Missing the "High" in High Performance CPR?

Missing the “High” in High Performance CPR?

Alan Perry

July 30, 2017

High Performance CPR is a generic term associated with various methods now used in the setting of cardiac arrest aimed at improving the survival rate and long-term outcomes of victims beyond outcomes obtained by standard AHA/ACLS guidelines. It is achieved by improving the quality and consistency of CPR and maximizing the effect of efficacious actions taken during the process.

High performance does not occur by accident or by writing an SOP, It takes education, practice and teamwork. It is a complicated process in which every team player must understand the whole process, what their area of responsibility is and how to best perform each task. It also takes leadership and communication. A gap in any area will decrease performance and potentially have a negative effect on the patient’s outcome.

Education on any high performance variant of CPR will likely require your agency to develop its own system with the approval and participation of your OMD(s). Since High Performance CPR is a skill every operational member of your organization must have for the system to work. Initial and on-going training programs should be put into place that convey the necessary knowledge, skills and abilities.

Because it is a team-based function it will also require regular practice and competency/skill verification. In most systems, providers will not always be working with the same crew members. Practical exercises across shifts/stations/battalions, with members functioning in all roles they might normally fill, will produce greater consistency of performance across the organization.

Teamwork can be difficult to achieve when you are not always working with the same members. This is where training to a standard and having all members of the team knowing the whole process pays off. There can be little variation across shifts/stations/battalions if you want everyone to work collaboratively in this fast-paced and stressful situation.

Leadership is important but not as much dependent on rank as where you find yourself. What is important is that the person taking the lead be competent and communicate effectively with other team members. This is no place to fuss over who’s going to lead, make the call and fall into line. If this falls apart the whole process can implode into utter confusion.

Communication is probably the most important skill. It requires both effective delivery of messages as well as good listening. A closed-loop communication model is best so that critical procedures and information can be tracked accurately by both the sender and receiver. This type of communication also helps keep the whole team aware of where they are in the resuscitation process.

It has been proven that effective CPR delivered early in a witnessed arrest and preceding defibrillation of VF produces the greatest possible benefit for the patient. It has also been proven that minimizing gaps in CPR created by analyzing rhythms, charging defibrillators and switching compressors improves outcomes. This is an excellent place to hone the communication and teamwork.

It should go something like this:

Scribe/Timekeeper:        Approaching 2 minutes CPR

ALS team leader:            Prepare for rhythm check and compressor switch.

                                      (Charge defibrillator)

                                      Switch compressors, clear the patient.

                                      (Examines rhythm, shocks if VF/VT) 2 seconds max.

                                      Resume compressions.

Scribe/Timekeeper:        Records actions/defibrillation/rhythm.

                                      Restarts CPR clock.

Looks simple right? Try this with a crew you have not worked with before, or with providers who have not practiced or don’t remember the process. It won’t be so simple.

Enjoy,

Alan

Resources:

http://www.resuscitationacademy.org/downloads/HPCPRToolkit110309.pdf

http://www.aedchallenge.com/articles/highperformancecpr.php

http://www.ems12lead.com/2016/06/14/high-performance-cpr-performance-not-protocol/

Healthcare in America

Healthcare in America

June 26, 2017

Alan E. Perry

Life, Liberty and the pursuit of happiness, as well as several other “civil rights” are afforded by our constitution. Nowhere does it say we will all have healthcare, or for that matter pick-up trucks, big bank accounts, or a reasonable IQ.

Our lives are shaped by our circumstances and how we react and adapt to move ourselves where we want to be. Each person selects their own priorities and accepts the risk and rewards of those decisions. Some plan, make good decisions, accept responsibility and do better. Some are short sighted, irrational and blame others for their misfortune. Granted some get handed circumstances that are inherently more difficult to manage than others purely because of chance, but this is the exception.

Individual health is affected largely by personal choice. There are exceptions to this, but again this is the exception not the norm and not the subject of this discussion. That being said; there are actions individuals can take to manage certain known risk such as hypertension and diabetes. But back to the issue; individuals must accept the responsibility for their health buy treating their bodies with respect, exercising, staying physically active, eating properly, managing their known conditions and avoiding risk that are not necessary.

The assertion of the “universal healthcare” concept is that everyone has a right to exactly the same healthcare, and that those who cannot afford it will receive it at the expense of those who can. This is the definition of socialism; will it stop here? I think not. This “universal healthcare” idea provides no incentive for (in fact punishes) those who take care of themselves and make wise decisions about their body and provides reward for those who squander their own resources and health. As an example, take a 50-year-old male who has taken care of himself and has no medical problems; he used to be able to get health insurance (if he chose to get it at all) at a very reasonable rate based on his age and absence of risk factors. Another 50-year-old male, who has been reckless, excessive and generally abusive to his body and sedentary has multiple medical problems and disabled as a result. Do they both get treated fairly? The healthy one sees his insurance rates and deductibles go up and he is no longer able to save for his retirement. The unhealthy one gets free healthcare and a disability check.

