To Resuscitate Or Not to Resuscitate

I am taking the PHTLS refresher course today and tomorrow. After serving in the military, it is interesting to sit in on a class that is civillian and does not deal with care under fire, tactical field care, or any of the other complications that give combat medics and general medical officers headaches and fits of frenzies.

Today, we had a discussion on shock and fluid management. Now. Shock, as a basic definition, is the lack of cellular oxygenation. The finely tuned machine called the human body ceases to work as it was designed to. Oxygen is inherently essential for the conduct of life and the movement of the well-oiled machine. That is not a question. First anaerobic metabolism starts. Then you get lactic acidosis. Then cells begin to die. Then you get organ failure. Then you get multisystems organ failure. Then YOU die. Not the best of technical explanations I know.

Now, coming from the point of view of a combat medic who must care for a Marine or sailor for up to two hours prior to evacuation, and even then it could be another 30-60 minutes before that sailor or Marine reached definitive medical care, I must be judicious in my judgments. Now. If I have a patient who has uncontrolled hemmorhage, either internal or open wound, he will be hypotensive. My training and experience tells me to give fluids in this case, only to perfuse the brain, liver and kidneys, roughly up to a blood pressure of 80 systolic.

Now through our conversation, it became clear that they did not agree with me. That we should be starting two large bore IVs on every trauma patient who is hypotensive and dumping a liter or two of fluid into them. To me this does not make sense. The end goal is not to bring the blood pressure up to 100 systolic. The end goal is to perfuse the tissues and organs. BP doesn't mean squat if it can't carry oxygen and nutrients. So what the hell does it matter what his BP is if he;s bleeding it out more than I can replenish it.

These patients need: (1) BLOOD; and (2) SURGERY. NOT IV fluids. NOT crystalloid fluids, of which 40-50% will shift into the interstitial spaces anyway. BLOOD. NOT. IV. FLUIDS.

To me this just plays into the whole wannabe rescue ranger mentality of alot of the old timer paramedics. Now, don't get me wrong. I love being a paramedic, and some of them are very good at what they do. But...they don't like to change. They don't like new ideas. They like IVs. They like "saves". They like patting themselves on the back.

This mindset is detrimental for the longevity of the paramedic career field, as well as to our patients. We need to find the underlying pathology behind the disease process. We need to not only treat the trouble breathing, but also the bi-ventricular deficiency. Pumping the CHF patient full of lasix and nitro will do not good if we do not improve cardiac output, inotropy, EF, and as a result perfusion, oxygenation. It will also decrease backward pressure, relieve pressure and workload on the heart and increase pump filling. Yet most paramedics only want to drop the lasix, the nitro, maybe some morphine, and load and go.

This is a problem of mindset. I do not want to be a cook book medic. I don't want our profession to be merely "treating what we see", or filling in the blanks we go along. We have come a long way since I first came into the field ten years ago. We are more professional. In some states we are licensed and looked at with the same respect as other licensed professionals and allied health professionals.

But we have a longer way to go.

Now, take this for example. Cordarone is an excellent drug. In a surgical, hospital setting, Cordarone has an excellent effectiveness for stopping VF and some forms of VT and increasing survival rates among Sudden Cardiac Arrest patients. Now. This is in the hospital. Where they are minutes away from definitive care. Where they are minutes away from PTCA (Percutaneous Transluminal Coronary Agioplasty), or CABG (Coronary Arterial Bypass Graft). Like right then.

So, they start carrying Cordarone on some buses in different cities to test the effectiveness of the drug in pre-hospital SCA cases. The studies came back that there was an increase in survival rates among prehospital SCA patients. BUT. IT DID NOT INCREASE 30-DAY SURVIVAL RATES FOR THOSE PATIENTS.

This drug costs $300 per dose. And why do we have it? So we can slap ourselves on the back and say "we got another save". This is an inherently faulty mindset and focus, people. We need to change it. We need to look forward. We need to look at our patients as a whole and treat the whole patient. We need to invest time and money into studies that will actually increase long-term survival rates. We don't need anymore slaps on the back. We need knowledgeable and educated paramedics who can read 12-leads, who can see a shift in the axis on the 12-lead, who can differentiate between CHF w/pulmonary edema Vs. aspiration pneumonia. We need Paramedics who can recognize a bi-fasicular block and know that Lidocaine can kill them. We need paramedics who will seek out and search for the root cause of the patient's signs and symptoms and not just treat the surface.

We need a new focus.

We need to be clinicians not technicians.

We need more study time.

We need to do actual rotations with ED, CTICU, S/TICU and heart center doctors.

We need to know what we're doing.

Most of all....

we need to firs do no harm.

PRIMUM NON NOCERE