.

5)     Change attracts attention: Our program required a change in the ambulance load-out. I (very subjectively) believe that this stimulated better rig-checks as the crews took the opportunity to review the new equipment.

6)     And more change: We took the opportunity to attach other small changes to the program not directly related to resuscitation. Some change lends itself to improve in ways you might not have previously considered.

7)     Teamwork: While I encountered initial resistance to Pit-Crew CPR concepts (“We get everything done that needs doing! Why change?”), I emphasized that the idea here is, as when you work with a great partner, with Pit-Crew CPR’s pre-assignments, things don’t just “get done”, they get done automagically. Less effort+improved CPR=happy crews.

So if you have the opportunity to participate in a research or pilot program, by all means do so. Even better, you may want to start one yourself! Yes, it will take a great deal of work, but you’ll be contributing quality data to pre-hospital medicine, and you may find yourself surprised at the return on investment for you and your service.

A passionate emergency responder and recognized speaker and educator on leadership and emergency services living in Connecticut, Rom Duckworth has more than twenty years of experience working in career and volunteer fire departments, public and private emergency medical services and hospital based healthcare systems. Connect at www.romduck.com
or the www.RescueDigest.com blog and podcast.

No related posts.

A recent EMSWorld.com article, Man vs. Machine: who won the CIRC trial reminded me of my participation in the trial (not as a patient!) as a paramedic at one of the clinical sites.

1. Research trial gives a group focus. I really enjoyed being part of the research trial. We received quarterly education programs and hands-on practice on the study protocol. We were tested and had to meet specific clinical benchmarks.

2. Focus on improvement after every encounter. After every cardiac arrest the machine data and run report were carefully analyzed by the site coordinator. Then we had a face to face meeting to discuss areas for improvement and what went well. I learned something every time.

3. Machines are really good at repetitive actions that require precision. People are not as good. The Auto Pulse does the same thing every time. It doesn’t get tired. It doesn’t get distracted. It doesn’t complain.

4. Paramedics are better than a machine at seeing the big picture, trouble shooting variation, and applying judgement. When paramedics are asked to perform a repetitive action that requires precision it distracts them from decision making and anticipating the next steps.

5. All change leads to more change. Adding a piece of equipment in the ambulance changes how equipment is stored, checked, deployed, and maintained. Processes need to change with change.

6. New change might be counter to other new change. Mechanical CPR devices have partly been promoted to be used during transport so EMS professionals can stay seated. That is a good change. But there is another good change it counters – not transporting patients in cardiac arrest.

7. Pit crews work. The pit crew process of assigning specific roles under the supervision of a crew leader works. Coupled with checklists and regular practice the pit crew should be able to improve patient encounters.

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I am convinced that in the workplace any incident of wrong doing – cheating, stealing, etc. – is always witnessed or realized by a co-worker. The part I have never understood is the lengths individuals will go to either pretend what they know is happening is not happening or protect someone that is clearly violating rules, ethics, or individuals. I just don’t get it.

Paramedic Bob Sullivan, at the EMS Patient Perspective, reminded us early in the month about how important it is to Do the Right Thing.

Brandon Otto shared a great set of notes and observations from the Western Massachusetts EMS Conference. As a speaker I would be thrilled to see if an attendees notes matched the key points I was trying to make.

The Rogue Medic uses his impressive skills in medical illustration to explain Why CPR Doesn’t Work for Trauma.

Jamie Davis, the Podmedic, interviews author Sandra Crowe about her book, Since Strangling is Not an Option. Oddly the holidays often remind us and lead to encounters with the most difficult people in our life. Get some tips from Jamie and Sandra.

David Konig, the Social Medic, shares 6 tips for EMS coverage at special events. I want to know if the wrestlers are really hurt of if that is part of the act. Do you know?

BetsyDuck at the Rescue Digest Blog explains how Keynote presentations at EMS conferences helps us know who we are and know about the group we belong to.

Do you know what you want to do after being a paramedic? This EMS1.com article shares 9 Reasons Why Nursing Should be Your Next Career Move.

Remember one of the best places to find blogs by paramedics is Paramedic.Alltop.com.

What were your favorite blog posts from November? What would you like to read more about? 

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I only thought Flash Mobs surprised flustered mall visitors with Christmas carols. Turns out Flash Mobs are also teaching equally bewildered fair goes and mall visitors to push hard and push fast. To both my surprise and general relief I have yet to be caught in the midst of a Flash Mob. How about you?

First CPR flash mob movie I found.

The best behind the scenes flash mob footage. Reassuring to know practice is involved. Unfortunately I can’t find the actual flash mob performance.

A flash mob that might have considered picking a more crowded location.

Be wary of a flash mob if you see lots of people with the same shopping bag.

Having taught lots of CPR classes I caution flash mobs about choosing attire other than scoop neck shirts and low rise pants.

I think a little viewer education about what is happening might be a good addition to the CPR flash mob.