In 1935 President Roosevelt and the Congress legislated the Social security act which created a financial safety net. In 1965 Medicare and Medicaid where added, Medicare provides financial assistance for healthcare to those 65 and over, Medicaid provides financial assistance for healthcare for low income families and individuals. These programs addressed the need for the elderly and the economically disadvantaged to have access to basic healthcare as a safety net, it never intended to put them on par with those who opted for more extravagant treatments and could afford them. Our government has programs to assist those who have trouble obtaining food, housing, medical care and education. It does not guarantee these. NGO’s have typically also assisted with these basic human needs, but again no guarantee.

By guaranteeing universal healthcare we are opening a very large can of parasitic worms and diminishing the value of personal accountability and self-determination. It will not take long before the authors of this malignancy begin demanding that everyone is entitled to a three-bedroom house with a garage, a new pick-up truck, free cable TV and an all-expense paid vacation semi-annually. Look closely, it’s already happening.

We live in a nation founded on the principals of personal responsibility, self-determination and respect and tolerance for those with differing views. It worked then, as it should now, because each person knew with certainty that if they worked and took responsibility for their actions they would have a much better chance of succeeding than those who choose to sit in the bars or street corners and refuse to contribute or better themselves. We raised our children to understand that if you did not become vested in your future and provide for your family there would be undesirable consequences.

As voters and taxpayers what are we to do when the numbers those receiving this ever-growing list of entitlements exceed the numbers of those paying for them. This Nation will collapse if this occurs, and it will be violent. We must find a way to get healthcare out of the corporation’s hands, out of the government’s hands, and back into the hands of the providers and the patient. We must also look at the broader problem that got us here in the first place and acknowledge that while we are all created equal, our decisions, actions and efforts will determine the amount of resources we will have as individuals and a Nation. as Thomas Jefferson put it " Free men are not equal".

The Three-man Medic Company

Three-man Medic Company

By Alan Perry, June 21, 2016

Congratulations on your promotion! Your new assignment is lieutenant on a Medic Company!? It should come as no surprise that the busiest piece of equipment, with the most at stake in the daily performance of it's duties, has finally been elevated to the company level. You and the other personnel assigned to your Medic Company are taking a huge step forward for Emergency Services. Thanks to this new concept your organization will be able to more efficiently and responsibly provide necessary emergency medical services to the public you serve.

“How did this happen?” you ask. Your City Council and the City Manager have been systematically looking at all city department functions looking for ways improve efficiency, reduce costs and improve retention of ALS personnel. The traditional Fire Department staffing model and even its name could be re-aligned to reflect what it actually does. After conducting an “operational effectiveness and efficiency” study and looking at evolving practices in staffing and deployment, the city manager and the interim Fire Chief determined that a major re-alignment of physical and human resources needed to occur. This included adding Company Officers on medics, Field Medical Officer Captains for each battalion and shift, a EMS Duty Chief for each shift, and a Division Chief of EMS.

With nearly 80% of the calls for service being related to medical emergencies, and only 5% actually involving any type of fire, the name has been changed to “Emergency Services”. Every station will have at least one three-man Medic Company in addition to a four-man Engine Company, and every Medic Company will have at least one ALS provider. These Medic Companies can handle 80% of EMS calls without the need for additional resources.

Second run engines have all been replaced by Rapid Response Companies, a three-man company in a medium duty truck equipped for firefighting and rescue operations without a pump or water. These trucks co-respond with Medic Companies on high acuity EMS calls for manpower, and function like flying squads for fire and rescue calls. They are much more cost effective to operate compared to the engines and ladders that were used before, each district has two. Engine Companies are staffed with four, safe levels of staffing are still maintained since Medics Companies co-respond to fires as well.

You noticed the changes in the promotional process you just participated in. The increased emphasis on EMS practices and operations in the process was not random. The City Manager and Fire Chief both realized that promotions within the organization need to reflect the current role of the Department as well as the need for a change in the culture of the organization.

The money your City is saving is being re-invested in a new training facility for public safety (EMS/Police/Fire), and an aggressive public education program focusing on health and safety issues through the Community Risk Reduction Division (formerly Fire Prevention). The Chief has indicated recently that the Department will be moving to correct pay compression issues due to consistent budget surpluses and possibly even provide a second set of turnout gear. As an added bonus, those who choose the EMS assignments receive a 10% salary differential.

In the Fire service these changes might seem radical, in business and politics they can't come fast enough. Many Fire Departments across the country are developing new and innovative ways to provide the public with the best return for their emergency services dollar independent of any industry guidance. At the national level there seems to be some lag in even acknowledging the need for realignment. The NFPA and IAFF are quick to protect the future of the fire Service and the employment of Firefighters but have not seriously addressed the need for any realignment of personnel or resources other than to protect the control and influence of the Fire Service on public safety. The diversity of Fire Service organizations and localities has a great deal to do with the difficulty in developing a recommendation that will work for us all. I think that if we seriously consider what the public both expects and needs in emergency services we can do what we do best, fix the problem so we can get the opportunity to be the heroes we want to be.

Sweet dreams,

https://www.ncbi.nlm.nih.gov/pubmed/10163385