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CPR, EPC, PHTLS, ACLS, AMLS, PEPP, ITLS, BLS … all of those certification courses. Do you attend certification courses with dread and low energy? Or do you attend to maximize your own learning and preparation for emergencies?

Maximize your success in certification courses with these tips:

1. Be prepared to learn. Do your best to avoid taking a certification class just as you have come off shift. Instead come to class rested, well fed, and energized. If you can read the book before class. At the least skim the main headings in each paragraph. Complete any pre-course work well before class starts.

2. Sit near the front of the room. Demonstrate your interest and willingness to learn by sitting in the front. You will learn more and be less distracted in the front.

3. Align with the right people. When it comes time for the inevitable group work (aka patient assessment stations) assign yourself to groups with other students that want to learn and make the most of the session. You know the Debbie Downers in your organization so do your best not to sit near them.

4. Ask questions to affirm and broaden your knowledge. A certification class is a focused opportunity to ask and get questions answered. Ask questions during lectures, skill stations, and assessment scenarios. Breaks and meal times are also good times to ask questions … especially to outside instructors.

5. Practice, practice, practice. Take advantage of opportunities to practice. If there is a down moment place a couple more endotracheal tubes, place more IO lines, or compress the manikin’s chest. Build muscle memory and familiarity with these important skills.

6. Honestly and specifically evaluate the course. Use the written evaluation to share honest and specific feedback on how to improve the course. Instructors and program coordinators appreciate specific critique. Let them know how to improve because you might be back in the same course in two years.

What are your tips for success in certification classes?

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Are Public Service Announcements (PSA’s), like this new disco theme combined with Hangover supporting cast member Dr. Ken Jeong, effective?

Or do they only provide some entertainment to those of this on the inside?

I have seen this video shared by dozens of Facebook and Twitter friends, but they are all EMS professionals. I have yet to see this video shared by any of my non-EMS friends. Have you?

It is a great message with an innovative spin on the delivery, but I need to be convinced that humorous PSA’s can push the needle on rates of bystander CPR.

Finally, how can I get cast in a PSA?

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The call to action in this video is incredible. The potential of the app for citizen first response to cardiac arrest is even more incredible. What are you doing to bring this app and capability to your community?

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What would you do?

“A patient has been impaled on a rod on an iron fence which has gone straight through the body. Would it be advised to shock this patient in cardiac arrest with an AED? Or would the shock be contradictory due to the metal object in said patient’s body?”

My Thoughts

1. The patient is not likely to have a shockable rhythm – vfib or vtach.

2. The patient with penetrating trauma as described likely has injuries incompatible with life.

3. Lots of patient’s have metal in their body – surgical plates for fractures, implanted pace makers, bullets not removed from previous injuries, etc. The likely issue is not the metal in the body but the conduction of electricity through the metal rod.

Your Thoughts?

This question is the classic classroom zebra. What would you do? Have you ever heard of an actual case like this?

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Kelly Grayson, author of the Ambulance Driver Blog, and TOTWTYTR, author of the Too Old To Work Too Young To Retire, paused from their breakfast at a New Jersey dinner to resuscitate a woman in an adjacent booth that experienced sudden cardiac arrest. Great work!

Kelly’s blog post of the event is OUTSTANDING – one of the best blog posts I have ever read.

Kelly and TOTWTYTR also prove that CPR is so easy anyone can do it.

They didn’t do anything heroic. They simply did what anyone in the restaurant could have done with less than 30 minutes of training and a dash of action orientation. If you don’t know CPR, learn it now.

1. Contact your local American Red Cross or American Heart Association Chapter.

2. Browse to Learn CPR

3. Purchase Friends and Family CPR from Amazon.

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David Konig has been schooling me in the ways and uses of “Internet Memes” and with some basic understanding I gave it a go with the Twitter Meme #ifiwereGovofWi (If I were Governor of Wisconsin). You could adapt this Twitter Meme for your own state by replace “WI” with your own state (you probably didn’t need that explanation). Some of these I have already posted on Twitter and some are new.

If I were Governor (general):

1. I would wear a red vest every day to rock it old school like former Governor Lee Dreyfus.

2. I would ban the use of road salt to save money, cars, fish, amphibians, and water bugs.

3. I would ask some scientists to figure out a non-toxic alternative to road salt.

4. I would promote the many options for online education from Wisconsin’s find Universities.

5. I would do more listening than talking.

If I were Governor (EMS):

1. I would extend the EMS recertification period from 2 years to 4 or 5 years.

2. I would adequately fund the State EMS office.

3. I would go on an ambulance ride along in Milwaukee, at night.

4. I would hire a full-time EMS Medical Director.

5. I would lead an effort to engage paramedics in preventive healthcare.

6. I would introduce a bill to remove the exemption of public safety vehicle operators from the statewide texting ban.

7. I would ask the City of Madison Fire Department to teach me and my staff CPR. The next year I would ask Private Ambulance Service to refresh us.

8. I would make CPR certification a requirement for  high school graduation.

If you were Governor what would do …

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